Implementation Outcomes of Strategies to Integrate Management of Moderate Acute Malnutrition (MAM) into Ethiopia’s Primary Health Care System: Application of the RE-AIM Framework

Implementation Outcomes of Strategies to Integrate Management of Moderate Acute Malnutrition (MAM) into Ethiopia’s Primary Health Care System: Application of the RE-AIM Framework | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Implementation Outcomes of Strategies to Integrate Management of Moderate Acute Malnutrition (MAM) into Ethiopia’s Primary Health Care System: Application of the RE-AIM Framework Alinoor Mohammed Farah, Yakob Desalegn, Beza Yilma, Sibhatu Biadgilign, and 10 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7071162/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background: In August 2019, Ethiopia's Ministry of Health launched the Integrated Management of Acute Malnutrition (IMAM) guideline, mandating Health Extension Workers (HEWs) to screen, admit, and provide biweekly follow-ups with specialized nutritious foods for children under five years of age and for pregnant/lactating women. This replaced the previous emergency-led model overseen by the National Disaster Risk Management Commission (NDRMC) and the World Food Program (WFP). Objective: This study aimed to assess the implementation outcomes of MAM integration into primary healthcare using the RE-AIM framework, evaluate the status of the designed implementation strategies, and identify operational successes and challenges. Method: We employed a mixed-methods approach to evaluate the outcomes of Moderate Acute Malnutrition (MAM) integration strategies using the RE-AIM framework. Implementation outcomes were assessed using indicators including reach, acceptability, adoption, fidelity, and implementation effectiveness/appropriateness. We conducted facility assessments on 101 randomly selected health posts and, conducted a retrospective chart review of MAM follow-up cards for children aged 6–59 months and pregnant and lactating women to assess implementation fidelity. Additionally, a structured adoption-assessment tool was developed to evaluate health system support for MAM integration across six WHO health system domains. We also conducted 12 in-depth interviews with the program implementers to explore the contextual factors and perceptions of the implemented strategies. Quantitative data were analyzed descriptively in Stata version 14.1, and qualitative transcripts underwent thematic analysis in NVivo version 14 using Braun and Clarke’s six-phase approach. Results: In terms of Reach, MAM services were nearly universal across 101 pilot health posts; 99 percent offered the service (88 percent biweekly) screening 66,921 children aged 6–59 months and 22,377 pregnant or lactating women monthly. Regarding effectiveness, chart reviews showed high fidelity to admission criteria (> 97 percent) and correct supplement distribution (90 percent). For Adoption, governance and service delivery integrated fully into primary healthcare, while health financing, information, workforce competencies, and logistics showed partial uptake. Under Implementation, equipment (MUAC tapes at 94 percent, scales at 42 percent) and commodities (RUSF in 75 percent of posts) were broadly available, though storage quality (23.6 percent) and HEW workload remained challenging. Qualitative findings indicated that advocacy, supervision, and mentorship improved HEW adherence to protocol, yet persistent equipment shortages, stockouts, and heavy workloads constrained service delivery. Budget constraints, parallel reporting systems, and staff turnover hindered MAM management integration into primary health care. Conclusion: The integration of MAM services into Ethiopia's primary healthcare system has achieved strong geographic coverage and frontline engagement; however, it faces resource constraints and supply chain inefficiencies. Securing sustainable financing and reinforcing policy frameworks are essential to sustain quality MAM care within Ethiopia's primary health care system. Figures Figure 1 Figure 2 Figure 3 Introduction Acute malnutrition (wasting) is characterized by rapid deterioration in a child’s nutritional status, resulting in low weight-for-height, reduced mid-upper arm circumference (MUAC), and nutritional edema [ 1 ]. It manifests as severe acute malnutrition (SAM) or moderate acute malnutrition (MAM), with global acute malnutrition (GAM), and the combined prevalence of SAM and MAM serves as a critical indicator of population-level nutritional emergencies[ 2 ]. Globally, 14 million children under the age of five suffer from SAM, while 31 million experience MAM [ 3 ]. Despite Ethiopia’s progress in reducing childhood wasting by five percentage points between 2000 and 2019[ 4 – 7 ], the 2019 Mini Ethiopia Demographic and Health Survey (EDHS) revealed alarming rates: 1.2 million wasted children, including 170,000 with SAM and 1 million with MAM[ 7 ]. This trajectory falls short of Ethiopia’s 2025 Global Nutrition Targets[ 8 ]. Although SAM management has been integrated into Ethiopia’s health system since 2008 [ 2 , 9 , 10 ], MAM integration remains nascent. Unlike SAM, which benefits from standardized global guidelines enabling successful health system integration of MAM lacks scalable models for integration, creating a policy vacuum filled by fragmented, humanitarian-focused approaches [ 11 , 12 ]. A pivotal shift occurred in August 2019, when Ethiopia’s Ministry of Health (MoH) launched the Integrated Management of Acute Malnutrition (IMAM) guideline, mandating Health Extension Workers (HEWs) to screen, admit, and provide biweekly follow-ups with specialized nutritious foods (SNF) for children under five years of age and pregnant/lactating women [ 21 ]. This replaced the previous emergency-led model overseen by the National Disaster Risk Management Commission (NDRMC) and the World Food Program (WFP) [ 22 ]. Currently piloted in 150 woredas, IMAM aims to transition MAM services from parallel humanitarian interventions to routine primary health care. Evaluations of wasting programs in low-income settings highlight systemic challenges in terms of structural readiness, clinical capacity, and integration [ 13 – 17 ]. However, these