Cost effectiveness of a community based prevention and treatment of acute malnutrition programme in Mumbai slums, India

Children in slums are at high risk of acute malnutrition and death. Cost-effectiveness of community-based management of severe acute malnutrition programmes has been demonstrated previously, but there is limited evidence in the context of urban slums where programme cost structure is likely to vary tremendously. This study assessed the cost-utility of adding a community based prevention and treatment for acute malnutrition intervention to Government of India Integrated Child Development Services (ICDS) standard care for children in Mumbai slums. The intervention is delivered by community health workers in collaboration with ICDS Anganwadi community health workers. The analysis used a decision tree model to compare the costs and effects of the two options: standard ICDS services with the intervention and prevention versus standard ICDS services alone. The model used outcome and cost data from the Society for Nutrition, Education & Health Action’s Child Health and Nutrition programme in Mumbai slums, which delivered services to 12,362 children over one year from 2013 to 2014. An activity-based cost model was used, with calculated costs based on programme financial records and key informant interviews. Cost data were coupled with programme effectiveness data to estimate disability adjusted life years (DALYs) averted. The community based prevention and treatment programme averted 15,016 DALYs (95% Uncertainty Interval [UI]: 12,246–17,843) at an estimated cost of $23 per DALY averted (95%UI:19–28) and was thus highly cost-effective. This study shows that ICDS Anganwadi community health workers can work efficiently with community health workers to increase the prevention and treatment coverage in slums in India and can lead to policy recommendations at the state, and potentially the national level, to promote such programmes in Indian slums as a cost-effective approach to tackling moderate and severe acute malnutrition. SNEHA is a secular, Mumbai-based non-profit organization addressing four major areas of public health in urban slums: child health and nutrition, maternal and newborn health, sexual and reproductive health, and prevention of violence against women and children. The Aahar acute malnutrition programme is located in Dharavi, one of the largest urban slums in Asia with an estimated population of 700,000 to over 1 million [13]. Under-five mortality rates in slum areas are estimated at 27 per 1000 live births [14]. The prevalence of severe acute malnutrition (measured by Weight-For-Height <-3SD) is high: 4% of infants under two years old (0–24 months old, 95% CI: 2.7–6.0) suffer SAM [14, 15]. In a subsequent survey, 20% of infants under two years old were wasted (weight-for-height/length z <-2, 95% CI: 17.7, 22.2), 4.6% severely wasted (weight-for-height/length z <-3, 95%CI: 3.5, 5.6), and 18.8% were stunted (height-for-age z score <-2, 95%CI: 16.7, 20.9) [12] (MUAC and oedema were not used). The CEA focused on one year during which the intervention was fully operational in five sectors of Dharavi. The project aimed to prevent and treat acute malnutrition in infants aged 0–3 years (more information on the project has been published in [2, 3]). Specifically, the Aahar acute malnutrition programme team identified six key result areas to reach these objectives: (1) prevent and treat acute malnutrition in infants under 3 years old; (2) increase in optimal breastfeeding practices among lactating mothers; (3) improve complementary feeding practices in infants 6 months to 3 years of age; (4) reduce infections and increase referrals and treatment of illnesses; (5) completion of immunizations; and (6) improve coverage of services provided by the ICDS. The programme monitoring system, using real time data collected via the mHealth platform, was based on these objectives and monthly reports against indicators were generated to track progress, identify gaps, and build adaptive strategies for optimal program performance. The indicators included were: 1) the total cumulative number of infants under three and pregnant women screened into the program, 2) the total number of pregnant women, SAM, MAM and Normal infants currently in the program, 3) the total number of infants who had left the program and reasons for leaving, 4) the population coverage of growth monitoring, 4) the number of home-based counseling visits to SAM infants, MAM infants, infants under 6 months, and pregnant women, 5) the number of SAM infants in OTP, 6) the number of SAM infants regularly consuming MNT. The mHealth platform used CommCare, a mobile application developed by Dimagi, USA [16]. The