Economic cost analysis of severe acute malnutrition treatment in two districts of Ethiopia: a cross-sectional study

BACKGROUND: Severe acute malnutrition (SAM) affects millions of children globally, and treatment coverage remains below 30% in many settings, including Ethiopia. Although the Community-Based Management of Acute Malnutrition (CMAM) program has expanded nationwide, persistent service gaps remains, partly due to insufficient evidence for accurate cost estimation and budgeting. To address this gap, this study estimated the total economic cost, including provider-side financial and caregiver costs, of treating SAM through the CMAM program in two operational areas of Action Against Hunger, Ethiopia, and identified major cost drivers. METHODS: A cross-sectional cost analysis was conducted in Girawa district (Oromia Region) and Adadle district (Somali Region) in 2024 from a societal perspective, including both provider-side financial and caregiver costs. Provider-side financial costs include personnel, medical supplies, therapeutic foods, equipment, transport and storage, and training and supervision. Caregiver costs include both direct costs (transport, food, and hospitalization-related expenses) and indirect costs (lost income and coping strategies). Provider-side financial costs were extracted and estimated using the FANTA CMAM costing tool. The tool automatically generated total cost per district, and the provider-side financial cost per SAM child was calculated by dividing total annual provider-side financial expenditure by the number of SAM cases treated. Caregiver costs were collected through structured exit interviews, analyzed using Excel, and summarized as mean cost per treatment episode. The mean caregiver cost was added to the provider-side financial cost to estimate the total economic cost per SAM child. RESULTS: The total annual provider-side financial cost for SAM treatment was USD 386,598 in Girawa district and USD 289,433 in Adadle district. Supplies, particularly RUTF and therapeutic milk, constituted the largest cost category in Girawa (57.7%), whereas repeated SAM-specific training and supervision represented the major share in Adadle (40.9%). The average provider-side financial cost per SAM child was USD 171.1 in Girawa and USD 325.2 in Adadle. The average caregivers incurred cost per SAM episode was USD 53.55. The total economic cost per SAM child, including caregiver expenses, was USD 224.65 in Girawa and USD 378.75 in Adadle. CONCLUSION: There is substantial variation in the cost of delivering SAM treatment across districts, highlighting the importance of context-specific district-level cost analyses. SAM-specific supplies and training intensity were the primary cost drivers. The incorporation of the household economic burden highlights an important but often overlooked dimension of treatment costs. These findings provide realistic district-level unit costs that can directly guide partners and governments in estimating resource needs for annual response plans while strengthening CMAM budgeting, planning, scaling up in Ethiopia.