assessments have focused almost exclusively on SAM, with little attention to MAM management or combined SAM/MAM approaches. As Ethiopia’s Ministry of Health and the World Food Program, supported by implementation research from Addis Ababa University, work to pilot MAM integration into primary health care, there is an urgent need to ensure that adding MAM services does not overwhelm already limited resources or compromise the quality of SAM care. To address this gap, our broader implementation research effort systematically designed and adapted context-specific strategies using the Expert Recommendations for Implementing Change (ERIC) taxonomy [ 18 ] and the RE-AIM framework to evaluate these strategies. The RE-AIM framework is a valuable tool for evaluating nutrition and health promotion programs in various settings. It assesses five dimensions: reach, effectiveness, adoption, implementation, and maintenance [ 19 ]. RE-AIM has been widely applied in various health fields, including interventions to improve community-based management of possible serious bacterial infections (PSBI) in young infants[ 20 ]. The framework has also been used for systematic reviews of interventions to prevent eating disorders in adults[ 21 ] and the evaluation of physical activity interventions in children [ 22 ]. However, its use for evaluating MAM integration models remains undocumented. Therefore, this study aims to assess the implementation outcomes of MAM integration into primary healthcare using RE-AIM, evaluate the status of designed implementation strategies, and identify operational successes and challenges to inform improvements. Methods Study setting The present study was part of a broader implementation research project conducted by the School of Public Health at Addis Ababa University in collaboration with the World Food Program and the Federal Ministry of Health of Ethiopia (FMOH). The aim of the parent project is to develop, pilot, and evaluate context-adapted strategies for sustainably integrating the management of MAM into Ethiopia’s national primary health care (PHC) system. The program operates under the governance of a technical advisory committee (TAC) (including WFP, FMoH, NDRMC and implementing partners), which provides strategic oversight. The present study was conducted in five selected districts in Amhara, Oromia, Sidama, Afar, Somali, and Southern Nations Nationalities and Peoples' Regions. The five districts selected for the implementation research were Girawa (Oromia region), Zala (SNNPR), Aleta Cheko (Sidama region), Mille (Afar Region), and Adadle (Somali Region). Study design and approach This study employed a formative, mixed-methods evaluation guided by the RE-AIM framework[23] to assess strategies for integrating MAM into primary health care. We evaluated four RE-AIM dimensions: Reach, Adoption, Implementation/Fidelity, and Acceptability. Quantitative and qualitative data were used to comprehensively identify program successes and areas for improvement. Quantitative Component Data collection methods and metrics were aligned with specific RE-AIM dimensions: 1. Reach: Quantified by the number of health posts providing MAM services. Calculated as the proportion of the target population (children aged 6–59 months and pregnant/lactating women [PLW]) enrolled in care. 2. Implementation/Fidelity: Facility Assessments: Evaluated health post infrastructure, staffing, and management practices to gauge fidelity of MAM service delivery. Chart Reviews: Analyzed MAM follow-up cards for children (6-59 months) and PLW to assess consistency and quality of care. 3. Adoption Mapped MAM integration across all six WHO Health System Building Blocks: service delivery, health workforce, information systems, medical products, financing, and leadership/governance. 4. Acceptability Surveyed Health Extension Workers (HEWs) to capture their perceptions of MAM integration and the adequacy of available resources. Qualitative component The qualitative component explored the implementation challenges in depth to also compliment the quantitative component of acceptability. Semi-structured interviews with woreda nutrition focal persons and HEWs identified barriers to fidelity, logistical constraints and contextual adaptations. Sample size and Sampling approach The study employed a mixed purposive and random sampling design to recruit respondents from all levels of the health system. For the qualitative component, we purposively selected 12 key informants: five woreda nutrition focal persons (one per region), five IMAM Technical Assistants (one per region), one representative from the Ministry of Health, and one from the World Food Program, capturing diverse perspectives on implementation challenges and adaptations. Concurrently, for the quantitative component, we randomly chose 101 health posts for facility assessments and chart reviews. One IMAM-implementing woredas where the implementation research was conducted and the enhancement strategies were implemented was selected from each of the five regions: Girawa (Oromia), Adadle (Somali), Mille (Afar), Aleta Chuko (Sidama), and Zala (SNNP). Within these pilot woredas, we randomly selected 101 health posts for assessment, distributed as follows: Oromia (31), Somali (15), Afar (11), Sidama (18), and SNNP (26). All 101 health posts were visited for on-site facility assessment and chart review. At each site, we reviewed approximately 10 follow-up cards for children aged 6–59 months (totaling 798 charts) and 10 cards for pregnant and lactating women (totaling 782 charts). These reviews provided quantitative measures of fidelity, such as record completeness, adherence to follow-up schedules, and the number of beneficiaries reached. Strategies under evaluation Table 1 provides an overview of the implementation strategies evaluated to enhance the integration of MAM management into Ethiopia’s primary healthcare system, organized by key thematic categories. These strategies span leadership and governance, service delivery, workforce development, financing, supply management, and strengthening health information. Table 1. Implementation Strategies Evaluated for Integrating MAM Services Category Sub-category Leadership Conduct the advocacy workshop on IMAM