Background The best management strategy for moderate acute malnutrition (MAM; weight-for-height z-score<-2) in low- & middle- income countries is unclear. Recently there has been a growth in the use of commercially produced ready to use food supplements (RUF) to treat MAM; these improve outcomes compared to routine care, albeit marginally, but their use in isolation does not address the underlying causes of undernutrition. Well delivered counselling has been found to be as effective as RUF, but requires sufficient staff time, which is not usually available; pilot work in Kenya found that staff spent an average of only 10 minutes per month interacting with families of children with MAM. Most supplies of RUF are currently donated by international agencies, but in the long run many middle-income countries will be expected to fund these themselves. We aimed to estimate the opportunity cost to individual country health systems of purchasing RUF, relative to employing staff to provide counselling.

Methods This was a costing study using secondary data. We identified 37 countries with rates of MAM greater than 5% from UNICEF/WHO/World Bank Child Malnutrition Estimates. Salary costs for nurses in each country were drawn from the Salary Explorer website and the cost of RUF from UNICEF supply division website. For each country we calculated the cost per month of full MAM treatment with RUF for every child (1 sachet per day) compared to the cost of nursing time in that country.

Results The mean cost of RUF was $8.22 (0.87) per month. The median starting salary of registered nurses was $1.49 per hour, but this varied from <$1 per hours for 10 countries to >$4 for five. For all but 6 (84%) countries full treatment with RUF exceeded the cost of 2 hours nursing time per month, and in 24 (65%) countries 4 hours of nursing time could be purchased per month at lower cost than RUF. If RUF was only used for half of children with MAM this could pay for 2 hours counselling for every per child in 24 (65%) countries.

Conclusion The cost of supplying RUF greatly exceeds staff time in most LMIC countries. Properly staffed counselling services using problem-oriented counselling interventions could usually be purchased at a much lower cost than RUF. Well-staffed trials of the efficacy and cost-effectiveness of problem-oriented counselling interventions for MAM are required before the widespread adoption of treatment with RUF.