The cost of implementing the C-MAMI tool to treat nutritionally vulnerable infants in Bangladesh

Location: Bangladesh

What we know: The C-MAMI tool was developed to guide the community-based management of uncomplicated cases of severe acute malnutrition (SAM) in infants under six months, as per the WHO 2013 guideline.

What this article adds: Save the Children carried out a calculation of the cost-efficiency of a protocol based on the C-MAMI tool in Bangladesh, compared to the standard, inpatient-based protocol. Costs were identified for both protocols, including inputs, health system costs, efficiency data (such as number of admissions/month), scale-up costs and costs to caregivers. The cost of C-MAMI to the healthcare provider (per clinic/month) was higher than the standard (USD1,007 vs USD466); however, it was found to be more cost efficient per infant treated (USD289 vs USD685). If fully integrated into the national health system, the cost of C-MAMI would reduce to an estimated USD536 per clinic/month and USD154 per infant treated. The cost for caregivers was found to be lower for C-MAMI compared to the standard (USD53 vs USD74 per caregiver/six months). Overall, the societal costs (healthcare provider + caregiver) were significantly lower in C-MAMI compared to standard (USD342 vs USD759), although both were judged to be cost-efficient.

Background

Current treatment guidelines for severe acute malnutrition (SAM) in infants under six months are based on very weak evidence and focused on inpatient care; WHO guidance recommends community-based management for uncomplicated cases (WHO, 2013). To help a fill a gap in programming guidance, the C-MAMI tool was developed to help catalyse community-based case management. Save the Children (SC) recently tested a protocol based on the C-MAMI tool for the treatment of “nutritional at-risk” infants in Barisal district, Bangladesh, estimating its effectiveness compared to the current standard inpatient protocol (results pending).

A secondary aim of the research was to calculate the cost and cost-efficiency of this new treatment method. This economic sub-study aimed to highlight major considerations in cost differences between standard inpatient protocol and the C-MAMI model from a societal prospective, considering costs to both the healthcare provider and caregivers.

Method

The C-MAMI model (intervention) and standard inpatient protocol (control) were implemented in 24 community clinics in Barisal district within the Ministry of Health (MoH) system, with support from SC staff. All infants receiving C-MAMI support were requested to attend weekly counselling appointments at the clinic and received home visits as necessary.

To estimate costs, programme inputs (“ingredients”) were identified and quantified and costs were assigned against these, informed by the study protocol, accounting data and expert observation. A simple decision tree was built to map the various treatment pathways in each study arm and guide the mapping of major resources for inclusion in cost calculations (Figure 1). Due to the integrated nature of the programmes, other health system costs were estimated through key informant interviews and published WHO-CHOICE values¹. Efficiency data, such as the number of admissions per month, were calculated from interim values at the time of costing data collection. 

Using information from the FANTA II Profiles results for Bangladesh, we also present the estimated cost for scaling up the implementation of the tool within an integrated health system, and this cost in relation to published government spending (Howlader, 2012).

Costs to caregivers, including direct costs and indirect time costs, were estimated through informal, anonymous interviews with a range of caregivers; programme defaulters are likely underrepresented.

Figure 1: Decision trees for the control treatment model and the intervention treatment model

Results

There are several key differences between the C-MAMI model and the standard protocol which need to be considered from a cost perspective. The C-MAMI model has a wider range of admission criteria, including maternal health indicators, and the treatment consists largely of weekly counselling and specialised lactation advice, compared to inpatient-feeding based on infant anthropometry only in the standard protocol.

Cost to healthcare providers

For the healthcare provider, the cost of the C-MAMI intervention was higher than the standard intervention (USD1007 vs USD466 per clinic per month), due to additional staff, staff training, tablet computers (for the MAMI app which accompanied the protocol), and capital costs of creating breastfeeding corners (Table 1). However, when this cost is applied to the number of children treated by each clinic each month (3.5 vs 0.7), the C-MAMI intervention becomes more cost-efficient than the standard model (USD289 vs USD685 per child treated).