Malnutrition is one of the main causes of infant morbidity and mortality in low-income countries [1]. According to the World Health Organization (WHO), nearly 45 million children under the age of five suffered from acute malnutrition in 2023, including more than 13 million with severe acute malnutrition (SAM), a critical form requiring urgent therapeutic intervention [2]. In the Democratic Republic of the Congo (DRC), the situation remains concerning, with high rates of chronic and acute malnutrition in several provinces, particularly in Kasai.

For the Kalonda West health District in the Kasai province, there is a high prevalence of severe acute malnutrition (SAM) among children under five years of age, due to factors such as food insecurity, poverty, limited access to healthcare, and insufficient community nutrition services [1][3]. While efforts are being made by technical partners (UNICEF, WFP, Ouermi Alain Saga) and the Congolese government to improve detection and treatment, few studies have documented the actual cost to households [4][5].

Understanding the economic implications of severe acute malnutrition (SAM) is essential for guiding subsidy policies and planning public health budgets. Furthermore, comparing the costs of care for children with SAM with those hospitalized for other conditions allows for an assessment of the additional financial burden imposed by malnutrition [5].

This study aims to estimate and compare the direct, indirect, and total costs of hospital care between children hospitalized for severe acute malnutrition (SAM) and children with normal nutritional status hospitalized for other conditions, in two referral hospitals in the Kalonda West health zone.

In this study, the direct costs associated with medications, nursing care, and dietary rations were clearly higher for children with severe acute malnutrition (SAM) than for children hospitalized for other pediatric conditions (Table 2). This observation reflects clinical reality. SAM requires specific treatments to correct nutritional deficiencies and prevent or treat associated infections, including medications, vitamin supplements, and rehydration solutions. In addition, close monitoring of weight, hydration status, and vital signs is essential, placing a greater burden on healthcare staff and increasing the use of medical supplies [6][7]. The therapeutic diet, enriched with protein and micronutrients, also contributes to increased costs [8]. These factors explain why direct expenses are higher in cases than in children with normal nutritional status, whose care requires less intensive interventions [9][10].

Indirect costs, primarily related to hospital stays, were also higher for malnourished children (Table 3). This reflects the time parents or guardians must dedicate to caring for their children, often at the expense of their income-generating activities. In rural or semi-urban areas, where income largely depends on informal work, this lost time represents a significant economic burden for households [7][10]. The extended stay is often linked to the clinical severity of the cases and the presence of comorbidities, such as respiratory infections or malaria, which require prolonged monitoring and care, with a consequent increase in the indirect financial burden [2].

The overall cost, combining direct and indirect expenses, was significantly higher for children with severe acute malnutrition (SAM) (Figure 1Figure 1). In Niger, the cost of severe acute malnutrition was as high, but much higher, than that found in our study [11].

In northern Senegal, a study revealed that the average total cost of managing severe acute malnutrition was USD 431.9 (standard deviation = 203.9), with staff costs representing the largest expense (33% of the total). Household expenses accounted for 45.3% of the total cost, or USD 195.6 (standard deviation = 103.6) [12].

This finding underscores the cumulative economic burden of SAM, combining the intensity of care and the loss of income for families. These results are consistent with national and regional observations [3][13], and emphasize the need for appropriate support strategies, such as subsidizing treatments, improving access to care, and strengthening national nutrition programs. These measures are undoubtedly essential to reducing the financial burden on households and improving the chances of recovery for malnourished children.

These results are like those found by Daures and colleagues, who demonstrated that indirect costs associated with managing severe malnutrition constitute a significant portion of the economic burden borne by households, especially in rural areas where income is based on daily labor. They also highlight that prolonged hospital stays, frequently complicated by comorbidities, lead to a significant decrease in family productivity, thus confirming the findings in the Congolese context [13].

Furthermore, the findings presented here align with those of Tadesse, who highlighted that the overall cost of severe acute malnutrition, combining direct medical expenses and indirect income losses, is significantly higher than for other common pediatric conditions. This convergence of results demonstrates that SAM constitutes a major economic problem for vulnerable households and reinforces the need for public policies aimed at reducing treatment costs and supporting affected families [14].

It is crucial to consider the psychological impact of severe acute malnutrition on families, beyond the direct and indirect costs. Prolonged hospitalization of a child generates stress that degrades the emotional well-being of parents, thus affecting their work performance and exacerbating the family’s economic hardship [13][15].

Severe acute malnutrition (SAM) also places additional strain on health systems.

In low-resource countries, it is common for referral hospitals to redeploy staff and equipment to meet the specific needs of malnourished children. This restricts the availability of care for other illnesses and leads to increased institutional spending [16].

At the community level, severe malnutrition in children has lasting effects on human capital. Children who survive severe acute malnutrition (SAM) often show delays in their growth and cognitive development, which may decrease their future economic and educational potential. Thus, the total cost also includes long-term productivity losses for the business [17].

Comparative research indicates that preventive nutritional interventions are significantly more cost-effective than curative treatments. According to Ould Abdeslam-Hamaz [18], funding for community-based micronutrient supplementation and awareness programs significantly reduces the incidence of severe acute malnutrition (SAM), leading to a decrease in associated direct and indirect costs.

The importance of intersectoral collaborations in reducing the economic burden of SAM is emphasized. The involvement of NGOs, international funders, and local stakeholders in providing financial support for treatments and establishing social safety nets improves household resilience and promotes greater equity in access to care [19].

StudyLimitations

Several limitations should be highlighted. First, the study does not distinguish between costs covered by external aid and those actually paid by households. Finally, the specific rural context of Kalonda West limits the generalizability of the results to other regions of the DRC or Africa.

This study, conducted in the Kalonda West health zone, demonstrated that hospital care for children suffering from severe acute malnutrition (SAM) incurs a significantly higher financial cost than for children hospitalized for other illnesses. Direct costs, primarily medication and hospitalization, constitute the bulk of the expenses, while indirect costs reflect the lost income for children with normal nutritional status and high transportation costs for those with other pediatric conditions. The results also reveal that total financial costs are significantly higher for children with normal nutritional status than for those with other conditions. These findings highlight the disproportionate impact of other childhood illnesses on vulnerable households, which often must mobilize substantial resources, with or without external support.

These findings call for multisectoral and structural actions, including:

Strengthening targeted subsidy and free healthcare policies for children with other illnesses.Community support and early outpatient care to reduce lengthy and costly hospitalizations.Integrating prevention into primary healthcare and food security interventions.

Finally, further studies incorporating cost-effectiveness, cost-benefit, and long-term economic burden analyses will be essential to support policymakers in building more equitable and resilient health systems.