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

Abstract

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.

Trial registration: NCT03043352 , ClinicalTrials.gov. Retrospectively registered.

Keywords: Community-based Management of Acute Malnutrition (CMAM); Cost-effectiveness; Lady Health Workers (LHWs); Pakistan; Severe Acute Malnutrition (SAM).

Conflict of interest statement

Ethics approval and consent to participate

For the overarching intervention carried out by Action Against Hunger and Aga Khan University, ethical approval was obtained from the National Bioethics Committee and the Aga Khan University Ethics Review Committee in Pakistan. This ethical approval also applied to the cost-effectiveness component of the study. For the overarching study written consent to participate was obtained from all parents/guardians of children prior to entering the study. For the cost-effectiveness component, for interviews with staff, community leaders and caretakers, the aim of the study was explained by the interviewer and oral consent obtained from all those that participated, before beginning the interview. Obtaining oral consent for the cost-effectiveness component was approved by the ethics committee. Although written consent would have been preferred, for this study verbal consent was considered most appropriate due to the unease that can be caused for illiterate parents/guardians signing a document they do not understand.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

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Figures

Fig. 1

The proportion of costs per activity for each arm

Fig. 2

Acceptability curve for LHW delivered care in the intervention arm

Fig. 3

Acceptability curve for outpatient facility-based care in the control arm

Fig. 4

Acceptability curves for outpatient facility-based care relative to LHW-delivered care