Treatment of moderate acute malnutrition through community health volunteers is a cost-effective intervention: Evidence from a resource-limited setting.

Treatment outcomes for acute malnutrition can be improved by integrating treatment into community case management (iCCM). However, little is known about the cost-effectiveness of this integrated nutrition intervention. The present study investigates the cost-effectiveness of treating moderate acute malnutrition (MAM) through community health volunteer (CHV) and integrating it with routine iCCM. A cost-effectiveness model compared the costs and effects of CHV sites plus health facility-based treatment (intervention) with the routine health facility-based treatment strategy alone (control). The costing assessments combined both provider and patient costs. The cost per DALY averted was the primary metric for the comparison, on which sensitivity analysis was performed. Additionally, the integrated strategy's relative value for money was evaluated using the most recent country-specific gross domestic product threshold metrics. The intervention dominated the health facility-based strategy alone on all computed cost-effectiveness outcomes. MAM treatment by CHVs plus health facilities was estimated to yield a cost per death and DALY averted of US$ 8743 and US$ 397, respectively, as opposed to US$ 13,846 and US$ 637 in the control group. The findings also showed that the intervention group spent less per child treated and recovered than the control group: US$ 214 versus US$ 270 and US$ 306 versus US$ 485, respectively. Compared with facility-based treatment, treating MAM by CHVs and health facilities was a cost-effective intervention. Additional gains could be achieved if more children with MAM are enrolled and treated.

Perceptions towards management of acute malnutrition by community health volunteers in northern Kenya.

Child undernutrition is a persistent challenge in arid and semi-arid areas due to low and erratic rainfall, recurrent droughts and food insecurity. In these settings, caregivers face several challenges in accessing health services for sick and/or malnourished children, including long distances to health facilities, harsh terrain, and lack of money to pay for transportation costs to the health facilities, leading to low service coverage and sub-optimal treatment outcomes. To address these challenges and optimize treatment outcomes, the World Health Organization recommends utilizing community health volunteers (CHVs) to manage acute malnutrition in the community. This study explored the perceptions of community members regarding acute malnutrition treatment by CHVs in Turkana and Isiolo counties in Kenya. The study utilized a cross-sectional study design and included a purposive sample of caregivers of children, CHVs, officers who trained and supervised CHVs and community leaders in the intervention area. Focus group discussions and key informant interviews were used to explore perceptions towards the management of acute malnutrition by CHVs. Generally, caregivers and CHVs perceived the intervention to be beneficial as it readily addressed acute malnutrition treatment needs in the community. The intervention was perceived to be acceptable, effective, and easily accessible. The community health structure provided a platform for commodity supply and management and CHV support supervision. This was a major enabler in implementing the intervention. The intervention faced operational and systemic challenges that should be considered before scale-up.

The impacts of task shifting on the management and treatment of malnourished children in Northern Kenya: a cluster-randomized controlled trial.

Treating children with acute malnutrition can be challenging, particularly regarding access to healthcare facilities during treatment. Task shifting, a strategy of transferring specific tasks to health workers with shorter training and fewer qualifications, is being considered as an effective approach to enhancing health outcomes in primary healthcare. This study aimed to assess the effectiveness of integrating the treatment of acute malnutrition by community health volunteers into integrated community case management in two sub-counties in northern Kenya (Loima and Isiolo). We conducted a two-arm non-inferiority cluster-randomized controlled trial across 20 community health units. Participants were children aged 6-59 months with uncomplicated acute malnutrition. In the intervention group, community health volunteers used simplified tools and protocols to identify and treat eligible children at home and provided the usual integrated community case management package. In the control group, community health volunteers provided the usual integrated community case management package only (screening and referral of the malnourished children to the health facilities). The primary outcome was recovery (MUAC ≥12.5 cm for 2 consecutive weeks). Results show that children in the intervention group were more likely to recover than those in the control group [73 vs 50; risk difference (RD) = 26% (95% CI 12 to 40) and risk ratio (RR) = 2 (95% CI 1.2 to 1.9)]. The probability of defaulting was lower in the intervention group than in the control group: RD = -21% (95% CI -31 to -10) and RR = 0.3 (95% CI 0.2 to 0.5). The intervention reduced the length of stay by about 13 days, although this was not statistically significant and varied substantially by sub-county. Integrating the treatment of acute malnutrition by community health volunteers into the integrated community case management programme led to better malnutrition treatment outcomes. There is a need to integrate acute malnutrition treatment into integrated community case management and review policies to allow community health volunteers to treat uncomplicated acute malnutrition.

