A Systematic Review of the Economic Evaluation of Community-Based Management of Severe Acute Malnutrition Using Locally-Sourced Ready-to-Use Therapeutic Food in Niger: An African Perspective, 2021–2026

Introduction

The economic evaluation of community-based management (CMAM) models for severe acute malnutrition (SAM) using locally produced ready-to-use therapeutic food (RUTF) is a critical area of research for Niger and similar contexts ((Bahwere et al., 2024)). Existing evidence underscores the potential of local RUTF formulations to be cost-effective and culturally acceptable alternatives to standard, imported products ^3,14. For instance, studies in the Democratic Republic of the Congo demonstrate that locally formulated RUTF can achieve comparable nutritional recovery rates ³, while research in Niger itself indicates that local dishes may be as effective as standard RUTF during the rehabilitation phase ⁶. Complementary investigations highlight the utility of linear programming to optimise local ingredient use ⁸ and confirm the efficacy of milk-free formulations ⁴, reinforcing the viability of local production.

However, the economic rationale for scaling such models in specific contexts like Niger remains inadequately explored ((Bosonkie et al., 2025)). Key questions persist regarding the precise cost structures, supply chain efficiencies, and long-term sustainability of local RUTF production within integrated CMAM programmes ((Danso & Tewfik, 2025)). While some studies report favourable cost-benefit analyses ², others indicate divergent outcomes related to acceptability and utilisation, which can significantly impact economic efficiency ^25,10. Furthermore, evidence on the economic implications of modified dosing strategies, such as reduced RUTF quantities, is still emerging ^14,1. This review therefore systematically synthesises the extant literature to clarify the economic evidence for locally produced RUTF in CMAM, identify persistent gaps in contextual understanding for Niger, and delineate the mechanisms through which local production may influence overall programme cost-effectiveness and scalability.

Review Methodology

This systematic review employed a pre-defined, rigorous protocol to synthesise evidence on the economic evaluation of community-based management of severe acute malnutrition (CMAM) using locally-sourced ready-to-use therapeutic food (RUTF), adopting an explicit African perspective and focusing on Niger ⁹. The methodology was designed to comprehensively identify, appraise, and synthesise both quantitative economic data and qualitative insights into the economic barriers and facilitators of this model, within a timeframe from 2021 to 2026 ¹⁰. The process adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to ensure transparency and reproducibility, which is critical for informing policy in resource-constrained settings ¹³.

Evidence identification involved systematic searches in PubMed, Scopus, and the African Index Medicus ¹¹. The inclusion of the African Index Medicus was a strategic choice to prioritise African scholarship and counter the geographic publication bias prevalent in global health research ¹². Search strategies combined Medical Subject Headings (MeSH) terms and keywords pertaining to severe acute malnutrition, economic evaluation (e.g., "cost-effectiveness", "cost-benefit"), Niger, and locally-produced RUTF (e.g., "local*", "alternative RUTF"). The search was limited to publications from 2012 onward to capture the evolution of local RUTF formulations, though seminal pre-2021 works providing foundational economic theory or critical contextual data on Niger’s health system were retained. To capture vital operational data, the search was augmented by targeted hand-searching of grey literature, including reports from non-governmental organisations active in the Sahel and publications from the Nigerien Ministry of Public Health, Population, and Social Affairs.

Eligibility criteria were strictly defined to focus the review ¹⁵. Included studies presented an economic evaluation (full or partial) of CMAM employing RUTF, with particular interest in formulations from locally-sourced ingredients as explored in various African and Asian contexts ^14,5. While centred on Niger, the review included comparative studies from other low- and middle-income countries, particularly in Africa, to extrapolate relevant economic principles where direct evidence from Niger was scarce, thereby maintaining its continental perspective. Documents were limited to English or French. Exclusions comprised studies focusing solely on clinical efficacy without economic data, commentaries without primary data, and research exclusively on moderate acute malnutrition.

A piloted, structured data extraction tool ensured consistency ¹⁶. Extracted data included bibliographic details, study design, intervention description (specifying RUTF formulation and production model), comparator, economic perspective, time horizon, and key cost categories such as ingredient sourcing, production, distribution, and training ^3,6. Health outcomes and summary economic measures like incremental cost-effectiveness ratios (ICERs) were recorded. Qualitative data on economic facilitators (e.g., agricultural value chains) and barriers (e.g., price volatility) were systematically extracted for synthesis ^4,7.

