Can community health workers manage uncomplicated severe acute malnutrition? A review of operational experiences in delivering severe acute malnutrition treatment through community health platforms

Abstract

Community health workers (CHWs) play an important role in the detection and referral of children with severe acute malnutrition (SAM) in many countries. However, distance to health facilities remains a significant obstacle for caregivers to attend treatment services, resulting in SAM treatment coverage rates below 40% in most areas of intervention. The inclusion of SAM treatment into the current curative tasks of CHWs has been proposed as an approach to increase coverage. A literature review of operational experiences was conducted to identify opportunities and challenges associated with this model. A total of 18 studies providing evidence on coverage, clinical outcomes, quality of care, and/or cost‐effectiveness were identified. The studies demonstrate that CHWs can identify and treat uncomplicated cases of SAM, achieving cure rates above the minimum standards and reducing default rates to less than 8%. Although the evidence is limited, these findings suggest that early detection and treatment in the community can increase coverage of SAM in a cost‐effective manner. Adequate training and close supervision were found to be essential to ensure high‐quality performance of CHWs. Motivation through financial compensation and other incentives, which improve their social recognition, was also found to be an important factor contributing to high‐quality performance. Another common challenge affecting performance is insufficient stock of key commodities (i.e., ready‐to‐use therapeutic food). The review of the evidence ultimately demonstrates that the successful delivery of SAM treatment via CHWs will require adaptations in nutrition and health policy and practice.

Bringing severe acute malnutrition treatment close to households through community health workers can lead to early admissions and improved discharge outcomes

“…The results of this study show that increased anthropometric measurements at admission are directly associated with an increased probability of being cured after treatment. The combination of early treatment and close follow-up due to the proximity of CHWs performing integrated management of childhood diseases could be the reason for the high effectiveness of iCCM+ interventions compared to the treatment provided at health centers [9]. Furthermore, the recovery rate achieved by CHWs in this study (95.5%) was the highest of all the iCCM+ experiences published to date, which range from 60.0% in India to 93.8% in Angola [8,43].…”

“…Since 2010, efforts have been made to add SAM treatment to the curative tasks that CHWs can provide close to families, referred to as the iCCM+ approach. A review of the operational experiences of this approach has recently been published [9] and shows that programs implementing this new community approach can achieve better outcomes in terms of recovery and defaulter rates than standard CMAM programs performed at HFs far away from the affected villages. This review also found that the iCCM+ model could potentially double the coverage of SAM treatment services, achieving over 80% treatment coverage in a cost-effective manner, reducing the time and money that the families would expend to treat their children at the health centers, which are usually located far away from their households [10,11].…”

“…The first general review of SAM management published by Collins et al in 2006 [4] stated that the severity and prognosis of SAM and the determinants of successful treatment are primarily dependent on the time of presentation. The increase in coverage achieved by the CHW-delivered approach was hypothesized to bring about improvements in early presentation or admissions when children have relatively less severe forms of the condition and few medical complications [9].…”

Bottlenecks and met needs for the treatment of severe acute malnutrition in pastoralists: Doolo zone of Somali region, Ethiopia.

“…This stock out of key commodities (i.e. RUTF) is a key challenge affecting performance [18,19] and contributes to poor compliance which in turn have a negative impact on effectiveness of the nutrition program [20]. There is often enough RUTF at country/regional level but the situation in the field can be very different; related to challenges with logistics/distribution of supplies [15].…”

The recovery rate from severe acute malnutrition among under-five years of children remains low in sub-Saharan Africa. A systematic review and meta-analysis of observational studies

“…SAM is continuing to be the major public health problem and an essential contributor to morbidity and mortality in under-five children [4,5]. In interventions taken by community health workers, a recovery rate of around 90% was estimated in a systematic review and meta-analysis done in middle-and low-income counties [6]. A study done in Asian and African countries reported that recovery rates from SAM ranges from 25% to 95% at inpatient management and 50% to 93% at outpatient management program [7][8][9][10][11][12].…”