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

1. Cost-effectivenessof 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. Severe acute malnutrition Severe wasting (complications) Nutritional oedema (complications) Severe wasting (no complications) Source: CDC and Concern DRC

5. 3 key developments have made CMAM possible… • Ready-to-Use-Therapeutic Foods (e.g. “Plumpy nut™”) • Mid Upper Arm Circumference for easy screening/ admission at community level • Community mobilisation and outreach

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

7. Mid-Upper Arm Circumference (MUAC)

8. Community Mobilisation/ Outreach Community volunteers ready to MUAC children

9. Tina Karnoi & Malha Tina Um Barow Kutum Mellit Koma Fata Barno Korma Serif El Fasher Kebkabiya Um Keddada Tawila & Dar el Saalam Taweisha El Laeit CMAM = increased coverage El Sayah El Sayah 100 kms Hospital/ traditional inpatient centre 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. 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 generalisableto 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 Lived Cured Died Died Covered by CMAM Lived Defaulted/ non recovered Died Lived Referred to inpatient CMAM implemented scenario 1 Malawi 2007 Died Lived Non CMAM care Not covered by CMAM Died CMAM cost effectiveness No treatment Lived Died Lived Non CMAM care CMAM not implemented scenario 2 hypothetical Died Lived No treatment Died

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 CMAM coverage in Dowa district March 2008: 41%

18. CMAM Costs

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

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

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