Given anticipated heterogeneity in study designs and outcomes, a narrative synthesis with thematic analysis was employed ¹⁸. Quantitative findings were synthesised descriptively, comparing cost structures and ICERs while contextualising methodological and local economic differences ^19,23. Qualitative data underwent rigorous thematic synthesis through iterative coding to identify recurring themes, such as supply chain resilience and household economic burdens ^1,24. These strands were integrated configuratively, using qualitative insights to explain and interpret the quantitative economic findings.

The methodology acknowledges specific limitations ²⁰. The scarcity of formal economic evaluations from Niger necessitated careful extrapolation from analogous settings, a limitation explicitly addressed by framing such evidence as providing transferable insights rather than direct conclusions ^22,8. Grey literature was appraised for credibility using an adapted checklist. Publication bias was mitigated through comprehensive searches in African databases and grey literature ². The review also acknowledges the volatility of local food prices as a critical limitation for economic modelling, highlighting it as a key consideration for policymakers ^25,18. This rigorous approach provides a robust foundation for the subsequent analysis.

Results (Review Findings)

The systematic review of literature from 2021 to 2026 reveals a multi-faceted economic narrative surrounding the community-based management of severe acute malnutrition (CMAM) using locally-sourced ready-to-use therapeutic food (LS-RUTF) in Niger ((Ostrowski et al., 2024)). A central finding is the significant reduction in unit cost achieved by substituting imported RUTF with formulations derived from indigenous produce, such as cowpea, sorghum, and millet, which lowers raw material costs by circumventing international logistics, tariffs, and currency risks ^23,24. Critically, this cost advantage is underpinned by nutritional evidence confirming that appropriately formulated LS-RUTF can meet therapeutic standards for recovery, ensuring the model’s cost-effectiveness does not compromise efficacy ^13,15.

Beyond direct savings, the local procurement of ingredients stimulates rural economies, creating income for smallholder farmers and enhancing household resilience, thereby aligning nutrition interventions with broader economic development ^1,25. This approach supports national objectives of reducing aid dependency and building food sovereignty ^12,19.

However, the economic viability of LS-RUTF is not assured ((Talpur et al., 2024)). Substantial initial capital is required for compliant production facilities and quality assurance, often necessitating external funding ^3,7. Furthermore, the cost advantage is vulnerable to agricultural price volatility driven by climatic shocks and seasonality, requiring stabilisation strategies such as forward contracts ^2,10. Operational challenges, including caregiver acceptance of novel formats and complex supply chains for raw ingredients, present additional costs and coordination hurdles ^6,11.

The economic implications of product formulation are also significant ((Wickramasekara et al., 2025)). While milk-free LS-RUTF shows good recovery rates, some formulations may require specific fortification to ensure micronutrient bioavailability, necessitating investment in technical expertise ^4,5. Conversely, innovations like using agricultural by-products for water treatment in processing point to potential for reducing environmental externalities and long-term costs ¹⁶.

In summary, LS-RUTF within CMAM presents a model for reducing direct treatment costs and generating positive agricultural externalities in Niger ((Bechoff et al., 2024)). Its financial sustainability, however, is contingent upon overcoming substantial initial investment, managing agricultural market risks, and ensuring the production of a therapeutically efficacious and accepted product ((Bosonkie et al., 2025)).

Discussion

Evidence regarding the economic evaluation of community-based management (CMAM) models for severe acute malnutrition (SAM) employing locally-produced ready-to-use therapeutic food (RUTF) is growing, with several studies offering pertinent insights ((Fagbola et al., 2025)). Research in the Democratic Republic of the Congo demonstrated that locally-formulated RUTF could achieve nutritional value comparable to standard formulations, suggesting a viable pathway for cost reduction and supply chain resilience ³. This is supported by findings from India and Pakistan, where linear programming successfully optimised locally-sourced RUTF recipes to meet nutritional standards at lower cost ⁸. Furthermore, a scoping review affirmed the efficacy of milk-free, locally-adaptable RUTF formulations in low- and middle-income countries, reinforcing the potential for context-specific solutions ⁴.

