Use of integrated management of acute malnutrition guidelines and cost implication in Uganda; A case study of severe acutely malnourished children admitted at Mwanamugimu Nutrition Unit, Mulago Hospital.

"Background: Despite development and dissemination of standardised nutritional management guidelines to harmonise treatment of Severe Acute Malnutrition (SAM) at global and national levels, there is lack of information about the application of these guidelines, utilisation of the available inputs and treatment cost implications. Objective: The focus of this study was to; (a). Establish the nutritional knowledge, attitude and practices of health workers involved in management of SAM, (b). Conduct a cost analysis, resource utilisation and the impact of the dietary and medical inputs used on the recovery of rehabilitated severe acutely malnourished children. Methods: Both a longitudinal prospective study and descriptive cross sectional survey were conducted on fifty nine (59) eligible severe acutely malnourished children, 6-24 months with medical complications and eighteen (18) health workers that managed these patients at Mwanamugimu Nutrition Unit (MNU), Mulago Hospital. Data was collected on four dependent variables (Use of protocol; Recovery of patients; Utilization and Cost of dietary and medical inputs). Data was also collected on two independent variables i.e. type of SAM at admission and HIV status. Data obtained from use of protocol was analyzed qualitatively; whereas other variables with the exception of recovery of patients were analyzed quantitatively. Equations adopted from Sphere standard (2011) were used to analyze recovery of patients. Descriptive statistics were obtained for dependent variables whereas the impact of independent variables to treatment cost was assessed using the Mann-whitney U test. Results: Of the eighteen (18) health workers interviewed, majority (50%) were nurses. Generally, health workers were using the Integrated Management of Acute Malnutrition (IMAM) guidelines. Over 80% of health workers had received in service training, followed IMAM guidelines, correctly defined SAM and knew the available therapeutic feeds and routine medicines. However, only 55.6% of respondents had access to a copy of IMAM guidelines. Likewise, only 50% knew the admission criteria in Outpatient Therapeutic Care (OTC). With the exception of initiating feeding within 10 minutes of admission to prevent hypoglycaemia, other nutritional status assessment, dietary and medical treatment were performed according to what is stated in IMAM guidelines. Over 70% of health workers had a positive attitude to use of protocol, hospitalisation of patients and use of therapeutic feeds. However, 72.2% stated presence of barriers during application of guidelines. Of the 59 severe acutely malnourished children, only 64.4% were discharged cured and others defaulted, died, failed to respond to treatment and some transferred. Majority (62.7%) of study patients were males, presented with non oedematous malnutrition (50.8%) and HIV negative (71.2%). The average treatment cost per cured child was US$ 279.8. This was 39.9% greater than the estimated cost for treating SAM in Africa. Analysis of the relationship between cost and type of SAM at admission showed a significant difference in two rehabilitation stages; phase I (p=0.01; 0.009 - 0.013: CI=95%), and transition (p=0.008; 0.007 – 0.01: CI=95%). However, no significant difference was observed at component level; ITC (p=0.494; 0.485 – 0.504: CI=95%). No significant difference was observed between cost and HIV status neither at stage level nor component level. The mostly used feeds were RUTF (3.56 sachets/ child/day) while routine medicines and laboratory tests were antibiotics (100% prescription) and malaria tests (81.6%) respectively. The least feeds were CSB porridge consumed during Phase II of rehabilitation (0.08 kg/child/day) while routine medicines and laboratory tests were measles vaccination and iron/folic acid supplementation at 2.6% each and blood microbiology tests (10.5%) respectively. Cost analysis of supplies also revealed that RUTF (US$ 44.73), antibiotics (US$19.15) and renal function tests (US$ 27.2) had the largest cost means. Analysis of time use by health workers showed that group activities took longer as compared to individual activities with the longest time spent on kitobero serving and supervision (55.4 minutes) while daily weight taking (2.6 minutes) took the smallest. However, the reverse was true when the trend was compared to cost implication. On average, the length of stay and daily weight gain in ITC was 23.11 day and 8.07 g/kg/day whereas in OTC it was 45.59 days and 4.77 g/kg/day respectively. Conclusion: Despite the fact that a large number of health workers used the IMAM guidelines, the treatment of severe acute malnutrition with medical complications was very expensive."