program at kebele, woreda and regional levels. Strengthening woreda level multisectoral coordination Service delivery Supportive Supervision and regular spot checks of IMAM protocol fidelity. Introducing the family MUAC approach. Avail implementation tools (Guidelines, follow-up cards, registration books, demonstration kits and other supplies). Making MAM Day flexible (consider making it multiple days/routine) Support in conducting monthly screening Strengthen reviewing of IMAM activities at woreda level (Review Meeting) Health workforce Provide training on IMAM protocol Provide training in logistics documentation & supply management Provide training on DHIS-II, documentation, and reporting Implement HEWs incentives and motivation mechanisms Provide onsite mentorship for HEWs Finance Introducing and developing matching fund allocation Map and integrate resources Supplies Support HEWs in doing timely forecast, quantification, and request of nutrition supplies Establish nutrition supplies misuse controlling taskforce committee Maintain and re-innovate existing storage facilities Health information Strengthening PMT at woreda and health center level ensure data quality Introducing one channel reporting system (DHIS-II) Data collection The data collection period for both the quantitative and qualitative components spanned from November 25 to December 4, 2024. Quantitative Data Collection: tools and procedures Chart Review: A retrospective chart review was conducted to examine the MAM follow-up cards for both children aged 6-59 months and pregnant and lactating women (PLW) at health facilities. This method provides insights into MAM implementation and fidelity. Facility Assessments: Surveys and structured observations were used to assess the infrastructure, supplies, staffing, and management of health posts. This method provided insights into implementation/fidelity and acceptability. Program Data Analysis: Program data, such as admission trends, service reach, and the proportion of health facilities implementing MAM management, were collected and analysed from routine program records. Adoption tool: To evaluate the extent to which key health system functions support the integration of Moderate Acute Malnutrition (MAM) management into primary health care, we developed a structured adoption-assessment tool. This tool comprises six domains (elements), each with specific indicators scored on a three-level scale (full = 2, partial = 1, none = 0). The total scores reflect the degree of adoption and guide targeted strengthening activities. We developed the tool by first selecting six health system functions: Governance, Health Financing, Health Information, Health Workforce, Medical Products, and Service Delivery, based on the WHO’s health system framework. Each indicator was scored on a three-level rubric: Full (2 points) when all criteria were met with documented evidence, Partial (1 point) when some but not all criteria were satisfied, and No (0 points) when the indicator was absent or non-functional. Semi‑structured interviews were conducted with ministry of health IMAM focal and regional IMAM technical assistants to clarify the practical implementation of each function. Qualitative Data Collection The in-depth interviews explored perceptions, challenges, and the impact of various strategies, and were semi-structured, allowing for in-depth exploration of the specific challenges and changes observed during implementation of strategies to enhance the MAM integration (Supplementary files). Data collection was conducted by proficient qualitative research assistants and investigators. They were conducted in local languages, transcribed, translated into English, and recorded. The interviewers also took notes during the sessions. Measurement Table 2 shows the measurement framework used to evaluate the integration of MAM services across RE-AIM dimensions . Table 2. Measurement Framework and Indicators for Evaluating MAM Integration Using the RE-AIM Framework Dimension Description Indicator(s) Reach -Service access/level of institutionalization -MAM service is available and integrated within primary health care. -These include mainly biweekly supplementation and follow ups for children. -% of HFs implementing MAM management routinely/biweekly -Children accessing MAM management and follow up services Effectiveness/Appropriateness -Intervention effects on target outcomes - Indicators under service and clinical outcomes Adoption -Intention to try or uptake: the extent to which key health system functions support the integration of MAM management into primary health care. - MAM integration across all six WHO Health System Building Blocks: service delivery, health workforce, information systems, medical products, financing, and leadership/governance. Implementation -Quality of MAM program delivery -% of HEWs on average trained/mentored on MAM management, logistics and documentation -Mean percentage of materials/ equipment available -Mean percentage of supplies available -% of HEWs supervised on MAM Management -% of health facilities with secure and enough storage for MAM commodities -% U5 children who are followed by the MAM protocol Acceptability -Satisfaction of MAM service delivery -Perceptions of service providers on integrating MAM into primary health care. -Ongoing implementation challenges Data management and analysis The collected data were systematically managed and analyzed to ensure quality, accuracy, and reliability. Data collectors participated in a three-day training session to standardize the procedures and minimize inconsistencies. Data collection was conducted digitally using the KoboToolbox, which allowed for the application of real-time validation rules to reduce errors and identify missing or inconsistent responses. After collecting, the data were exported to Stata version 14.1 software packages for cleaning. Data cleaning involved addressing outliers, resolving inconsistencies, and managing missing data points. For adoption, health system domains (Governance, Health Financing, Health Information, Health Workforce, Medical Products, and Service Delivery) were assessed using predefined indicators scored as follows: 2 points for full achievement, 1 for partial, and 0 for