Original Article
Open Access

Integration of Acute Malnutrition Treatment Into Integrated Community Case Management in Three Districts in Southern Mali: An Economic Evaluation

Bernardette Cichon, Noemí López-Ejeda, Magloire Bunkembo Mampindu, Aliou Bagayoko, Mahamadou Samake and Pilar Charle Cuellar
Global Health: Science and Practice June 2024, 12(3):e2300431; https://doi.org/10.9745/GHSP-D-23-00431

Figures & Tables

Figures

  • FIGURE
    FIGURE

    Costs Associated With Integrating Treatment of Acute Malnutrition Into Integrated Community Case Management, by Ingredient, in Three Districts, Southwest Mali

    Abbreviations: AAH, Action Against Hunger; CHW, community health worker; RUTF, ready-to-use therapeutic food.

Tables

  • TABLE 1.

    Characteristics of the Three Study Districts, Southwest Mali

    BafoulabéKayesKita
    Total populationa233,647513,172432,531
    Size19,808 km222,704 km235,626 km2
    Population densitya11.8/km222.6/km212.1/km2
    Participating health centers, no.214950
    Participating CHW sites, no.344590
  • TABLE 2.

    Supervision Models Used at Health Centers and CHW Sites, Southwest Mali

    Biannual SupervisionQuarterly SupervisionMonthly SupervisionNutrition-Specific Supervision
    Bafoulabé: Basic level of supervision
    TargetHealth centers and CHW sitesCHW sitesCHW sitesN/A
    ApproachApproximately 8 days of supervision, including 3 days for problem sites, 1 day report writing/presentation and 2 for travelThree sites visited during each supervision (12 sites over year)Conducted with standard iCCM supervision checklist
    Team composition3 people from national and regional Ministry of Health3 people from district-level Ministry of HealthTeam from health center and community health association
    Kayes: Medium level of supervision
    TargetHealth centers and CHW sitesHealth centers and CHW sitesCHW sitesN/A
    ApproachApproximately 8 days of supervision, including 3 days for problem sites, 1 day report writing/presentation and 2 for travelApproximately 15 sites visited during each supervision (60 over the year)Conducted with standard iCCM supervision checklist
    Team composition3 people from national and regional Ministry of Health3 people from the district-level Ministry of Health, including chief doctor, and community health and social development focal pointsHealth center technical directors, a member of community health association, and 1 Action Against Hunger supervisor, who covers 10–12 CHW sites each (1 site per day)
    Kita: High level of supervision
    TargetHealth centers and CHW sitesHealth centers and CHW sitesCHW sitesCHW sites
    ApproachApproximately 8 days of supervision, including 3 days for problem sites, 1 day report writing/presentation and 2 for travelTeam visits 1 health center and 1 CHW site per day—approximately 30 sites visited during each supervision (120 over the year)Conducted with standard iCCM supervision checklistConducted with community-based management of acute malnutrition supervision checklist
    Team composition3 teams of 3 people including individuals from national and regional Ministry of Health3 teams of 2–4 people, including district’s chief doctor, nutrition, community health, and social development focal points of the district level Ministry of HealthHealth center technical directors, a member of community health association, and an Action Against Hunger supervisor. Each of the 6 Action Against Hunger supervisors covers 15 sites/month (1 site/day).3 Action Against Hunger doctors supervised by district’s nutrition focal point conduct nutrition-specific supervisions, with each doctor covering 30 CHW sites with the aim to visit 2 sites/day and spend 1 week/month supporting the nutrition and community health focal points

    • Abbreviations: CHW, community health worker; iCCM, integrated community case management; N/A, not applicable.

  • TABLE 3.

    Overview of Cost Data Collected at CHW Sites and Health Centers, Southwest Mali

    ActivityIngredients
    Trainings for CHWs and health center directors

    • Staff salaries (Action Against Hunger, government, health facility)

    • CHW time

    • Room rental

    • Training materials

    • Per diems, accommodation, and meals

    • Transport costs

    Supervision

    • Staff salaries (Action Against Hunger, government)

    • Transport (car or motorbike usage, fuel)

    • Per diem/ accommodation

    • Supervisor meetings

    Treatment (direct treatment costs)

    • Salaries (government and health center staff)

    • CHW salaries

    • Ready-to-use therapeutic foods, medicines

    • Health center costs (space, upkeep, materials and running costs)

    • CHW site costs (space, upkeep, materials and running costs)

    Supply logistics

    • Salaries (Action Against Hunger, government and other partner staff).

