Low-dose RUTF protocol and improved service delivery lead to good programme outcomes in the treatment of uncomplicated SAM: a programme report from Myanmar.

The treatment of uncomplicated severe acute malnutrition (SAM) requires substantial amounts of ready-to-use therapeutic food (RUTF). In 2009, Action Contre la Faim anticipated a shortfall of RUTF for their nutrition programme in Myanmar. A low-dose RUTF protocol to treat children with uncomplicated SAM was adopted. In this protocol, RUTF was dosed according to beneficiary's body weight, until the child reached a Weight-for-Height z-score of ≥-3 and mid-upper arm circumference ≥110 mm. From this point, the child received a fixed quantity of RUTF per day, independent of body weight until discharge. Specific measures were implemented as part of this low-dose RUTF protocol in order to improve service quality and beneficiary support. We analysed individual records of 3083 children treated from July 2009 to January 2010. Up to 90.2% of children recovered, 2.0% defaulted and 0.9% were classified as non-responders. No deaths were recorded. Among children who recovered, median [IQR] length of stay and weight gain were 42 days [28; 56] and 4.0 g kg(-1) day(-1) [3.0; 5.7], respectively. Multivariable logistic regression showed that children older than 48 months had higher odds of non-response to treatment than younger children (adjusted odds ratio: 3.51, 95% CI: 1.67-7.42). Our results indicate that a low-dose RUTF protocol, combined with specific measures to ensure good service quality and beneficiary support, was successful in treating uncomplicated SAM in this setting. This programmatic experience should be validated by randomised studies aiming to test, quantify and attribute the effect of the protocol adaptation and programme improvements presented here.

Cost-effectiveness of community vegetable gardens for people living with HIV in Zimbabwe.

BACKGROUND: There is little evidence to date of the potential impact of vegetable gardens on people living with HIV (PLHIV), who often suffer from social and economic losses due to the disease. From 2008 through 2011, Action Contre la Faim France (ACF) implemented a project in Chipinge District, eastern Zimbabwe, providing low-input vegetable gardens (LIGs) to households of PLHIV. Program partners included Médecins du Monde, which provided medical support, and Zimbabwe's Agricultural Extension Service, which supported vegetable cultivation. A survey conducted at the end of the program found LIG participants to have higher Food Consumption Scores (FCS) and Household Dietary Diversity Scores (HDDS) relative to comparator households of PLHIV receiving other support programs. This study assessed the incremental cost-effectiveness of LIGs to improve FCS and HDDS of PLHIV compared to other support programs. METHODS: This analysis used an activity-based cost model, and combined ACF accounting data with estimates of partner and beneficiary costs derived using an ingredients approach to build an estimate of total program resource use. A societal perspective was adopted to encompass costs to beneficiary households, including their opportunity costs and an estimate of their income earned from vegetable sales. Qualitative methods were used to assess program benefits to beneficiary households. Effectiveness data was taken from a previously-conducted survey. RESULTS: Providing LIGs to PLHIV cost an additional 8,299 EUR per household with adequate FCS and 12,456 EUR per household with HDDS in the upper tertile, relative to comparator households of PLHIV receiving other support programs. Beneficiaries cited multiple tangible and intangible benefits from LIGs, and over 80% of gardens observed were still functioning more than one year after the program had finished. CONCLUSIONS: Cost outcomes were 20-30 times Zimbabwe's per capita GDP, and unlikely to be affordable within government services. This analysis concludes that LIGs are not cost-effective or affordable relative to other interventions for improving health and nutrition status of PLHIV. Nonetheless, given the myriad benefits acquired by participant households, such programs hold important potential to improve quality of life and reduce stigma against PLHIV.

Perspectives for integration into the local health system of community-based management of acute malnutrition in children under 5 years: a qualitative study in Bangladesh.

