Cost-effectiveness of the treatment of uncomplicated severe acute malnutrition by community health workers compared to treatment provided at an outpatient facility in rural Mali

Abstract

BackgroundThe Malian Nutrition Division of the Ministry of Health and Action Against Hunger tested the feasibility of integrating treatment of severe acute malnutrition (SAM) into the existing Integrated Community Case Management package delivered by community health workers (CHWs). This study assessed costs and cost-effectiveness of CHW-delivered care compared to outpatient facility-based care.MethodsActivity-based costing methods were used, and a societal perspective employed to include all relevant costs incurred by institutions, beneficiaries and communities. The intervention and control arm enrolled different numbers of children so a modelled scenario sensitivity analysis was conducted to assess the cost-effectiveness of the two arms, assuming equal numbers of children enrolled.ResultsIn the base case, with unequal numbers of children in each arm, for CHW-delivered care, the cost per child treated was 244 USD and cost per child recovered was 259 USD. Outpatient facility-based care was less cost-effective at 442 USD per child and 501 USD per child recovered. The conclusions of the analysis changed in the modelled scenario sensitivity analysis, with outpatient facility-based care being marginally more cost-effective (cost per child treated is 188 USD, cost per child recovered is 214 USD), compared to CHW-delivered care. This suggests that achieving good coverage is a key factor influencing cost-effectiveness of CHWs delivering treatment for SAM in this setting. Per week of treatment, households receiving CHW-delivered care spent half of the time receiving treatment and three times less money compared with those receiving treatment from the outpatient facility.ConclusionsThis study supports existing evidence that the delivery of treatment by CHWs is a cost-effective intervention, provided that good coverage is achieved. A major benefit of this strategy was the lower cost incurred by the beneficiary household when treatment is available in the community. Further research is needed on the implementation costs that would be incurred by the government to increase the operability of these results.Electronic supplementary materialThe online version of this article (10.1186/s12960-018-0273-0) contains supplementary material, which is available to authorized users.

Bringing severe acute malnutrition treatment close to households through community health workers can lead to early admissions and improved discharge outcomes

“…This study shows that children receiving SAM treatment from CHWs generally exhibited a less severe stage at admission, with lower rates of edema and better anthropometric condition compared to children treated at HFs. A previous analysis on the cost-effectiveness of this new approach for SAM management with CHWs as treatment providers showed that families can save half the time and one-third of the money that it would cost to treat their children at the HFs [22]. This cost-saving could prevent families from delaying the initiation of required nutritional treatment, allowing children to be admitted in a relatively less severe condition.…”

“…A review of the operational experiences of this approach has recently been published [9] and shows that programs implementing this new community approach can achieve better outcomes in terms of recovery and defaulter rates than standard CMAM programs performed at HFs far away from the affected villages. This review also found that the iCCM+ model could potentially double the coverage of SAM treatment services, achieving over 80% treatment coverage in a cost-effective manner, reducing the time and money that the families would expend to treat their children at the health centers, which are usually located far away from their households [10,11].…”

Cost and cost-effectiveness analysis of treatment for child undernutrition in low- and middle-income countries: A systematic review

“…This is in support of findings from a study conducted in Mali assessing the cost-effectiveness of treatment of uncomplicated SAM using CHWs and outpatient facilities. In this study, treatment using CHWs was cost-effective 64 .…”

“…The review identified four studies assessing costs incurred by community volunteers during the implementation of CMAM 24,62, 64,65 . Two studies conducted in Mali and Pakistan compared the cost effectiveness of treatment of uncomplicated SAM by community health workers (CHWs) to outpatient facility based programs 64,65 . The study in Mali reported that delivery of treatment by CHWs ($259 per child recovered) was more cost-effective compared to the outpatient facility care ($501 per child).…”

Can community health workers manage uncomplicated severe acute malnutrition? A review of operational experiences in delivering severe acute malnutrition treatment through community health platforms

“…Additional cost‐effectiveness evidence is provided by the Mali study, where services provided in the facility (control group) were compared with services provided in a facility and by CHWs at household level (intervention group; Rogers et al, ). Authors applied a similar societal perspective with an activity‐based costing analysis.…”