none. For acceptability, provider satisfaction and perceived challenges were assessed using Likert scale responses from structured questionnaires. All quantitative analyses were conducted in Stata v14.1, with descriptive statistics (proportions) and stratification by region. Qualitative data from the in-depth interviews (IDIs) were transcribed and analyzed using Nvivo software version 14. Thematic analysis was conducted to identify key themes and insights related to ongoing integration challenges within the primary health care system. Thematic analysis followed Braun and Clarke’s six-step framework: (1) familiarization through repeated reading; (2) generation of initial codes in NVivo; (3) collating codes into candidate themes; (4) reviewing themes against the dataset; (5) defining and naming themes; and (6) producing a narrative report enriched with illustrative quotations. Analytical memos documented emerging patterns, researcher reflections, and coding decisions throughout the process. The findings were triangulated with quantitative results to enhance the depth and validity of the conclusions. Results a. Reach Nearly universal access to MAM services was achieved across the 101 pilot health posts, with 99 percent (n=100) offering the service and 88 percent on a biweekly schedule (12 percent monthly) (Table 1). Table 3: Health post providing MAM service (n=101) Frequency n (%) HPs providing MAM service 100 (99.0) Frequency of MAM service Routine (every 2 weeks) 88 (88.0) Routine (every month) 12 (12.0) Over the 10-month evaluation, health posts screened an average of 66,921 children aged 6–59 months per month (range: 60,760–76,701) and 22,377 pregnant or lactating women (PLW) per month (range: 19,609–26,399) (Figure 1). Retention gaps between identification and sustained follow-up were substantial. On average, 28 percent of children and 24 percent of PLW identified with MAM did not complete the recommended biweekly visits. These gaps peaked in August (52 percent for children and 36 percent for PLW) and were lowest in May (13 percent for children) and the early months for PLW (7 percent) (Figure 2 and 3). b. Acceptability of MAM Services (Provider Perspective) HEWs demonstrated strong readiness and confidence in delivering integrated MAM services. Nearly all respondents (96%) felt confident managing MAM in children aged 6–59 months and pregnant or lactating women (PLW), and 94% agreed that their training adequately prepared them. District-level advocacy was also effective, with 92% of respondents recognizing its role in supporting service delivery. The commitment to integrating MAM screening and follow-ups into routine duties was equally high (95%) (Supplementary Table 1). Despite this enthusiasm, HEWs reported mixed perceptions of resource adequacy. While 83% felt supported by their supervisors, fewer than half believed they had sufficient storage space (36%) or equipment (41%) for MAM commodities. Nearly half (49%) experienced frequent stock-outs of key supplies (RUSF and CSB++). Pressure from communities or local authorities to admit clients outside the eligibility criteria was reported by 42% of HEWs, although 48% reported minimal or no such pressure (see Supplementary Table 2). c. Implementation Essential equipment was largely available for anthropometry (94% MUAC tapes; 72% child spring scales), but fewer sites had functioning weighing scales (42%) or thermometers (53%) (Supplementary Table 3). Among essential nutrition commodities, 75.3 percent of health posts had ready-to-use supplementary foods (RUSF) in stock and 73.3 percent had CSB++ (corn-soy blend) available. Vitamin A capsules were present in 61.4 percent of posts, while deworming tablets were available in 59.4% of posts (Supplementary Table 3). Monitoring tools showed a high uptake of registration materials: 90.1 percent of the health posts maintained MAM registration books for children and 93.1 percent for pregnant and lactating women, but only 44.5 percent kept up-to-date stock cards for RUSF and CSB++ (Supplementary Table 4). Dedicated storage infrastructure existed at 88.1 percent of posts, with 23.6 percent rated as very good and 56.2 percent as good; 48.3 percent used pallets, 64.0 percent had secure perimeters, and 78.7 percent reported adequate ventilation (Supplementary Table 4). On average, each health post was staffed by 2.1 HEWs (SD = 1.2). External supervision was nearly universal, with 99% of posts reporting at least one supervisory visit; 76% occurred within the previous three months (Supplementary Table 5). However, over half of the HEWs (52.5%) felt that they had more work than they could manage, and 5.9% reported always feeling overworked. Training coverage in the past six months was highest for IMAM protocols (70.3%), followed by supply management (61.4%) and HMIS/DHIS-II (46.5%). Despite this, 84.2% of health posts experienced shortages of RUSF or CSB++ during this period (Supplementary Table 5). Chart review fidelity (Supplementary Table 6) demonstrated high adherence to age and MUAC admission criteria (>97%) and correct SNF distribution (90% of visits). However, only 33% of children received deworming, and 68% of child-visit records documented outcomes of each visit. d. Adoption of the MAM Program The overall adoption of IMAM varied across the six WHO health system building blocks (Table 4). Governance was fully established with dedicated Technical Working Groups and coordinated alignment of all nutrition actors under the MOH and Regional Health Bureau leadership. Service delivery has also achieved full integration: outpatient MAM admission and management now managed within the Health Extension Package at health posts. In contrast, health financing remains a gap: no regular pooled budget or costed action plans at the woreda level support IMAM activities, although HEWs are salaried on the Ministry of Health payroll. Health information systems showed partial adoption, with only selected MAM indicators incorporated into DHIS-II. Workforce adequacy is rated as full, sufficient HEWs cover child health, but competency gaps persist among health managers and HEWs in IMAM-specific technical and organizational skills. Finally, medical products and logistics are partially adopted: transportation