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Cost-effectiveness of community-based management of severe acute malnutrition (CMAM) Kate Golden Senior Nutrition Advisor.

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Presentation on theme: "Cost-effectiveness of community-based management of severe acute malnutrition (CMAM) Kate Golden Senior Nutrition Advisor."— Presentation transcript:

1 Cost-effectiveness of community-based management of severe acute malnutrition (CMAM) Kate Golden Senior Nutrition Advisor

2 What is Community based Management of Acute Malnutrition (CMAM)? Also and previously known as Community-based Therapeutic Care (CTC)

3 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

4 Source: CDC and Concern DRC Severe wasting (complications) Severe acute malnutrition Nutritional oedema (complications) Severe wasting (no complications)

5 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

6 Ready-to-Use-Therapeutic Foods Can eat at home Can only be prepared/ eaten in a centre RUTFTraditional therapeutic milks

7 Mid-Upper Arm Circumference (MUAC)

8 Community volunteers ready to MUAC children Community Mobilisation/ Outreach

9 El Fasher Um Keddada Mellit Kutum Taweisha El Laeit Malha Tawila & Dar el Saalam Tina Karnoi & Um Barow Koma Korma Serif Kebkabiya Fata Barno Tin a CMAM = increased coverage El Sayah Hospital/ traditional inpatient centre 100 kms Outpatient centre

10 CMAM also means: Earlier detection and treatment Better adherence to treatment =better treatment outcomes

11 CMAM: effective…but is it cost-effective?

12 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…

13 Intervention Cost per DALY (US$) Promotion of breastfeeding3-11 Zinc management of diarrhoea73 Vitamin A supplementation6-12 Iron fortification66-70 Hygiene promotion3 Traditional Expanded Programme on Immunisation (EPI)7 Case management of lower respiratory infections398 HIV peer education programmes for high risk groups37 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

14 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

15 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 Died Lived Died Lived Died Non CMAM care No treatment CMAM cost effectiveness

16 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

17 Malawi Programme Outcomes Outcomes of children exiting the OTPNumber% Cured % Died281.0% Default (91) or non-recovered (38)1294.6% Exits referred to inpatient853.1% Total OTP Exits2780 CMAM coverage in Dowa district March 2008: 41%

18 CMAM Costs Total cost% of total cost Source Capital costs (annual equivalent): Cars and motorbikes (Concern) 11,5902% Concern finance system Computers (Concern) 2,5431% Concern finance system Sub-total capital costs: 14,1333% Recurrent costs: Food - RUTF (Concern) 148,51932% Concern finance system Admin - Concern 97,53221% Concern finance system Direct staff - international (Concern) 56,83312% Concern finance system Transport - fuel, maintenance (Concern) 37,0048% Concern finance system Direct staff - national (Concern) 34,1227% Concern finance system Other miscellaneous costs (Concern) 24,9465% Concern finance system Local clinic staff & supervisors (Government) 24,6005% Estimated allocation from DHO budget Admin - government 14,2143% Estimated allocation from DHO budget Training costs, including venue and per diems (Concern) 8,8002% Concern finance system Medical supplies (largely government) 5,7731% Concern finance system + estimated allocation from DHO budget Inpatient costs for OTP referrals (government) 4,2271% Unit cost per child multiplied by total OTP to ITP referrals Sub-total recurrent costs: 456,57197% Total costs 470,703100%

19 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’

20 Other assumptions Parameter Base case Worst case Best caseSource of base case (and range) General Annual background mortality rate for under-fives in2.4% 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 factor3.0%5.0%0.0%Standard factor Years of life lost (YLL) * Base: Fox-Rushby & Hanson, 2001 Worst + best: using discount factors above

21 Per child treatment costs used in the model (2007 $) Base case Worst case Best case Average cost per child treated in CMAM Base: Total CMAM costs divided by total CMAM exits Worst case: +25% of base case Best case: -25% on all non-RUTF costs with RUTF cost same as base case Average cost per child treated in non-CMAM care Assumes 1 in 4 SAM cases receive ITP, while 3 in 4 receive set of 3 clinic visits Base case: Average cost of 1 ITP stay + 3 sets of 3 clinic visits with drugs. Worst case: -25% of base case Best case: +25% of base case

22 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

23 Sensitivity analysis

24 Thanks


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