Cichon Bernardette, López-Ejeda Noemí, Samake Salimata, Aton Cornelia, Dougnon Abdias Ogobara, Samake Mahamadou N'tji, Bagayoko Aliou, Bunkembo Magloire, Rutishauser-Perera Alexandra, Charle-Cuellar Pilar
Operations Department, Action Against Hunger UK, 6 Mitre Passage, London, SE10 0ER, UK.
EPINUT Research Group (ref. 920325), Unit of Physical Anthropology, Department of Biodiversity, Ecology and Evolution, Complutense University of Madrid, Madrid, Spain.
BMC Public Health. 2025 Jan 20;25(1):233. doi: 10.1186/s12889-025-21411-5.
Acute malnutrition treatment coverage remains low worldwide, causing significant morbidity and mortality. Decentralisation of treatment to Community Health Worker (CHW) sites has shown to be an effective strategy to improve access and increase coverage, but evidence on the cost and cost-effectiveness of this approach as well the use of simplified treatment protocols in conflict settings is lacking. The objective of this study was to determine cost per child treated as well as the cost-effectiveness of the hybrid model of treatment delivery (where treatment is provided at both health facilities and CHW sites) using either a standard protocol (Intervention 1) or simplified protocol (Intervention 2) compared to standard treatment at health facilities only (Control) in the conflict affected region of Gao in Northern Mali.
This economic evaluation was part of a three-arm cluster randomized controlled trial which enrolled 2038 children with moderate and severe acute malnutrition. Outcomes assessed were cost per child treated as well as average and incremental cost-effectiveness ratios for cost per child cured and disability adjusted life year (DALY) averted. A within study trial horizon, from March 2020 to July 2021, was used. Cost data were collected from accountancy records and through key informant interviews using a societal perspective. Treatment admission and outcome data were obtained from the main trial.
In the base case scenario the cost per child treated was 272 US$, 179 US$ and 210US$ in the Control, Intervention 1 and 2 groups, respectively. Cost per child cured was 356 US$ in the Control, 219 US$ in the Intervention 1 and 226 US$ Intervention 2 groups. Ready-to-use therapeutic foods (RUTF) costs among SAM children treated with a simplified protocol were 5.7 US$ less per child. The average cost per DALY averted was 173.1 US$ in the Control compared to 60.3 US$ in the Intervention 1 and 53 US$ in the Intervention 2.
This study shows that involving CHWs in acute malnutrition treatment reduces the cost per child treated and is a cost-effective strategy, due to lower treatment costs and greater coverage in the decentralised model. Switching to a simplified protocol in a conflict setting can lead to cost savings particularly in terms of RUTF, and should be considered where weight-based admission, monitoring or dosage is not possible or RUTF stocks are running low.
The study protocol was registered under reference ISRCTN-60,973,756 on the 15th of October 2020.
全球急性营养不良治疗覆盖率仍然很低，导致了大量的发病和死亡情况。将治疗工作下放到社区卫生工作者（CHW）站点已被证明是一种有效的策略，可提高可及性并扩大覆盖率，但缺乏关于这种方法的成本和成本效益以及在冲突环境中使用简化治疗方案的证据。本研究的目的是确定在马里北部加奥受冲突影响地区，与仅在医疗机构进行标准治疗（对照）相比，采用标准方案（干预1）或简化方案（干预2）的混合治疗模式（在医疗机构和CHW站点均提供治疗）治疗每名儿童的成本以及成本效益。
这项经济评估是一项三臂整群随机对照试验的一部分，该试验纳入了2038名中度和重度急性营养不良儿童。评估的结果包括每名接受治疗儿童的成本以及每名治愈儿童和避免的伤残调整生命年（DALY）的平均成本效益比和增量成本效益比。采用了2020年3月至2021年7月的研究内试验期限。成本数据从会计记录中收集，并通过关键信息提供者访谈，采用社会视角。治疗入院和结果数据从主要试验中获得。
在基础病例情景中，对照组、干预1组和干预2组中每名接受治疗儿童的成本分别为272美元、179美元和210美元。对照组中每名治愈儿童的成本为356美元，干预1组为219美元，干预2组为226美元。采用简化方案治疗的重度急性营养不良儿童中，即食治疗性食品（RUTF）的成本每名儿童减少5.7美元。对照组中每避免一个DALY（伤残调整生命年）的平均成本为173.1美元，干预1组为60.3美元，干预2组为53美元。
本研究表明，让社区卫生工作者参与急性营养不良治疗可降低每名接受治疗儿童的成本，并且由于分散模式下治疗成本更低且覆盖率更高，这是一种具有成本效益的策略。在冲突环境中改用简化方案可节省成本，特别是在RUTF方面，并且在无法进行基于体重的入院、监测或剂量计算或RUTF库存不足的情况下应予以考虑。
该研究方案于2020年10月15日在ISRCTN - 60,973,756的编号下注册。