and supply management rely on partner support, and woreda offices maintain limited storage capacity for MAM commodities. Table 4: Adoption of MAM program across the WHO building blocks Elements Indicator Level Score Health system functions Governance Technical leadership A technical working group for IMAM Full 2 Regulation and coordination Regulation and coordination of nutrition actors (including INGOs, CSOs, UN agencies and donors) aligning with the IMAM guideline. Full 2 Health financing Regular budget-pooled funding Regular budget from pooled funds to support covering financing for IMAM No 0 Annual costed action plans Annual costed action plans covering IMAM interventions (woreda level review meeting and supervision) No 0 Health workers payroll Staff in health facilities involved in IMAM on government payroll Full 2 Health information Health information system (HIS) National DHIS-II includes moderate acute malnutrition (MAM) indicators Partial 1 Health workforce Adequate health workers Adequate number of qualified health workers with geographic coverage for comprehensive child health care Full 2 Competences of health managers and health workers Adequate technical and organizational management skills for IMAM implementation/IMAM rollout. Partial 1 Medical products Logistic management system National logistic management system for drugs and medical supplies including for IMAM Partial 1 Storage Adequate storage for MAM product available and managed by woreda health office Partial 1 Service delivery MAM admission and management Outpatient management of moderate acute malnutrition (MAM) as part of the health extension program (HEP) Full 2 Qualitative component Qualitative evaluation examined the achievements of implementation strategies and ongoing challenges across six themes: Leadership and Governance, Service Delivery, Health Workforce, Financial Planning, Supply Chain and Resource Management, and Health Information Systems. Leadership & Governance Advocacy workshops and stakeholder engagement were pivotal in shifting perceptions and securing local commitments. Advocacy sessions attended by woreda leaders, community elders, and partners clarified that IMAM was a targeted treatment program rather than general food distribution program. As one woreda nutrition focal explained, “Advocacy was conducted in the presence of woreda leaders and other stakeholders. There are changes in terms of increased awareness among the community not only among the community but also among the leaders.” (Afar IMAM TA) Local authorities pledged matching funds, improved security for storage sites, and collaborated on road repairs, although regular coordination meetings often fell short because of competing priorities. “There should be a regular meeting every 15 days or every month, but because there are a lot of other agendas, there is a gap in the regularity of meetings… There is also a gap in fulfilling their mandates and an issue of budget.” (Afar IMAM TA) Community leaders, particularly women’s groups and traditional elders, mobilized households for screening, repaired roads to support supply transport, and helped minimize the misuse of therapeutic foods. However, religious leaders were largely excluded from orientation workshops due to a lack of resources, which limited their potential influence. a. Service Delivery Supportive Supervision: Regular, MAM-specific supervisory visits improved HEW adherence to admission/discharge criteria, data documentation, and supply management. One nutrition focal person described how supervisory checklists corrected earlier errors: “Some HEWs used to register only 12.5 cm of MUAC as discharge criteria. But now, with MAM-specific supportive supervision, we have solved these errors by supporting them to work according to the MAM guideline.” (Afar Woreda Nutrition Focal) Strong supervision correlates with faster recovery times and higher cure rates. In areas with inconsistent oversight, recovery took longer and documentation gaps persisted. Onsite Mentorship: Immediate on-the-job coaching helped HEWs to correct errors in real time. In regions where mentorship was implemented, HEWs reported greater confidence and fewer protocol deviations: “We use a standardized checklist during visits—if there is a gap, we develop an action plan on the spot. If it’s a minor error, like admission/discharge criteria, we mentor them immediately.” (Afar Woreda Nutrition Focal) However, resource and staffing shortages have prevented the widespread rollout of mentorship. Many woredas lack trained personnel and budgets for regular visits. Flexible Service Delivery Models: Flex-day MAM services, which allow beneficiaries to attend any day, were viewed as a means to reduce overcrowding and defaulter rates. However, HEWs cautioned that without additional manpower and clear guidance from the MOH, flexible schedules risk overburdening staff and confusing communities. “Although flexible days could help manage large crowds, the workload for HEWs will increase significantly. They are already managing services for over 200 beneficiaries every two weeks.” (Afar Woreda Nutrition Focal) Family MUAC Approach: Training mothers to use MUAC tapes was recognized as a low-cost, high-impact strategy for early malnutrition detection and for reducing HEW workload. One respondent highlighted its simplicity and community acceptability: “It’s very easy. It needs resources to give orientation. Then the women will start screening at home—our community is very interested in nutrition programs.” (Oromia Nutrition Focal) However, sporadic training, limited coverage, and lack of orientation materials hampered scale‐up; only two or three woredas had piloted Family MUAC at the time of evaluation. b. Health Workforce Development Capacity Building: Formal IMAM training, which combines protocol instruction and logistics management, significantly improved HEW performance. HEWs learned to maintain bin cards and manage supplies effectively: “There was a big issue in this woreda related to bins and cards, but now there is no health post without a functioning bin card or model. This is the result of training and refresher courses.” (Oromia Nutrition Focal) Frequent refresher sessions during review meetings further