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

Abstract

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