Community case management of acute malnutrition by community health workers in southern Bangladesh: Examining quality of care and cost-effectiveness.
Abstract: Severe acute
malnutrition (SAM), evidenced by severe wasting and/or edema, reflects recent illness
and nutrient deficits and is the cause of one to two million preventable child deaths
each year. Recent advances in the treatment of SAM have enabled severely wasted children
to recover at home, rather than in crowded therapeutic feeding centers or
under-resourced, over-burdened health ... read morefacilities. Due to its promising performance in
promoting quick recovery and decreasing mortality rates in emergency situations, the
community-based management of acute malnutrition (CMAM) has received much attention in
international nutrition policy. In 2007, the United Nations promoted its global
expansion into areas with a high burden of SAM and its integration with other
community-based health and nutrition activities. However, there is limited evidence
regarding the impact of adding this delivery mechanism to existing community-based
nutrition infrastructure. This dissertation addressed key debates and operational
concerns around integrating CMAM into existing community-based health and nutrition
programs by researching aspects of a pilot intervention implemented by Save the Children
USA (SCUS) in southern Bangladesh. As part of a child survival program using a cadre of
community health workers (CHWs) to deliver preventive and curative care to children in
areas underserved by the formal health system, the community case management (CCM) of
SAM was introduced to the CHW workload using an adapted CMAM classification algorithm.
Study results were compared between the intervention upazila implementing the CCM of SAM
and a comparison upazila implementing the facility-based treatment of SAM according to
WHO protocol. This dissertation was comprised of three analyses. The first analysis
evaluated the capacity of CHWs to effectively identify and treat children suffering from
SAM without complications. This analysis found that 89% of assessed CHWs achieved 90%
error-free case management or higher. The second analysis examined the association
between the quality of care provided by CHWs and their number of work responsibilities
by comparing the performance of two groups of CHWs with different workloads: one group
providing preventive care in addition to implementing CCM of pneumonia and diarrhea, and
another group additionally treating SAM. This analysis found that the CHWs who were
managing cases of SAM worked significantly more hours than those who were not, but
maintained quality of care on both curative and preventive work tasks. The third
analysis investigated the cost-effectiveness of community-based treatment of SAM
compared to facility-based treatment by estimating costs incurred by both care providers
and participating households in the two study upazilas, and coupling this analysis with
effectiveness evidence generated in another arm of the study. Results from this research
revealed that community-based treatment of SAM was more cost-effective than
facility-based treatment, and resulted in considerably lower costs for participant
households. This research provides a timely investigation into the opportunities and
challenges of integrating CMAM into existing community-based health and nutrition
infrastructure. Findings suggest that CHWs are capable of managing cases of SAM at
community level, and that this service delivery mechanism is cost-effective. Results
from this dissertation support the use of CHWs in the community-based management of SAM
in Bangladesh, in order to expand access to treatment for children in areas underserved
by the formal health system.
Thesis (Ph.D.)--Tufts University, 2011.
Submitted to the Dept. of Food Policy & Applied Nutrition.
Advisor: Kate Sadler.
Committee: Harold Alderman, and Jennifer Coates.
Keywords: Nutrition, and Public health.read less