reinforced adherence, although the high turnover among trained staff necessitated repeated training. Documentation gaps persisted because many newly posted HEWs lacked prior IMAM training. Workload Management: HEWs’ workloads remained heavy, and engaging additional staff (e.g., Food Distributing Agents, health center personnel, and Woreda staff) helped only where incentives and coordination existed. Food Distributing Agents are often illiterate or unpaid, limiting their usefulness: “FDAs cannot measure MUAC or register properly; most are illiterate. They cannot help reduce HEWs’ workload in any meaningful way.” (Afar Woreda Nutrition Focal) Health center and woreda staff sometimes assisted, but competing responsibilities and budget constraints restricted sustained support. Incentivizing and Motivating HEWs: Non-monetary recognition, such as certificates for top-performing health posts, boosts morale. As one respondent noted, “We could not give money, but we give certificates. Certificates were given to health posts ranked 1–3 for their accomplishments.” (Aleta Cheko Nutrition Focal) However, monetary incentives remained largely unmet due to budget shortfalls and HEWs often felt overworked without commensurate compensation for their efforts. c. Financial Planning & Budget Integration Woredas lacked dedicated budgets for IMAM activities, and nutrition partners covered the transportation and commodity costs. Advocacy was needed to integrate IMAM into annual costed plans and leverage the newly formed kabine structure at the kebele level for budget allocation. “But allocating matching fund just for nutrition is difficult at the woreda level... currently, there is resource scarcity at the woreda level due to different reasons.” (Afar IMAM TA) d. Supply Chain & Resource Management The misuse of RUSF and CSB++ has declined due to community advocacy and engagement with legal authorities. However, intermittent stockouts persisted, and warehousing conditions varied. Storage infrastructure was often inadequate, with only a minority using pallets or secure perimeters. Logistics documentation improved waybills became nearly universal, but ledger books, stock cards, and distribution pads remained unevenly available. "We found Plumpy’Nut in shops, but it was due to a gap in monitoring; once corrective action was taken, some shops were closed" (Sidama IMAM TA). e. Health Information & Data Systems Challenges in the health information system remain significant barriers to effective program implementation. One major issue is the lack of comprehensive training for HEWs and other frontline staff on the proper use of reporting tools, such as the District Health Information System (DHIS). Moreover, the presence of parallel reporting systems remains a persistent challenge. Various stakeholders and partners often require different reporting formats and indicators, leading to duplication of effort and an increased workload for health workers. "We have reported the gaps repeatedly to the MOH. The reporting should be one channel, the HMIS is online and easy to use, and WFP can also get reports from that. So, we have asked, and it has started, but it has gaps" (Sidama IMAM-TA). Discussion The study indicated that while MAM services have achieved near-universal geographic coverage, 99 percent of health posts offer MAM management. Population-level reach remains uneven, with substantial gaps between case identification and follow-up. Health Extension Workers express strong confidence in delivering integrated MAM services and generally welcomed the program; however, persistent concerns about resource adequacy and recurrent stockouts highlight ongoing operational barriers. Although governance and service delivery show robust adoption, critical shortfalls in health financing, information systems, and supply chain management threaten the sustainability of gains. HEWs demonstrated strong readiness and confidence in delivering integrated MAM services despite mixed perceptions of resource adequacy. Although essential equipment and commodities were generally available, gaps persisted in the monitoring tools and storage infrastructure. studies indicated that integrating nutrition services into existing health programs is generally well-accepted by communities and health workers, leading to increased service utilization and efficiency[ 24 , 25 ]. Properly trained and supervised community health workers can effectively manage cases of severe acute malnutrition[ 26 , 27 ]; however, persistent challenges, such as inadequate staffing, insufficient training, and broader health system constraints, often hinder integration efforts[ 24 , 28 ]. Successful integration requires strengthening health systems, optimizing task allocation, and synchronizing work schedules across sectors[ 28 , 29 ]. Frontline workers adopt various practices that both facilitate and impede nutrition integration, influenced by societal, organizational, and individual factors[ 30 ]. Despite these challenges, integrated approaches have shown potential for improving service coverage and treatment outcomes in countries such as Malawi, Ghana, and Zambia[ 17 ]. Adoption of the MAM program varied across the six WHO health system building blocks: governance and service delivery were fully established, whereas health financing, information systems, and logistics were only partially adopted. Integrating nutritional interventions into health systems and community programs can enhance maternal and child health outcomes. Studies have demonstrated positive impacts when nutrition is incorporated into extension services, health systems, and intersectoral programs[ 31 – 33 ]. Key factors for successful integration include clear leadership, shared priorities, adequate workforce training, and strong coordination across sectors and administrative levels[ 32 , 34 ]. Community-based integrated programs that utilize local workers can deliver cost-effective, multifaceted services, such as nutrition education, health care, and family planning[ 35 ]. However, fully integrating nutrition across all health system functions remains challenging, particularly in financing and supply management[ 29 ]. Careful program design, active community participation, and ongoing evaluation