This study assessed the cost-effectiveness of adding the community-based management of severe acute malnutrition (CMAM) to a community-based health and nutrition programme delivered by community health workers (CHWs) in southern Bangladesh. The cost-effectiveness of this model of treatment for severe acute malnutrition (SAM) was compared with the cost-effectiveness of the 'standard of care' for SAM (i.e. inpatient treatment), augmented with community surveillance by CHWs to detect cases, in a neighbouring area. An activity-based cost model was used, and a societal perspective taken, to include all costs incurred in the programme by providers and participants for the management of SAM in both areas. Cost data were coupled with programme effectiveness data. The community-based strategy cost US$26 per disability-adjusted life year (DALY) averted, compared with US$1344 per DALY averted for inpatient treatment. The average cost to participant households for their child to recover from SAM in community treatment was one-sixth that of inpatient treatment. These results suggest that this model of treatment for SAM is highly cost-effective and that CHWs, given adequate supervision and training, can be employed effectively to expand access to treatment for SAM in Bangladesh.

This study assessed the quality of care provided by community health workers (CHWs) in managing cases of severe acute malnutrition (SAM) according to a treatment algorithm. A mixed methods approach was employed to provide perspectives on different aspects of quality of care, including technical competence and acceptability to caretakers. CHWs screened children at community level using a mid-upper arm circumference measurement, and treated cases without medical complications. Fifty-five case management observations were conducted using a quality of care checklist, with 89.1% (95% confidence interval: 77.8-95.9%) of CHWs achieving 90% error-free case management or higher. Caretakers perceived CHWs' services as acceptable and valuable, with doorstep delivery of services promoting early presentation in this remote area of Bangladesh. Integration of the treatment of SAM into community-based health and nutrition programs appears to be feasible and effective. In this setting, well-trained and supervised CHWs were able to effectively manage cases of SAM. These findings suggest the feasibility of further decentralization of treatment from current delivery models for community-based management of acute malnutrition.

Objective: To understand and compare the primary barriers households face when accessing treatment for cases of childhood severe acute malnutrition (SAM) in different cultural settings with different types of implementing agencies. Design: The study presents a comparative qualitative analysis of two SAM treatment services, selected to include: (i) one programme implemented by a nongovernmental organization and one by a Ministry of Health; and (ii) programmes considered to be successful, defined as either coverage level achieved or extent of integration within government infrastructure. Results from individual interviews and group discussions were recorded and analysed for themes in barriers to access. Setting: Sindh Province, Pakistan; Tigray Region, Ethiopia. Subjects: Beneficiary communities and staff of SAM treatment services in two countries. Results: Common barriers were related to distance, high opportunity costs, knowledge of services, knowledge of malnutrition and child's refusal of ready-touse foods. While community sensitization mechanisms were generally strong in these well-performing programmes, in remote areas with less programme exposure, beneficiaries experienced barriers to remaining in the programme until their children recovered. Conclusions: Households experienced a number of barriers when accessing SAM treatment services. Integration of SAM treatment with other community-based interventions, as the UN recommends, can improve access to life-saving services. Efforts to integrate SAM treatment into national health systems should not neglect the community component of health systems and dedicated funding for the community component is needed to ensure access. Further research and policy efforts should investigate feasible mechanisms to effectively reduce barriers to access and ensure equitable service delivery.