cost-effectiveness of community-based management of severe acute malnutrition (cmam) kate golden...
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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