are essential for developing sustainable, context-specific integrated nutrition interventions [ 34 ]. Qualitative findings highlighted that advocacy and multisectoral coordination have successfully shifted perceptions and fostered local ownership, while targeted supervision and on-site mentorship bolstered HEW performance. Although the Family MUAC approach holds promise, its effectiveness depends on sustainable funding, consistent training, and clear policy support. Addressing persistent gaps in human resources, logistics, and data systems is essential for sustaining and scaling up IMAM integration. These findings align with evidence from other studies that emphasize the value of such strategies not only for MAM but also for broader maternal, newborn, and child health (MNCH) programs[ 36 – 38 ]. Integrating community-based management of acute malnutrition (CMAM) into health systems requires more than technical guidelines; it demands strengthened coordination, targeted training for frontline workers, and a consistent and reliable supply of essential commodities[ 39 , 40 ]. Supervision is a key driver of improved health worker performance; however, studies highlight the difficulty of maintaining high-quality and regular supervision amidst systemic constraints such as limited resources, competing priorities, and geographic inaccessibility[ 41 ]. Task shifting and family MUAC have shown promise in improving community nutrition programs and reducing the workload of health workers. Studies have demonstrated that mothers can effectively screen their children for malnutrition using MUAC tapes, with a sensitivity and specificity comparable to that of community health workers[ 42 , 43 ]. Integrating the treatment of acute malnutrition by community health volunteers into existing programs has led to better outcomes, including higher recovery and lower default rates[ 44 ]. Task shifting is a viable option for improving health system efficiency and access to care in low-resource settings[ 45 ]. Supply chain effectiveness is essential for ensuring uninterrupted service delivery; however, health product supply chains in developing countries face numerous challenges, including ineffective distribution networks, stock-outs, and coordination problems among stakeholders [ 46 , 47 ]. These issues significantly affect access to essential medicines and health technologies. [ 48 ]. Addressing both supply and demand constraints in local value chains is crucial for improving nutritional outcomes in developing countries[ 49 ]. Finally, information systems are increasingly important for measuring and improving the quality and coverage of health services[ 50 ]. However, the implementation of health information systems, such as DHIS, in low- and middle-income countries faces several challenges. While these systems can improve data timeliness and completeness[ 51 ], barriers include inadequate infrastructure, unreliable Internet, and lack of training[ 52 ]. Parallel reporting systems and unintegrated tools create duplication and increase the workload [ 53 ]. To improve DHIS implementation, recommendations include integrating systems, providing regular training and supervision, enhancing infrastructure, and promoting local ownership[ 52 , 53 ]. This study had several limitations. First, facility assessments and chart reviews provide only a snapshot in time and cannot capture long-term maintenance or evolving trends in service quality without repeated measurements. By design, the evaluation focused on early implementation; therefore, long-term sustainability (maintenance) remains unassessed and will require follow-up studies to understand institutionalization over time. Finally, our reliance on routine data means that chart review findings depend entirely on the completeness and accuracy of MAM follow-up cards; any documentation gaps or data quality issues directly undermine the validity of our fidelity and effectiveness measures. Conclusions In conclusion, the integration of MAM services into Ethiopia’s primary healthcare system has achieved remarkable geographic coverage and strong frontline engagement; however, it continues to struggle with resource constraints and supply chain inefficiencies. Moving forward, securing sustainable financing and reinforcing policy frameworks will be essential to sustain high-quality and equitable MAM care within Ethiopia’s primary health care system. Abbreviations CMAM Community Management of Acute Malnutrition CSB++ Corn-Soy Blend Plus Plus CSOs Civil Service Organizations DHIS District Health Information System DRMC Disaster Risk Management Commission EDHS Ethiopia Demographic and Health Survey HEP Health Extension Program HEW Health Extension Workers IDI In-depth Interview IMAM Integrated Management of Acute Malnutrition INGOs International Non-Profit Organizations MAM Moderate Acute Malnutrition MNCH Maternal, Newborn, and Child Health MOH Ministry of Health MUAC Mid-Upper Arm Circumference PLW Pregnant and Lactating Women RE-AIM Reach, Effectiveness, Adoption, Implementation, and Maintenance RUSF Ready-to-Use Supplementary Food SAM Severe Acute Malnutrition SD Standard Deviation SNF Specialized Nutritious Food UN United Nations WFP World Food Programme WHO World Health Organization Declarations Ethics approval and consent to participate This study was conducted according to the guidelines laid down in the Declaration of Helsinki, and all procedures involving research study participants were approved by the Institutional Review Board (IRB) of the College of Health Sciences, Addis Ababa University. Additionally, the necessary permissions were obtained from the relevant federal and local government offices/authorities. Participants were provided with a detailed explanation of the study’s purpose, procedures, potential benefits, and risks before they provided their written informed consent. Throughout the process, participants were assured of their right to decline or refuse to answer any or all questions without facing any consequences. Privacy was strictly maintained, and all the information collected was kept confidential. To ensure data security, all audio recordings were stored on a password-protected computer accessible only to the researchers involved in