Aahar acute malnutrition programme was implemented in partnership with ICDS where 30 Anganwadis (one local ICDS child care centre per population of 1000) covered a total population of 30,000. ICDS standard activities in the communities included growth monitoring (to track weight-for-age), food distribution (take-home-rations), breastfeeding advice, complementary food advice and referral for immunization. In collaboration with the Anganwadis and government health workers, the programme was delivered by Aahar acute malnutrition programme community health workers who facilitated participation of caregivers and their infants younger than 3 years. Their responsibilities included facilitating growth monitoring of weight-for-height with ICDS, counselling, referrals, and support access to treatment. They received intensive training and were monitored and supervised closely by field supervisors based on real time performance tracking. The programme had two components: treatment and prevention of acute malnutrition. The admission criteria for entering the SAM and MAM treatment protocol were: 1) anthropometric measurement: to be screened as MAM or SAM based on Weight-For-Height (WFH) (respectively <-2 SD and <-3SD), 2) age: be less than 3 years old and 3) location: living in the intervention area. The treatment component included provision of locally made Ready to Use Therapeutic Food—called Medical Nutrition Therapy (MNT) in this setting for SAM infants only, referrals to government health facilities for medical screening and immunization for MAM and SAM infants, growth monitoring and home-based counselling for MAM and SAM infants, and monitoring in daycare centres for MAM and SAM infants. ‘MNT cup’ is a locally produced Ready to Use Therapeutic Food (RUTF) made of peanut, soybean oil, skimmed milk powder, sugar, micronutrient premix and emulsifier produced by Nutrition Research and Rehabilitation Centre (NRRC). Aahar’s MNT provision characteristics: 8 weeks per child, once to twice daily, only for SAM children over 6 months who had medical screening and appetite test. The micronutrient content follows WHO recommendations and uses a micronutrient premix18. The nutritional composition per cup is as follow: energy 540 (kcal), proteins (g) 16, lipids (g) 34. The nutritional composition per 100g equivalent Plumpy’Nut (RUTF formule F100): energy (kcal) 543, proteins (g) 14, lipids (g) 36. Daycare centres were physical places in the community, staffed by a teacher and helper to promote nutritional treatment for SAM/MAM infants. The treatment protocol included the following steps. Infants identified with SAM were referred to either the Nutritional Rehabilitation and Research Centre (NRRC) which is the equivalent of a stabilisation centre (as in CMAM) or to community-based health camps organised by SNEHA (equivalent of an OTP), their anthropometrics were recorded, an appetite test was administered, and a doctor examined the infants for medical complications. Infants with medical complications were referred to appropriate public health facilities. Infants with uncomplicated SAM were followed up for weight gain at home. Infants with SAM or MAM aged 15–36 m were optionally enrolled at SNEHA day care centres where they received cognitive stimulation and fortified snacks (porridge). In the home-based approach, infants with uncomplicated SAM were prescribed MNT by a doctor, based on the RUTF WHO reference chart, for a period of 8 weeks. If the child was unable to achieve the target weight in the first two weeks, further investigations were carried out for weight stagnation. If the child had not reached the target weight by the end of the intervention period, she was reassessed clinically. Drop-outs and irregular consumption were checked regularly and, if a mother or caretaker refused to go to the NRRC, attend a health camp, or give MNT to the child, the child was retained in the programme, but with counselling and weight monitoring only. If a child defaulted from the MNT 8-week protocol and consumed MNT irregularly, the mother or primary caregiver was counselled again on the importance of regular consumption. Issues were identified during programme implementation related to MNT consumption adherence due to poor taste and high density. If MNT was not consumed for a week or a few days, the number of days missed were added to the treatment duration (up to a maximum of one additional month). MNT was discontinued until recovery if the child had diarrhoea and the doctor was informed. Infants identified with SAM or MAM were referred to one of five municipal health posts in the area for immunization. Monthly health camps were organized in community spaces or day care centres by a medical doctor trained