Cost-effectiveness of community-based management of severe acute malnutrition (CMAM)

Kate Golden

Senior Nutrition Advisor

What is Community based Management of

Acute Malnutrition (CMAM)?

Also and previously known as Community-based Therapeutic Care (CTC)

What is CMAM?

• Decentralised treatment of severe acute malnutrition

• First piloted in 2002 by Concern and Valid International

• An alternative to the traditional model that only treated children on in-patient basis

• Endorsed as best practice for treatment of severe acute malnutrition by UN in 2007

Source: CDC and Concern DRC

Severe wasting (complications)

Severe acute malnutrition

Nutritional oedema

(complications)Severe wasting

(no complications)

3 key developments have made CMAM possible…

1. Ready-to-Use-Therapeutic Foods (e.g. “Plumpy nut™”)

2. Mid Upper Arm Circumference for easy screening/ admission at community level

3. Community mobilisation and outreach

Ready-to-Use-Therapeutic Foods

Can eat at home Can only be prepared/ eaten in a centre

RUTF Traditional therapeutic milks

Mid-Upper Arm Circumference (MUAC)

Community volunteers ready to MUAC children

Community Mobilisation/ Outreach

El Fasher

Um Keddada

Mellit

Kutum

Taweisha

El Laeit

Malha

Tawila & Dar el Saalam

TinaKarnoi

&Um Barow

Koma

KormaSerifKebkabiya

Fata Barno

Tina

CMAM = increased coverage

El Sayah

El Sayah

Hospital/ traditional inpatient centre

100 kms

Outpatient centre

CMAM also means:

• Earlier detection and treatment• Better adherence to treatment

=better treatment outcomes

CMAM:effective…but is it

cost-effective?

Disability-Adjusted Life Year (DALY)

• Expressed as # of life years lost due to:– early death – ill-health– disability

• Combines mortality and morbidity into a single, common metric

• That metric allows interventions to be costed and compared

• Is DALY something to be averted or gained? Debate continues…

InterventionCost per

DALY (US$)Promotion of breastfeeding 3-11

Zinc management of diarrhoea 73

Vitamin A supplementation 6-12

Iron fortification 66-70

Hygiene promotion 3

Traditional Expanded Programme on Immunisation (EPI) 7

Case management of lower respiratory infections 398

HIV peer education programmes for high risk groups 37

Anti-retroviral therapy for HIV/AIDS (sub-Saharan Africa) 922

Insecticide-treated bed nets (sub-Saharan Africa) 11

Treatment of severe acute malnutrition (Zambia/ Malawi) 41/ 42

Cost per DALY averted various interventions

Results• CMAM was highly cost effective under the ‘base

case’• CMAM still cost effective in ‘worst case’• CMAM cost 42 US$ (2007) per DALY averted as

implemented in Dowa District in Malawi January – December 2007

• Results are likely generalisable to similar contexts (similar to results from Zambia)

• Future research: A more complex model using larger data sets could better identify key drivers of cost effectiveness – e.g. coverage

Methods: Decision Tree

CMAM implemented

scenario 1 Malawi 2007

CMAM not implemented

scenario 2 hypothetical

Covered by CMAM

Cured

Died

Defaulted/ non recovered

Referred to inpatient

Not covered by CMAM

Non CMAM care

No treatment

Lived

Lived

Lived

Lived

Lived

Died

Died

Died

Died

DiedLived

Died

Lived

Died

Non CMAM care

No treatment

CMAM cost effectiveness

Methods: what we knew

• Outcomes of cases treated in CMAM programme in Dowa district

• Coverage of the CMAM programme• Costs of the main project inputs from

Concern & government

Malawi Programme Outcomes

Outcomes of children exiting the OTP Number %

Cured 2538 91.3%

Died 28 1.0%

Default (91) or non-recovered (38) 129 4.6%

Exits referred to inpatient 85 3.1%

Total OTP Exits 2780  

CMAM coverage in Dowa district March 2008: 41%

CMAM CostsTotal cost % of total cost Source

Capital costs (annual equivalent):

Cars and motorbikes (Concern) 11,590 2% Concern finance systemComputers (Concern) 2,543 1% Concern finance system

Sub-total capital costs: 14,133 3%

Recurrent costs:

Food - RUTF (Concern) 148,519 32% Concern finance system

Admin - Concern 97,532 21% Concern finance system

Direct staff - international (Concern) 56,833 12% Concern finance system

Transport - fuel, maintenance (Concern) 37,004 8% Concern finance system

Direct staff - national (Concern) 34,122 7% Concern finance system

Other miscellaneous costs (Concern) 24,946 5% Concern finance system

Local clinic staff & supervisors (Government) 24,600 5%Estimated allocation from DHO budget

Admin - government 14,214 3%Estimated allocation from DHO budget

Training costs, including venue and per diems (Concern) 8,800 2% Concern finance system

Medical supplies (largely government) 5,773 1%

Concern finance system + estimated allocation from DHO budget

Inpatient costs for OTP referrals (government) 4,227 1%Unit cost per child multiplied by total OTP to ITP referrals

Sub-total recurrent costs: 456,571 97%Total costs 470,703 100%

Methods: what we didn’t know

• Mortality rate of children with SAM who were not treated – a killer assumption

• Mortality rate of children with SAM who received ‘non-CMAM treatment’

Other assumptions

ParameterBase case

Worst case

Best case Source of base case (and range)

General

Annual background mortality rate for under-fives in 2.4%

None used

None used

Based on Bachmann 2009: under-five deaths per 1000 live births in , 2007 (UNICEF 2008) divided by 5 to represent one year of these live births

Discount factor 3.0% 5.0% 0.0% Standard factor

Years of life lost (YLL) * 32.7 22.1 67.2

Base: Fox-Rushby & Hanson, 2001Worst + best: using discount factors above

Per child treatment costs used in the model (2007 $)

Base case

Worst case

Best case

Average cost per child treated in CMAM 169.3 211.6 140.3

Base: Total CMAM costs divided by total CMAM exitsWorst case: +25% of base caseBest case: -25% on all non-RUTF costs with RUTF cost same as base case

Average cost per child treated in non-CMAM care 16.7 12.5 20.9

Assumes 1 in 4 SAM cases receive ITP, while 3 in 4 receive set of 3 clinic visitsBase case: Average cost of 1 ITP stay + 3 sets of 3 clinic visits with drugs. Worst case: -25% of base caseBest case: +25% of base case

Benchmarks - WHO

• Highly cost effective intervention – if an intervention averts a DALY for less than the per capita GNI (or GDP)

• Cost effective if avert a DALY for less than 3 times the GNI

Sensitivity analysis

Thanks