Barriers to access for severe acute malnutrition treatment services in Pakistan and Ethiopia: a comparative qualitative analysis

Abstract Objective: To understand and compare the primary barriers households face when accessing treatment for cases of childhood severe acute malnutrition (SAM) in different cultural settings with different types of implementing agencies. Design: The study presents a comparative qualitative analysis of two SAM treatment services, selected to include: (i) one programme implemented by a nongovernmental organization and one by a Ministry of Health; and (ii) programmes considered to be successful, defined as either coverage level achieved or extent of integration within government infrastructure. Results from individual interviews and group discussions were recorded and analysed for themes in barriers to access. Setting: Sindh Province, Pakistan; Tigray Region, Ethiopia. Subjects: Beneficiary communities and staff of SAM treatment services in two countries. Results: Common barriers were related to distance, high opportunity costs, knowledge of services, knowledge of malnutrition and child's refusal of ready-touse foods. While community sensitization mechanisms were generally strong in these well-performing programmes, in remote areas with less programme exposure, beneficiaries experienced barriers to remaining in the programme until their children recovered. Conclusions: Households experienced a number of barriers when accessing SAM treatment services. Integration of SAM treatment with other community-based interventions, as the UN recommends, can improve access to life-saving services. Efforts to integrate SAM treatment into national health systems should not neglect the community component of health systems and dedicated funding for the community component is needed to ensure access. Further research and policy efforts should investigate feasible mechanisms to effectively reduce barriers to access and ensure equitable service delivery

The "ComPAS Trial" combined treatment model for acute malnutrition: study protocol for the economic evaluation.

BACKGROUND: Acute malnutrition is currently divided into severe (SAM) and moderate (MAM) based on level of wasting. SAM and MAM currently have separate treatment protocols and products, managed by separate international agencies. For SAM, the dose of treatment is allocated by the child's weight. A combined and simplified protocol for SAM and MAM, with a standardised dose of ready-to-use therapeutic food (RUTF), is being trialled for non-inferior recovery rates and may be more cost-effective than the current standard protocols for treating SAM and MAM. METHOD: This is the protocol for the economic evaluation of the ComPAS trial, a cluster-randomised controlled, non-inferiority trial that compares a novel combined protocol for treating uncomplicated acute malnutrition compared to the current standard protocol in South Sudan and Kenya. We will calculate the total economic costs of both protocols from a societal perspective, using accounting data, interviews and survey questionnaires. The incremental cost of implementing the combined protocol will be estimated, and all costs and outcomes will be presented as a cost-consequence analysis. Incremental cost-effectiveness ratio will be calculated for primary and secondary outcome, if statistically significant. DISCUSSION: We hypothesise that implementing the combined protocol will be cost-effective due to streamlined logistics at clinic level, reduced length of treatment, especially for MAM, and reduced dosages of RUTF. The findings of this economic evaluation will be important for policymakers, especially given the hypothesised non-inferiority of the main health outcomes. The publication of this protocol aims to improve rigour of conduct and transparency of data collection and analysis. It is also intended to promote inclusion of economic evaluation in other nutrition intervention studies, especially for MAM, and improve comparability with other studies. TRIAL REGISTRATION: ISRCTN 30393230 , date: 16/03/2017

Evaluation of the cost-effectiveness of the treatment of uncomplicated severe acute malnutrition by lady health workers as compared to an outpatient therapeutic feeding programme in Sindh Province, Pakistan

Background: Due to the limited evidence of the cost-effectiveness of Community Health Workers (CHW) delivering treatment for severe acute malnutrition (SAM), there is a need to better understand the costs incurred by both implementing institutions and beneficiary households. This study assessed the costs and cost-effectiveness of treatment for cases of SAM without complications delivered by government-employed Lady Health Workers (LHWs) and complemented with non-governmental organisation (NGO) delivered outpatient facility-based care compared with NGO delivered outpatient facility-based care only alongside a two-arm randomised controlled trial conducted in Sindh Province, Pakistan. Methods: An activity-based cost model was used, employing a societal perspective to include costs incurred by beneficiaries and the wider community. Costs were estimated through accounting records, interviews and informal group discussions. Cost-effectiveness was assessed for each arm relative to no intervention, and incrementally between the two interventions, providing information on both absolute and relative costs and effects. Results: The cost per child recovered in outpatient facility-based care was similar to LHW-delivered care, at 363 USD and 382 USD respectively. An additional 146 USD was spent per additional child recovered by outpatient facilities compared to LHWs. Results of sensitivity analyses indicated considerable uncertainty in which strategy was most cost-effective due to small differences in cost and recovery rates between arms. The cost to the beneficiary household of outpatient facility-based care was double that of LHW-delivered care. Conclusions: Outpatient facility-based care was found to be slightly more cost-effective compared to LHW-delivered care, despite the potential for cost-effectiveness of CHWs managing SAM being demonstrated in other settings. The similarity of cost-effectiveness outcomes between the two models resulted in uncertainty as to which strategy was the most cost-effective. Similarity of costs and effectiveness between models suggests that whether it is appropriate to engage LHWs in substituting or complementing outpatient facilities may depend on population needs, including coverage and accessibility of existing services, rather than be purely a consideration of cost. Future research should assess the cost-effectiveness of LHW-delivered care when delivered solely by the government

