Simplifying Treatment for Acute Malnutrition
Authors:
· Dr. Cesaire Ouedraogo, Nutrition Research Coordinator, International Rescue Committee-Mali
· Bethany Marron, Senior Advisor on Global Uptake of Simplified Approaches, International Rescue Committee-Airbel Impact Lab
Globally, 50 million children are suffering from acute malnutrition, and 18 million of these children are living in humanitarian contexts where the International Rescue Committee (IRC) operates. There is a proven cure — a daily dose of a fortified, peanut-based paste taken over the course of several weeks — but only 20% of children receive this life-saving treatment. While this status quo is staggering, the numbers are getting worse: There is a global food insecurity crisis, particularly in the Sahel region of Africa and East Africa, where it is driven and exacerbated by climate change, armed conflict, and rising global food prices. Mali alone is facing the worst insecurity the country has seen in 10 years, with children shouldering the highest burden. To reach all malnourished children at scale, we need solutions that can better leverage the finite resources we have now, while significantly expanding the set of resources we deploy over time.
The current system to treat malnutrition is complex, costly, and chronically underfunded. The standard approach to treating malnourished children divides them into two groups — severely malnourished and moderately malnourished — and treats them with different protocols and products at different delivery points. Malnutrition is a continuum condition, and this bifurcation has led to an inefficient delivery system, limiting the scale of children that can be reached with limited resources.
The IRC has designed and tested a radically simpler, scalable treatment protocol that treats all forms of acute malnutrition at a single point of care, using simplified diagnosis and dosing. We have designed and adapted ways to deliver this care in homes and communities, addressing many of the barriers of the current system. These “simplified approaches” to treatment include:
- A simplified, combined protocol: This protocol collectively treats children on the continuum of malnourishment (whether moderately or severely) in the same program and location, instead of dividing into two programs based on severity. Our protocol uses a simple, single diagnostic criteria, instead of complex measurements. And our protocol utilizes one treatment product, instead of two different products for moderate and severe malnutrition that require different supply chains.
2. Caregiver diagnosing: This approach — called Family MUAC — equips caregivers with a tape that can measure the Middle-Upper-Arm-Circumference (MUAC) of a child, empowering families to test children for malnutrition themselves at home, instead of requiring travel to a health facility. Through this approach, caregivers can monitor their children’s nutrition status without traveling long distances and know when to respond based on simple color-coding indicators (green, yellow, and red).
3. Community health worker delivery: This approach empowers community health workers to deliver treatment in communities instead of only at health centers, which can be difficult to access in humanitarian contexts. It also includes a simple toolkit that is accessible to low-literacy community health workers.
Simplified approaches to treatment have breakthrough potential in driving coverage beyond the status quo. They collectively address inefficiencies in the current system and the barriers that families face in receiving care. In multiple pilots and a clinical trial, treating over 100,000 children, the IRC and our partners have demonstrated how these approaches are as effective and more cost-effective than the standard treatment approach.
With support from The Rockefeller Foundation, the IRC conducted three research projects to generate additional evidence on the effectiveness of the simplified, combined protocol and caregiver diagnosing.
Improving Cost-Effectiveness
Our first study was designed to better understand the socioeconomic costs and potential cost savings of the simplified protocol. The survey included interviews with nearly 1,500 caregivers, more than 200 Ministry of Health and health center staff members, over 150 households with children (aged 6–59 months) actively receiving treatment for acute malnutrition, as well as IRC staff in the Nara health district. We found the simplified protocol cost the IRC 11% less per child than the traditional protocol, reducing the financial cost per child from $81 to $72. We also found the average cost per child treated is $4.56 for caregivers — factoring in 1) the opportunity cost of their time, 2) foregone income and 3) out-of-pocket expenses for transportation. While small compared to the financial costs of treatment, this is a significant amount for households in Mali, where GDP per capita is $859. Accessing treatment for malnutrition costs families the equivalent of one full day of income on average. Results show that the opportunity cost of time spent accessing treatment accounts for a much larger proportion of beneficiary costs than any out-of-pocket expenses. This first-of-a-kind study will help inform future research and global costing tools that could be adapted to focus more on travel time.
Enhancing the Family MUAC Approach
Our second study examined the effectiveness of the MUAC approach and assessed barriers to conducting regular MUAC screenings. Based on in-depth feedback from our clients, the team tested a reminder system, integrated with existing women’s financial savings groups and a behavioral science-informed video detailing how to use the MUAC tape to diagnose children. This pilot in the Nara district of Mali had strong results: before being trained in a savings group, 36.8% of women reported feeling “Confident in my ability to use [MUAC tape] independently,” whereas after the intervention, 69% of women reported feeling confident in using the tape. On the strength of this initial prototyping, we’ll be testing these interventions at greater scale in our pilots in Mali and observing the impact of diagnosing children early and at home.
Monitoring Relapses After Treatment
Finally, the IRC implemented an observational study to understand the frequency of and reasons for relapses in acute malnutrition in children after being treated with the simplified, combined protocol. The study was implemented in ten randomly selected health areas in the Nara district. At enrollment, the program team collected baseline data on the children’s treatment history, admission criteria to the treatment program and anthropometric measures. We then monitored the nutritional progress of the children in the community through fortnightly home visits thereafter. Relapse rates are similar to the standard approach: 26% of children relapsed by 6 months, standard relapse rates range from 10–70%.
From Evidence to Action
The IRC, with support from The Rockefeller Foundation, is addressing malnutrition through holistic approaches — aiming to reduce the drivers of malnutrition with programs that reduce food insecurity, while also delivering efficient, streamlined treatment, care and learning for local communities. Our research has produced several important learnings that will guide our malnutrition work globally moving forward:
· Improving access to malnutrition treatment by changing when and where it is delivered may not only reduce costs for caregivers but also encourage adherence and participation.
· Developing new treatment assessments and procedures requires working alongside caregivers themselves to secure buy-in and participation.
· Implementing the simplified protocol is less expensive per child compared to the standard protocol, in addition to being cheaper.
This evidence has already helped to drive immediate and long-term efforts to refine program guidelines by Mali’s Ministry of Health — as well as in other countries. Our research roadmap is now focused on demonstrating the feasibility of switching from a standard to a simplified protocol — a key question for policymakers planning for scale — as well as testing new ways to further simplify and decentralize treatment to continuously improve scalability and cost-effectiveness.
The scope of the global food crisis is devastating, but as demonstrated by this evidence, there is a solution. Political will and financial resources to address acute malnutrition have increased but without coordinated action, this momentum will not be sustained. Twenty years ago, the United States changed the trajectory of the HIV/AIDS epidemic with the President’s Emergency Plan for AIDS Relief (PEPFAR), which provided executive leadership and congressional legislation backed by sustained funding. PEPFAR has since saved 25 million lives and increased treatment coverage by 71%. Today, the US can once again save millions of lives and demonstrate global leadership by tackling acute malnutrition and ensuring that every child in need can access lifesaving treatment — a PEPFAR-like investment is needed.
To learn more about the IRC’s Airbel Impact Lab malnutrition efforts, please visit us here.