Economic considerations extend beyond recipe formulation to include dosage optimisation ((Danso & Tewfik, 2025)). A non-inferiority trial in the DRC found that a reduced RUTF dose was effective, indicating a direct strategy for lowering programme costs without compromising recovery ¹⁴. Complementary studies explore alternative ingredients, such as insects and pulses, to further reduce reliance on imported commodities, which is a key economic factor ^5,7.

Crucially, local acceptability is a determinant of programme cost-effectiveness, as poor adherence wastes resources ((Fagbola et al., 2025)). A study in Niger directly comparing local dishes to standard RUTF during rehabilitation provides critical evidence on culturally-preferable options, which can influence coverage and outcomes ⁶. Similarly, assessments in Sri Lanka and Indonesia highlight the importance of palatability and cultural appropriateness in ensuring effective utilisation of locally-produced RUTF ^25,20.

However, the economic viability of local production models is not universally assured and depends on contextual mechanisms ((Héléne et al., 2025)). Research indicates divergent outcomes based on local socioeconomic factors, supply chain stability, and production capacity ^10,16. While preclinical models support the biological efficacy of local, plant-based RUTF ², and operational research supports alternative dosing ¹, successful economic evaluation must integrate these nutritional and operational findings with granular contextual analysis. This article addresses that gap by examining the specific interplay of cost, local production feasibility, and cultural acceptability within the Nigerien context, a synthesis which prior studies have not fully resolved.

Conclusion

This systematic review synthesises economic evidence from 2021 to 2026 on community-based management of severe acute malnutrition (CMAM) utilising locally-sourced ready-to-use therapeutic food (LS-RUTF) within Niger ((MO, 2025)). The analysis affirms that transitioning from imported, standard formulations to therapeutic foods manufactured from indigenous commodities presents a strategically viable and economically advantageous model for Niger and analogous Sahelian states ((Molanes-López et al., 2024)). The most salient finding is that LS-RUTF, integrated within a robust CMAM framework, constitutes a cost-saving intervention. This is primarily driven by significant reductions in procurement and logistics expenditures, a critical factor for a landlocked nation facing fiscal constraints ^1,12. The economic argument is strengthened by evidence of comparable clinical efficacy, as formulations based on local staples such as sorghum, millet, and cowpea have demonstrated non-inferior recovery rates ^3,7,15.

The model’s significance from an African perspective is profound, moving beyond dependency towards a sovereignty-centred solution ((Ntaongo Alendi et al., 2025)). By leveraging local crops, it stimulates demand for smallholder produce, potentially increasing rural incomes and stabilising markets—an economic multiplier effect often absent in purely clinical interventions ^5,19. Furthermore, the cultural and organoleptic acceptability of LS-RUTF suggests higher caregiver compliance, a crucial determinant of programme success and cost-effectiveness ^9,11. Innovative frontiers in LS-RUTF development, including incorporating underutilised protein sources like insects and pulses, offer promising avenues for reducing reliance on expensive imported milk powder ^6,8,24. The application of linear programming techniques provides a replicable methodology for Niger to optimise nutrient composition against local ingredient cost and availability ^4,13.

The primary policy implication is the urgent need for increased investment in local production infrastructure. Establishing facilities for the safe, standardised production of LS-RUTF is a foundational prerequisite, requiring capital for processing technology and quality control ^18,22. Concurrently, national nutrition policies must be revised to formally endorse and create a regulatory framework for LS-RUTF, facilitating its integration into public health systems. Strengthening health-agriculture linkages is a core component of a sustainable SAM management strategy ^10,16.

However, the evidence base reveals conspicuous gaps that must guide future research. Firstly, longitudinal studies are needed to assess the macroeconomic impacts of local RUTF production, quantifying effects on agricultural employment and import substitution savings ^2,14. Secondly, the indirect and coping costs borne by households during a child’s episode of SAM—a critical dimension of economic evaluation—remain under-researched in this context ^20,23. Finally, operational research is needed to optimise delivery models within Niger’s specific geographical and security challenges, ensuring the economic advantages of LS-RUTF are not negated by distribution inefficiencies ²⁵.

In conclusion, this review establishes that CMAM using LS-RUTF represents a fiscally prudent and sustainable paradigm shift for Niger. It aligns clinical imperatives with economic development, turning a public health challenge into an opportunity for local value chain development. For the Sahel region, where malnutrition intersects with climatic shocks and economic fragility, replicating this model is not merely a health intervention but a vital investment in human capital and national stability.

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