    • Transport to district level, from district to health center, and from health center to CHW site

    • Storage at district level and health center

    Coordination meetings (steering and technical committee)

    • Salaries (Action Against Hunger, government and partner staff)

    • Room rental and food

    • Transport (car motorbike usage and fuel)

    • Per diem and accommodation

    Action Against Hunger support costs

    • Support staff

    • Office costs

    • Accommodation and per diem

    • Abbreviation: CHW, community health worker.

  • TABLE 4.

    Number of Children Treated for Acute Malnutrition at Health Centers and by CHWs, Southwest Mali

    BafoulabéKayesKita
    Children included in study sample, no.8621,9303,320
    Children treated at health centers, no. (%)549 (63.7)1,580 (81.9)2,793 (84.1)
    Children treated by CHWs, no. (%)313 (36.3)350 (18.1)527 (15.9)
    Children treated per health center, average293256
    Children treated per CHW, average986

    • Abbreviation: CHW, community health worker.

  • TABLE 5.

    Outcomes for Children Treated for Acute Malnutrition, Southwest Mali

     BafoulabéKayesKita
    All children
     Treated, no.8621,9303,320
     Cured, no.5771,6632,704
     Cured, % (95% CI)66.9 (63.8, 70.1)86.2 (84.6, 87.7)81.4 (80.1, 82.8)
     Defaulted, % (95% CI)15.3 (12.9, 17.7)1.8 (1.1, 2.3)6.4 (5.6, 7.2)
     Transferred, % (95% CI)16.9 (14.4, 19.4)11.9 (10.5, 13.4)11.7 (10.7, 12.8)
     Died, % (95% CI)0.8 (0.2, 1.4)0.1 (0.04, 0.3)0.4 (0.2, 0.6)
    Community health worker sites
     Treated, no.313350527
     Cured, no.227303412
     Cured, % (95% CI)72.5 (67.6, 77.5)86.9 (83.3, 90.4)78.2 (74.6, 81.7)
     Defaulted, % (95% CI)6.4 (3.7, 9.1)5.7 (3.3, 8.2)6.6 (4.5, 8.8)
     Transferred, % (95% CI)21.1 (16.5, 25.6)7.4 (4.7, 10.2)14.8 (11.8, 17.8)
     Died, % (95% CI)000.4 (0.2, 0.9)
    Health centers
     Treated, no.5491,5802,793
     Cured, no.3501,3602,295
     Cured, % (95% CI)63.8 (59.7, 67.8)86.1 (84.4, 87.8)82.2 (80.7, 83.6)
     Defaulted, % (95% CI)20.4 (17.0, 23.7)0.8 (0.4, 1.3)6.3 (5.4, 7.2)
     Transferred, % (95% CI)14.6 (11.6, 17.5)12.9 (11.3, 14.6)11.2 (10.0, 12.3)
     Died, % (95% CI)1.3 (0.03, 2.2)0.1 (0.05, 0.3)0.4 (0.2, 0.6)

    • Abbreviation: CI, confidence interval.

  • TABLE 6.

    Project Costs by Activity for Each Study Location in the Base Case, Southwest Mali