in SAM management. Infants with SAM were mobilized for health check-ups which included anthropometric measurement, diagnosis of illnesses, and review of diet patterns. Weekly follow-up of infants with severe and moderate acute malnutrition at their home was conducted to monitor nutritional status and provide nutrition counselling and health education for mothers. These weekly sessions were not always possible due to mother’s or caretaker’s lack of time or availability or willingness to participate. In some instances, the child was only weighed as the mother or caretaker refused home counselling; in other instances, the mother or caretaker refused both growth monitoring and home counselling. The programme did not include discharge criteria and ‘cured’ infants remained in the programme and were followed in the prevention component based on real time data monitoring. Cured infants were: 1) SAM infants who improved to MAM or normal (Weight-for-Height z >-3 SD (WHO 2006 growth references) for at least 1 month over the 1 year period extended by the 3 following months as change in nutritional status may be delayed); 2) MAM infants who improved to normal (Weight-for-Height z >-2 SD for at least 1 month within 12 months extended by the 3 following months as change in nutritional status may be delayed). Prevention of acute malnutrition included home-based counselling for pregnant women, monthly home-based counselling for caretakers of infants below six months of age for promotion of appropriate feeding practices, monthly growth monitoring for all infants aged 0–3 years, and community awareness and capacity building of Anganwadi workers. Infants under six months also had their immunizations monitored and referred to municipal health posts for required immunizations. During the monthly screening, infants’ growths were monitored using individual growth cards. Community activities, often in conjunction with government and international campaigns (e.g. breastfeeding week), were organised to raise awareness. Training and capacity building of community health workers and ICDS staff focused on maternal and child health and nutrition issues to build the capacity of frontline staff and to develop knowledge about malnutrition and infant and young child feeding practice guidelines. Refresher training was conducted for deeper understanding and reinforcement of the key messages that needed to be delivered in the community. Additionally, community health workers benefited from additional training compared to the ICDS staff and were closely supervised and monitored by field supervisors. Supportive supervision employed performance tracking based on monthly target achievement (e.g. number of infants visited, number of infants weighed, number of pregnant women enrolled and visited, etc.). A decision tree model (Fig 1) described the pathways along which a child might proceed if admitted to the treatment and prevention programme or if benefitting only from ICDS standard care. Cured, SAM: Improved to MAM or normal (Weight-for-Height z >-3 SD (WHO 2006 growth references) for at least 1 month over the 1 year period extended by the 3 following months as change in nutritional status may be delayed) Cured, MAM: Improved to normal (Weight-for-Height z >-2 SD for at least 1 month within 12 months extended by the 3 following months as change in nutritional status may be delayed) Failure to recover, SAM: Remained SAM. Failure to recover, MAM: Moved from MAM to SAM, or remained MAM over the 1 year period. Failure to recover, Normal: Moved from normal to MAM or SAM over the 1 year period. Default, SAM, MAM or Normal: Turned 3 years old, migrated, or was screened incorrectly. Relapse, SAM: Recovered but relapsed to SAM over the 1 year period. Live, Children in the programme (SAM, MAM or normal): Based on programme data Live, Children not in the programme (SAM no treatment, MAM no treatment or normal): Based on data from survey data. Infants exited the programme in one of four ways: cured, death, default, or failure to recover. Infants of normal nutritional status benefitted from the prevention component. Infants with SAM and MAM who were not part of the programme and received standard ICDS services only were assumed to have the same mortality rates as untreated infants. The normal treatment path for MAM and SAM leading to ‘cured’ was “screened, receiving services as described in the treatment section” (1. in decision tree MAM / SAM ‘receiving services’). In some cases, MAM and SAM infants followed other paths that did not lead to ‘cured’ due to refusal of home visits and MNT consumption (2. in decision tree ‘not receiving full services’). The ‘normal’ infants received services for prevention (1. Normal infants