Transcript Cost-effectiveness of community-based management of severe

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
Severe acute malnutrition
Severe wasting
(complications)
Nutritional
oedema
(complications)
Severe wasting
(no complications)
Source: CDC and Concern DRC
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
RUTF
Can eat at home
Traditional
therapeutic milks
Can only be prepared/
eaten in a centre
Mid-Upper Arm
Circumference (MUAC)
Community Mobilisation/
Outreach
Community volunteers ready to MUAC children
CMAM =
increased coverage
Tina
Karnoi
&
Tin
Um Barow
a
Malha
Kutum
Mellit
Fata Barno
Serif
Koma
El Sayah
El Sayah
Korma
Kebkabiya
El Fasher
Um Keddada
Tawila & Dar el Saalam
Taweisha
100 kms
El Laeit
Hospital/ traditional inpatient centre
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…
Cost per DALY averted various interventions
Intervention
Promotion of breastfeeding
Zinc management of diarrhoea
Cost per
DALY (US$)
3-11
73
Vitamin A supplementation
6-12
Iron fortification
66-70
Hygiene promotion
3
Traditional Expanded Programme on Immunisation (EPI)
7
Case management of lower respiratory infections
398
HIV peer education programmes for high risk groups
37
Anti-retroviral therapy for HIV/AIDS (sub-Saharan Africa)
922
Insecticide-treated bed nets (sub-Saharan Africa)
11
Treatment of severe acute malnutrition (Zambia/ Malawi)
41/ 42
Results
• CMAM was highly cost effective under the ‘base
case’
• CMAM still cost effective in ‘worst case’
• CMAM cost 42 US$ (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
Cured
Lived
Died
Died
Covered by
CMAM
Defaulted/
non recovered
Referred to
inpatient
CMAM
implemented
scenario 1
Malawi 2007
Not covered by
CMAM
CMAM cost
effectiveness
Lived
Non CMAM
care
No treatment
Died
Lived
Died
Lived
Died
Lived
Died
Lived
CMAM not
implemented
scenario 2
hypothetical
Non CMAM
care
Died
No treatment
Lived
Died
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
Cured
Died
Default (91) or non-recovered (38)
Exits referred to inpatient
Total OTP Exits
Number
%
2538
91.3%
28
1.0%
129
4.6%
85
3.1%
2780
CMAM coverage in Dowa district March 2008: 41%
CMAM Costs
Total cost
Capital costs (annual equivalent):
Cars and motorbikes (Concern)
Computers (Concern)
Sub-total capital costs:
11,590
2,543
14,133
% of total cost Source
2% Concern finance system
1% Concern finance system
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% budget
Admin - government
Training costs, including venue and per diems
(Concern)
14,214
3% budget
Estimated allocation from DHO
Estimated allocation from DHO
Medical supplies (largely government)
Inpatient costs for OTP referrals (government)
Sub-total recurrent costs:
Total costs
8,800
2% Concern finance system
5,773
Concern finance system +
estimated allocation from DHO
1% budget
Unit cost per child multiplied by
1% total OTP to ITP referrals
4,227
456,571
470,703
97%
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
Base
case
Worst
case
Best
case
Source of base case (and range)
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, 2001
Worst + best: using discount factors above
Parameter
General
Per child treatment costs used in the
model (2007 $)
Base Worst
case case
Average cost per
child treated in
CMAM
Average cost per
child treated in
non-CMAM care
169.3
16.7
211.6
12.5
Best
case
140.3
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
20.9
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
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