Community case management of acute malnutrition by community health workers in southern Bangladesh: Examining quality of care and cost-effectiveness

Severe acute malnutrition (SAM), evidenced by severe wasting and/or edema, reflects recent illness and nutrient deficits and is the cause of one to two million preventable child deaths each year. Recent advances in the treatment of SAM have enabled severely wasted children to recover at home, rather than in crowded therapeutic feeding centers or under-resourced, over-burdened health facilities. Due to its promising performance in promoting quick recovery and decreasing mortality rates in emergency situations, the community-based management of acute malnutrition (CMAM) has received much attention in international nutrition policy. In 2007, the United Nations promoted its global expansion into areas with a high burden of SAM and its integration with other community-based health and nutrition activities. However, there is limited evidence regarding the impact of adding this delivery mechanism to existing community-based nutrition infrastructure. This dissertation addressed key debates and operational concerns around integrating CMAM into existing community-based health and nutrition programs by researching aspects of a pilot intervention implemented by Save the Children USA (SCUS) in southern Bangladesh. As part of a child survival program using a cadre of community health workers (CHWs) to deliver preventive and curative care to children in areas underserved by the formal health system, the community case management (CCM) of SAM was introduced to the CHW workload using an adapted CMAM classification algorithm. Study results were compared between the intervention upazila implementing the CCM of SAM and a comparison upazila implementing the facility-based treatment of SAM according to WHO protocol. This dissertation was comprised of three analyses. The first analysis evaluated the capacity of CHWs to effectively identify and treat children suffering from SAM without complications. This analysis found that 89% of assessed CHWs achieved 90% error-free case management or higher. The second analysis examined the association between the quality of care provided by CHWs and their number of work responsibilities by comparing the performance of two groups of CHWs with different workloads: one group providing preventive care in addition to implementing CCM of pneumonia and diarrhea, and another group additionally treating SAM. This analysis found that the CHWs who were managing cases of SAM worked significantly more hours than those who were not, but maintained quality of care on both curative and preventive work tasks. The third analysis investigated the cost-effectiveness of community-based treatment of SAM compared to facility-based treatment by estimating costs incurred by both care providers and participating households in the two study upazilas, and coupling this analysis with effectiveness evidence generated in another arm of the study. Results from this research revealed that community-based treatment of SAM was more cost-effective than facility-based treatment, and resulted in considerably lower costs for participant households. This research provides a timely investigation into the opportunities and challenges of integrating CMAM into existing community-based health and nutrition infrastructure. Findings suggest that CHWs are capable of managing cases of SAM at community level, and that this service delivery mechanism is cost-effective. Results from this dissertation support the use of CHWs in the community-based management of SAM in Bangladesh, in order to expand access to treatment for children in areas underserved by the formal health system

Cost-effectiveness of the community-based management of severe acute malnutrition by community health workers in southern Bangladesh

PRIFPRI3; ISI; CRP4; B Promoting healthy food systems; G Cross-cutting gender theme; HarvestPlusHarvestPlus; PHND; A4NHCGIAR Research Program on Agriculture for Nutrition and Health (A4NH

Does greater workload lead to reduced quality of preventive and curative care among community health workers in Bangladesh?

PRIFPRI3; ISI; CRP4PHND; A4NHCGIAR Research Program on Agriculture for Nutrition and Health (A4NH

Quality of care for severe acute malnutrition delivered by community health workers in southern Bangladesh

PRIFPRI3; ISI; B Promoting healthy food systems; CRP4PHND; A4NHCGIAR Research Program on Agriculture for Nutrition and Health (A4NH

Community health worker perceptions of structural barriers to quality of care and community utilisation of services in Bangladesh

PRIFPRI3; ISI; CRP2PHND; PIMCGIAR Research Program on Policies, Institutions, and Markets (PIM