receiving services). Screened normal infants were measured (weight and height) monthly after the initial screening and caretakers were counselled on optimal feeding practices and followed while the child was <6 m and if her mother was breastfeeding. Nevertheless, some of the screened normal infants did not receive all prevention services (2. Normal infants not receiving services); they were not measured if they were unavailable at the time of measurement or if their caregivers refused to have them weighed. Some of these infants only benefited from the community events in the area such as breastfeeding promotion. Finally, infants less than 3 years old who were not part of the programme were assumed to benefit from ICDS standard care only and were normal, MAM receiving no treatment or SAM receiving no treatment. The analysis aimed to value the total costs of community treatment of SAM and MAM and prevention of acute malnutrition. An activity-based cost (ABC) analysis was used to estimate the total costs by cost centre. We identified cost centres by grouping activities that were related and validated them with SNEHA staff (S1 Table). They included all costs incurred by SNEHA and the households of infants with SAM. The treatment and prevention programme was evaluated for one year from February 2013 to January 2014 when the programme was fully operational. Costing was done using programme yearly costs, key documents including budget and financial reports, and key informant interviews with SNEHA staff (financial, programme, administrative, monitoring). The yearly costs of the treatment and prevention programme were the basis for the cost centres, with time allocation used to split staff salaries and associated costs across cost centres. Time allocation grids were designed based on interviews with SNEHA staff (community organiser, programme coordinator, programme officers, trainers). Activities for each profile were identified based on the post terms of references and were amended as necessary by the staff during an interview. The time spent was as well estimated on a daily and monthly basis. Interviews with the staff managers were conducted to check activities and time estimate. Cost centres allocation was then done using an allocation grid designed in collaboration with the financial team. We grouped supervision costs in one cost centre to allow for comparison with other studies using similar grouping. All costs were expressed in local currency, and converted from Indian Rupees to US dollars using the July 2014 exchange rate when the analysis was conducted (US$ = INR 60.14). We used US dollars in order to compare our findings with those of previous studies. Baseline and endline survey costs were not included. We assumed a 2-year shelf life for fixed assets. One-time setup costs were allocated at 50% (the residuum allocated to the programme covering other areas). We were not able to value the cost of ICDS standard care and assumed zero cost in the costing. The estimated costs of the programme therefore represent the incremental cost of adding such a programme to standard ICDS activities. Outcome data for infants in the treatment and prevention programme were collected by the mHealth platform (Table 1). Over the time of the study, 12,362 (49% female) infants were enrolled in treatment or prevention programmes, (8980 prevention, 3382 treatment). Of the infants admitted to the treatment programme, 1888 were cured (56%: 60% cured in infants with SAM and 55% cured in infants with MAM), 1056 (31%) failed to recover, 227 (8%) defaulted, 8 (0.2%) died and 203 (6%) did not receive full services (either receiving home visits but not being weighed, or not receiving home visits and not being weighed). Of the 1888 infants who were cured, 75 (18% of the SAM cured) relapsed into the SAM category during the study period of one year (Table 1). Here it is important to note that, unlike in a CMAM programme, the cured infants were not discharged and readmitted when screened for SAM again. These infants were still being monitored even after being considered as cured. Mortality ratios were 2% for the prevention and treatment programme, 1.9% for prevention only, 2.4% for treatment only (Table 1). DALYs are a measure of overall disease burden, expressing the number of healthy life years that are lost due to illness and death. Here, DALYs combined years of life lost (YLL) due to premature mortality related to SAM/MAM and years lived with acute malnutrition (YLD). For each node in the decision tree, either YLL or YLD were calculated using standard formulas for calculating DALYs based on YLD = number of prevalent cases * disability weighting * duration of the SAM episode and YLL = number of fatal cases * (residual life expectancy at mean age at death). Assumptions for calculation of YLL and YLD are described in Table 2. The probability and uncertainty of each outcome were calculated based upon programme data on mortality and recovery rates (Table 2) using similar methods to those of previous studies [5, 6]. We decided not to use discounting and age weighting in the base case scenario due to their controversial nature. Age weighting implies that the value of life depends on age while discount rate refers to the annual loss of value in percent. Nevertheless, to make the findings comparable to other studies [5, 6], we used the same parameters for age weight and discount rate as in these studies. We used the mHealth programme data when possible. However, for age at death of infants with SAM, the small number of cases could not give us a reliable average. Thus, we estimated the age of death as the age at SAM + the duration of SAM episode based upon a previous study [5]. We used the expected mortality ratio in the population when infants exited the programme or received only ICDS standard care (2.6% in NFHS-3 [11]). For untreated, non-responder and defaulter SAM and MAM case fatality ratios (7.6% for SAM and 3.4% for MAM) were estimated based on Pelletier et al.’s study [23] averaging the death rate for SAM and MAM respectively from 9 studies [17–26]. The case fatality rate used for untreated SAM is lower than the ones used in other studies; 18.1% in Wilford [6], 20.7% in Puett et al. [5], 18% in Bachmann [4]. This can be explained by the fact that they were based on MUAC rather than WFH, with MUAC being a better predictor of mortality than WFH [30–32]. For normal infants who left the programme, death rate was based on infant mortality rate in slums (2.6% in NFHS-3 [11]). Following Bulti et al. [33], the number of SAM deaths averted was calculated as excess mortality * proportion of treated SAM cases cured by the programme * number of SAM cases treated by the programme. We used the disability weighting for severe wasting established by the Global Burden of Disease 2010 project [28]. For the levels of services received for infants with SAM, we used the confidence interval to reflect lower and higher disability weight. We used the same disability weight for infants with MAM as there were no data in the literature, but also used the lower confidence limit to reflect lower disability weight. Estimates of DALYs averted were calculated for prevention and treatment compared to standard ICDS care. The incremental cost-effectiveness ratio (ICER) for the treatment and prevention programme versus the ICDS standard care alone was calculated as the estimated cost per DALY averted as no ICDS related cost was included for both options. Based on the 2001 recommendation of the Commission on Macroeconomics and Health, the World Health Organization classifies interventions as ‘highly cost-effective’ for a given country if they avert a DALY for less than per capita gross national income (GNI) or gross domestic product (GDP), and cost-effective if they avert a DALY for less than 3 times GNI or GDP. In India, GNI per capita was 1570 US$ in 2013 [34]. Sensitivity analyses were conducted for base, worst and best case using assumptions in Table 2 and a +/-25% range. The worst case scenario was based on the 25% CI with all inputs varying together and presented the least favourable results. Uncertainty analysis was undertaken to develop scenarios with Dirichlet probabilities assigned to each possible outcome. The Dirichlet distribution was the natural choice for modelling the uncertainty in the transition probabilities of the decision tree models, because each node could result in two or more mutually exclusive outcomes. The cost uncertainty analysis was conducted by assigning cost centre to outcomes in the decision tree. The average costs for the individual decision tree nodes were used. Calculations of DALYs, costs, estimated cost per DALY averted, and related uncertainties were performed in R version 3.4.0 (R Core Team 2017) [35]. Uncertainty analyses were based on 10,000 iterations, and 95% uncertainty intervals (UI) were defined as the 2.5th and 97.5th percentiles of the resulting uncertainty distributions. Potential risk of bias was addressed by taken into account uncertainty in the decision tree parameters using a Monte Carlo-based uncertainty analysis. Furthermore, we performed sensitivity analyses by altering the main mortality scenarios, and by performing alternative social weighting scenarios. Ethical clearance was granted by the ethical committee of Bandra Holy Family Hospital and Medical Research centre in Mumbai. We complied with the Principles of Ethical Practice of Loughborough University.