    Activities and IngredientsBafoulabéKayesKita
    Trainings subtotal, US$ (% of total)26791 (15.3)34199 (6.3)62092 (7.4)
     CHW sites
      Cost of training staff3903.5 (2.2)5171.1 (1)10908.4 (1.3)
      Cost of room rental, materials, and supplies1485 (0.8)1869 (0.3)3576.0 (0.4)
      Per diem and transport19959.9 (11.4)23930.8 (4.4)44242.0 (5.3)
     Training of health center directors1442.3 (0.9)3228.0 (0.6)3365.4 (0.4)
    Supervision subtotal, US$ (% of total)27819 (15.9)174551.1 (32.3)232047.8 (27.5)
     Action Against Hunger staff timea12788.8 (7.3)138635.7 (25.6)154373.6 (18.3)
     Directorate of Health and community health association staff timea3304.4 (1.9)2434.0 (0.5)8309.5 (1.0)
     Health center staff timeb8704.2 (5.0)9451.6 (1.7)23146.7 (2.8)
     Transport, communication, supplies3021.6 (1.7)10603.6 (2.0)22705.3 (2.7)
     Per diem and accommodation0.08096.7 (1.5)18183.1 (2.1)
     Supervisor meetings0.05329.5 (1.0)5329.5 (0.6)
    Direct treatment costs subtotal, US$ (% of total)89658.4 (51.1)183721.8 (34.0)323047.8 (38.7)
     Health center staff salaries29508.5 (16.8)57377.7 (10.6)97173.1 (11.5)
     CHW salaries3705.6 (2.1)3867.0 (0.7)14638.0 (1.7)
     RUTFs and medicine41244.0 (23.5)92692.0 (17.2)154657.0 (18.4)
     Health center costs (space and upkeep)2090.7 (1.2)5391.80 (1.0)6025.82 (0.7)
     CHW site costs (space and upkeep)572.2 (0.3)966.8 (0.2)3187.9 (0.4)
     Active case finding0.0 (0)1465.6 (0.3)2845.0 (0.3)
     Materials and supplies12537.4(7.2)21960.9 (4.1)47752.7 (5.7)
    Supply logistics subtotal, US$ (% of total)14315 (8.2)14932 (2.8)22257 (2.6)
     Personnel818.3 (0.5)618.0 (0.1)1422.2 (0.2)
     Transport (RUTF)8021.2 (4.6)9685.9 (1.8)14756.4 (1.8)
     Storage of supplies5475.6 (3.1)4628.5 (0.9)6078.2 (0.7)
    Coordination meetings of the steering and technical committee, US$ (% of total)8467 (4.8)8426 (1.6)8500 (1.0)
     Personnel5744.2 (3.2)5677.2 (1.1)5744.2 (0.7)
     Room rental, per diem, accommodation1719.9 (1.0)1719.9 (0.3)1719.9 (0.2)
     Transport1003.1(0.6)1028.7 (0.2)1035.7 (0.1)
    Action Against Hunger support costs, US$ (% of total)8324 (4.8)124440 (23.0)191910 (22.8)
     Personnel8317.7 (4.7)107755.0 (19.9)164433.2 (19.5)
     Per diem and accommodation0.0 (0)1535.0 (0.3)1445.0 (0.2)
     Transport0.0 (0)7002.8 (1.3)13357.3 (1.6)
     Office costs5.8 (<0.1)8147.4 (1.5)12.674.2 (1.5)
    Total, US$ (% of total)175373.8 (100)540270.6 (100)843084.6 (100)
    Cost to Action Against Hunger50610 (28.9)330506.63 (61.2)458443.4 (54.3)
    Cost to other international NGOs and UN agenciesc63196.4 (36.0)119893.6 (22.2)216855. (25.7)
    Cost to the government, community health association, and community61567.5 (35.1)89870.4 (16.6)167786.7 (19.9)

    • Abbreviations: CHW, community health worker; NGO, nongovernmental organization; RUTF, ready-to-use therapeutic food; UN, United Nations.

    • ↵aIncludes supervision to CHW sites and support/supervision of health centers.

    • ↵bSupervision of CHW sites only.

    • ↵cThese include Save the Children, Population Services International, and UNICEF.

  • TABLE 7.

    Cost per Child Treated and Cured in the Observed Base Case Analysis, Southwest Mali

    Bafoulabé, US$ (95% CI)Kayes, US$ (95% CI)Kita, US$ (95% CI)
    Total cost175373.8 (159839.9, 191948.4)540270.6 (476549, 588147.6)843084.6 (734885.4, 912231.8)
    Total cost per child treated203.4 (185.4, 222.7)

    279.9

    (246.9, 304.7)

    		253.9 (221.4, 274.8)
     Excluding RUTF costs155.6 (140.9, 165.2)

    231.9

    (218.2, 248.0)

    		207.4 (193.5, 219.8)
    Total cost per child recovered303.9 (267.6, 346.4)324.9 (282.9, 358.9)311.8 (268.6, 342.0)
     Excluding RUTF costs232.5 (203.3, 256.9)269.1 (249.9, 292.1)254.6 (234.7, 273.5)

    • Abbreviations: CI, confidence interval; RUTF, ready-to-use therapeutic food.

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Integration of Acute Malnutrition Treatment Into Integrated Community Case Management in Three Districts in Southern Mali: An Economic Evaluation
Bernardette Cichon, Noemí López-Ejeda, Magloire Bunkembo Mampindu, Aliou Bagayoko, Mahamadou Samake, Pilar Charle Cuellar
Global Health: Science and Practice Jun 2024, 12 (3) e2300431; DOI: 10.9745/GHSP-D-23-00431
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