BACKGROUND: Acute malnutrition is a major cause of death among under-five children in low- and middle-income countries. United Nations agencies recommend the integration of community-based management of acute malnutrition (CMAM) into the local health systems for sustainability. The objective of the study was to assess the preparedness of the health system to implement CMAM targeting children under-five years in two sub-districts of Bangladesh. METHODS: The assessment was performed through direct observation of 44 health centres, individual interviews of seven policy makers, three donors, four health and nutrition implementing partners, 29 health workers, and review of secondary data. Assessment themes, derived from the WHO six Building Blocks, were nutrition governance, nutrition financing, health service delivery, human resources, equipment and supply, referral, monitoring and supervision mechanism. They were subdivided into 16 criteria. Findings were compared with CMAM operational recommendations according to WHO, Valid International and Food and Nutrition Technical Assistance guidelines. RESULTS: The government of Bangladesh has developed inpatient and outpatient CMAM guidelines, and a policy offering free-of-charge health care for under-five children. Nutrition coordination was not under full government leadership. Most of funds (74%) dedicated to CMAM were provided by donors, for short-term interventions. Of the total 44 health centres assessed, 39 (88.6%) were active, among which 4 (10.2%) delivered inpatient services, 35 (89.8%) outpatient services, and 24 (61.5%) outreach services. These were regarded as opportunities to include CMAM activities. There were 48.9% vacant positions and the health workers were not trained for management of acute malnutrition. Equipment and supplies did not meet the operational recommendations for management of acute malnutrition. CONCLUSION: Implementing CMAM through the health centres of both sub-districts would warrant progressive strengthening of the overall health system in the light of identified barriers. A short term strategy would consist of strengthening government coordination of nutrition interventions, exploring additional funding sources, equipping and supplying functional health centres, training health workers and actively involving community health workers to cope with health facility staff shortage. A mid-term strategy would consist of securing permanent funding for CMAM, rehabilitating non-functional health centres, attracting and retaining health workers in rural areas.

Protecting child health and nutrition status with ready-to-use food in addition to food assistance in urban Chad: a cost-effectiveness analysis.

BACKGROUND: Despite growing interest in use of lipid nutrient supplements for preventing child malnutrition and morbidity, there is inconclusive evidence on the effectiveness, and no evidence on the cost-effectiveness of this strategy. METHODS: A cost effectiveness analysis was conducted comparing costs and outcomes of two arms of a cluster randomized controlled trial implemented in eastern Chad during the 2010 hunger gap by Action contre la Faim France and Ghent University. This trial assessed the effect on child malnutrition and morbidity of a 5-month general distribution of staple rations, or staple rations plus a ready-to-use supplementary food (RUSF). RUSF was distributed to households with a child aged 6-36 months who was not acutely malnourished (weight-for-height > = 80% of the NCHS reference median, and absence of bilateral pitting edema), to prevent acute malnutrition in these children. While the addition of RUSF to a staple ration did not result in significant reduction in wasting rates, cost-effectiveness was assessed using successful secondary outcomes of cases of diarrhea and anemia (hemoglobin <110 g/L) averted among children receiving RUSF.Total costs of the program and incremental costs of RUSF and related management and logistics were estimated using accounting records and key informant interviews, and include costs to institutions and communities. An activity-based costing methodology was applied and incremental costs were calculated per episode of diarrhea and case of anemia averted. RESULTS: Adding RUSF to a general food distribution increased total costs by 23%, resulting in an additional cost per child of 374 EUR, and an incremental cost per episode of diarrhea averted of 1,083 EUR and per case of anemia averted of 3,627 EUR. CONCLUSIONS: Adding RUSF to a staple ration was less cost-effective than other standard intervention options for averting diarrhea and anemia. This strategy holds potential to address a broad array of health and nutrition outcomes in emergency settings where infrastructure is weak and other intervention options are infeasible in the short-term. However, further research is needed to establish the contexts in which RUSF is most effective and cost-effective in preventing acute malnutrition and morbidity among vulnerable children, compared to other options.