Integrated community-based management of severe acute child malnutrition : Studies from rural Southern Ethiopia

Background: The World Health Organization (WHO) recommends the community-based Outpatient Therapeutic Program (OTP) as a standard treatment protocol for the management of uncomplicated Severe Acute Malnutrition (SAM) at the community level. OTP has been scaled up and integrated into the existing grassroots level government health systems in several developing countries. The aim of this thesis was to assess the implementation and outcome of a scaled-up and integrated OTP service provided at community level. Methods: One qualitative study and three quantitative studies were conducted in southern Ethiopia. Children admitted to 94 integrated OTPs, their caregivers and health extension workers providing primary health care services in the nearby health posts were included in this study. The quantitative studies were based on data generated from observation of a cohort of 1,048 children admitted to the integrated OTPs. Result: On admission 78.8% of the children had SAM. The majority of these children 60.2% exited the program neither achieving program recovery criteria nor being transferred to inpatient care. Fourteen weeks after admission to OTP, 34.6% were severely malnourished and 34.4% were moderately malnourished, thus 69.0% were still acutely malnourished. Ready-to-use Therapeutic Foods (RUTFs) provided for SAM children were commonly shared with other children in the household and sold as a commodity for the collective benefit of the family thus admitted children received only a portion of the provided amount. Further, the program suffered a severe shortage of RUTFs, where only 46.6% of admitted children were given the recommended amount of RUTFs by providers on admission and only 34.9% of these had uninterrupted provision during the follow-up. Conclusion: The integrated OTPs we studied provide a constrained service and the use of RUTFs by families is not as intended by the program. The majority of admitted children remained acutely malnourished after participating in the program for the recommended duration. For integrated OTPs to be effective in chronically food-insecure contexts, interventions that also address the economic and food needs of the entire household are essential. This may require a shift to view SAM as a symptom of broader problems affecting a family rather than as a disease of an individual child. In addition, further research is needed to understand the health system context regarding RUTFs and medication supply and service utilization of integrated OTPs