Incentive preferences for community health volunteers in Kenya: findings from a discrete choice experiment.

BACKGROUND: Community health volunteers (CHVs) play crucial roles in enabling access to healthcare at the community levels. Although CHVs are considered volunteers, programmes provide financial and non-financial incentives. However, there is limited evidence on which bundle of financial and non-financial incentives are most effective for their improved performance. METHODS: We used a discrete choice experiment (DCE) to understand incentive preferences of CHVs with the aim to improve their motivation, performance and retention. Relevant incentive attributes were identified through qualitative interviews with CHVs and with their supervisors. We then deployed a nominal group technique to generate and rank preferred attributes among CHVs. We developed a DCE based on the five attributes and administered it to 211 CHVs in Kilifi and Bungoma counties in Kenya. We used mixed multinomial logit models to estimate the utility of each incentive attribute and calculated the trade-offs the CHWs were willing to make for a change in stipend. RESULTS: Transport was considered the incentive attribute with most relative importance followed by tools of trade then monthly stipend. CHVs preferred job incentives that offered higher monthly stipends even though it was not the most important. They had negative preference for job incentives that provided award mechanisms for the best performing CHVs as compared with jobs that provided recognition at the community level and preferred job incentives that provided more tools of trade compared with those that provided limited tools. CONCLUSION: A bundled incentive of both financial and non-financial packages is necessary to provide a conducive working environment for CHVs. The menu of options relevant for CHVs in Kenya include transport, tools of trade and monthly stipend. Policy decisions should be contextualised to include these attributes to facilitate CHW satisfaction and performance.

"It's like these CHCs don't exist, are they featured anywhere?": Social network analysis of community health committees in a rural and urban setting in Kenya.

BACKGROUND: In Kenya, Community Health Committees (CHC) were established to enhance community participation in health services. Their role is to provide leadership, oversight in delivery of community health services, promote social accountability and mobilize resources for community health. CHCs form social networks with other actors, with whom they exchange health information for decision-making and accountability. This case study aimed to explore the structure of a rural and an urban CHC network and to analyze how health-related information flowed in these networks. Understanding the pathways of information in community settings may provide recommendations for strategies to improve the role and functioning of CHCs. METHODS: In 2017, we conducted 4 focus group discussions with 27 community discussants and 10 semi-structured interviews with health professionals in a rural area and an urban slum. Using social network analysis, we determined the structure of their social networks and how health related information flowed in these networks. RESULTS: Both CHCs were composed of respected persons nominated by their communities. Each social network had 12 actors that represented both community and government institutions. CHCs were not central actors in the exchange of health-related information. Health workers, community health volunteers and local Chiefs in the urban slum often passed information between the different groups of actors, while CHCs hardly did this. Therefore, CHCs had little control over the flow of health-related information. Although CHC members were respected persons who served in multiple roles within their communities, this did not enhance their centrality. It emerged that CHCs were often left out in the flow of health-related information and decision-making, which led to demotivation. Community health volunteers were more involved by other actors such as health managers and non-governmental organizations as a conduit for health-related information. CONCLUSION: Social network analysis demonstrated how CHCs played a peripheral role in the flow of health-related information. Their perception of being left out of the information flow led to demotivation, which hampered their ability to facilitate community participation in community health services; hence challenging effective participation through CHCs.