Severe acute malnutrition treatment delivered by community health workers in emergency settings of Mali (iCCM+ Project)

INTERVENTION: The study design includes three arms: ‐ Control arm: treatment is provided only in health centers following the national protocol. Admission criteria: Edema +/++ and/or WHZ <‐3 z‐score and/or MUAC <115mm. Treatment: RUTF according to weight (170 Kcal/kg/day). Discharge criteria: WHZ >‐1.5 z‐score or MUAC >=125 mm. ‐ Intervention Arm 1: treatment is provided in health centers and outside by community health workers following national protocol. Admission criteria: Edema +/++ and/or WHZ <‐3 zscore and/or MUAC <115mm. Treatment: RUTF according to weight (170 Kcal/kg/day). Discharge criteria: WHZ > ‐1.5 zscore or MUAC >=125 mm. ‐ Intervention arm 2: treatment is provided in health centers and outside them by community health workers following a modified protocol. Admission criteria: Edema +/++ and/or MUAC <115mm. Treatment: fixed amount of 2 sachets of RUTF /day (1000 Kcal/day) except children under 5Kg who will receive 1 sachet/day (500Kcal/day). Discharge criteria: WHZ >‐1.5 z‐score or MUAC >=125mm. All children in the three study arms will receive a weekly follow‐up until meeting a discharge criterion. Each cluster will correspond to one treatment provider (health centre or its group of CHWs) which means that there will be 6 groups of providers by arm. However, in order to avoid final real imbalance in cluster size, the unit of randomization will be the health centre with a block allocation ratio of 2:1:1. CONDITION: Uncomplicated severe acute malnutrition of children 6 to 59 months ; Nutritional, Metabolic, Endocrine ; Malnutrition PRIMARY OUTCOME: ; Data will be extracted directly from the patient records existing in the health centers and health huts at the end of the study:; 1. Recovery rate: proportion of children achieving and maintaining the discharge criteria during two follow‐up visits (two consecutive weeks); 2. Default rate: proportion of children absent of two follow‐up visits (two consecutive weeks); 3. Decease rate: proportion of children who die during treatment or in transit to inpatient care; 4. Referral rate: proportion of children referred to inpatient care due to the appearance of medical complications or nutritional treatment failure (non‐response considered as oedema still present after 21 days, weight loss for two consecutive visits, not weight gain in 14 days, or failure in the appetite test); INCLUSION CRITERIA: 1. Children from 6 to 59 months of age 2. Diagnosed with uncomplicated severe acute malnutrition 3. Positive appetite test result 4. Without any medical danger sing (severe oedema, unable to drink or suck, severe vomit, convulsing, non‐response to external stimuli, severe palmar pallor, severe difficulty breathing, spontaneous bleeding, dark urine, unable to sit/stand, severe diarrhea/dehydration) SECONDARY OUTCOME: ; 1. Coverage compared at baseline and end‐line from two population‐based surveys conducted at the beginning and end following the standardized SLEAC methodology; 2. Cost‐effectiveness: cost per child treated and cost per child recovered. Financial information for the cost‐effectiveness analysis will be taken towards the middle of the recruitment period using as a source the logistics and financial records of the Action Against Hunger offices and the health district authorities; Obtained monthly from the patient records:; 3. Severity at admission (MUAC and WHZ measurements and oedema proportion); 4. Recovery time: time spent in treatment until being discharged as cured; 5. Number of follow‐up visit absent in those children recovered; 6. Number of RUTF sachets consumed by those children recovered; 7. Average weight and MUAC gain of those children recovered; 8. Number of cases treated for other non‐severe common diseases in an integrated manner (diarrhea, malaria, acute respiratory infection);