this study. Consent for publication Not applicable Availability of data and materials The transcripts are available from the corresponding author on reasonable request . Competing interests The authors declare that they have no conflicts of interest. Funding This study was funded by WFP Ethiopia. The views expressed herein are solely those of the authors and do not reflect the views of the WFP or any other stakeholder. Author contribution AM, SH conceived the study. AM analyzed the data and wrote the first draft with inputs from SH, YD and SB. All authors have read and approved the final manuscript. Acknowledgements The authors wish to thank the study data collectors, the woreda health office, HEWs and IDIs participants References WHO. Supplementary foods for the management of moderate acute malnutrition in infants and children 6–59 months of age. World Health Organization Geneva; 2012. Force MT. Moderate acute malnutrition: a decision tool for emergencies. Global Nutrition Cluster; 2017. WHO. Levels and trends in child malnutrition child malnutrition: UNICEF/WHO/World Bank Group Joint Child Malnutrition Estimates: Key findings of the 2023 edition. World Health Organization; 2023. CSA and ICF. Ethiopia demographic and health survey 2011. Maryland, USA: Central Statistical Agency of Ethiopia and ICF International Addis Ababa, Ethiopia and Calverton; 2012. CSA and ICF. Ethiopia demographic and health survey 2011. Maryland, USA: Central Statistical Agency and ICF International,: Addis Ababa, Ethiopia and Calverton; 2012. p. 430. CSA. and ICF, Ethiopia demographic and health survey, Addis Ababa, Ethiopia and Calverton, Maryland, USA . 2016. Ethiopian Public Health Institute (EPHI). [Ethiopia] and ICF, Ethiopia Mini Demographic and Health Survey 2019: Final Report. Rockville, Maryland, USA: EPHI and ICF. 2019. UNICEF. Global action plan on child wasting: a framework for action to accelerate progress in preventing and managing child wasting and the achievement of the Sustainable Development Goals. 2021. Hall A, Blankson B, Shoham J. The impact and effectiveness of emergency nutrition and nutrition-related interventions: a review of published evidence 2004–2010. Emerg Nutr Netw; 2011. Lenters LM, et al. Treatment of severe and moderate acute malnutrition in low-and middle-income settings: a systematic review, meta-analysis and Delphi process. BMC Public Health. 2013;13:1–15. Shoham J, McGrath M. Editorial perspective on the continuum of care for children with acute malnutrition. Field Exch. 2019;60:2. Lenters L, Wazny K, Bhutta ZA. Management of severe and moderate acute malnutrition in children. Reproductive, maternal, newborn, and child health: disease control priorities. 3rd edition. Washington, DC: World Bank, 2016: pp. 205–223. Deconinck H, et al. Review of community-based management of acute malnutrition in the postemergency context: synthesis of lessons on integration of CMAM into national health systems in Ethiopia, Malawi and Niger. Washington: FANTA AED; 2008. Deconinck H, et al. Review of community-based management of acute malnutrition implementation in West Africa: summary report. Washington: FANTA AED; 2011. Aguayo VM, et al. Community management of acute malnutrition (CMAM) programme in P akistan effectively treats children with uncomplicated severe wasting. Matern Child Nutr. 2018;14:e12623. Renzaho AM, et al. Assessing the impact of integrated community-based Management of Severe Wasting Programs in conflict-stricken South Sudan: a multi-dimensional approach to scalability of nutrition emergency response programs. Int J Environ Res Public Health. 2021;18(17):9113. Maleta K, Amadi B. Community-based management of acute malnutrition (CMAM) in sub-Saharan Africa: case studies from Ghana, Malawi, and Zambia. FoodNutr Bull. 2014;35(2suppl1):S34–8. Powell BJ et al. A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project. Implementation science, 2015. 10: pp. 1–14. Glasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health promotion interventions: the RE-AIM framework. Am J Public Health. 1999;89(9):1322–7. Tiruneh GT, et al. Effect of community-based newborn care implementation strategies on access to and effective coverage of possible serious bacterial infection (PSBI) treatment for sick young infants during COVID-19 pandemic. PLoS ONE. 2024;19(3):e0300880. Nacke B, et al. A systematic review of reach, adoption, implementation and maintenance of Internet-based interventions to prevent eating disorders in adults. Eur J Pub Health. 2021;31(Supplement1):i29–37. McGoey T, et al. Evaluation of physical activity interventions in children via the reach, efficacy/effectiveness, adoption, implementation, and maintenance (RE-AIM) framework: a systematic review of randomized and non-randomized trials. Prev Med. 2016;82:8–19. Glasgow RE, et al. RE-AIM planning and evaluation framework: adapting to new science and practice with a 20-year review. Front public health. 2019;7:64. Ryman TK, et al. Community and health worker perceptions and preferences regarding integration of other health services with routine vaccinations: four case studies. J Infect Dis. 2012;205(suppl1):S49–55. Pérez-Escamilla R, Engmann C. Integrating nutrition services into health care systems platforms: Where are we and where do we go from here. Matern Child Nutr. 2019;15:e12743. Ogobara Dougnon A, et al. Impact of integration of severe acute malnutrition treatment in primary health care provided by community health workers in rural Niger. Nutrients. 2021;13(11):4067. Puett C, et al. Sometimes they fail to keep their faith in us’: community health worker perceptions of structural barriers to quality of care and community utilisation of services in B angladesh. Matern Child Nutr. 2015;11(4):1011–22. Phuka J, et al. A job analysis of community health workers in the context of integrated nutrition and early child development. Volume 1308. Annals of the New York Academy of Sciences; 2014. pp. 183–91. 1. Deconinck H, et al. Integrating acute malnutrition interventions into national health systems: lessons from Niger. BMC Public Health. 2016;16:1–7. Namugumya BS, et al. Integrating Nutrition actions in Service Delivery: the practices of Frontline workers in Uganda. Int J health policy Manage. 2022;11(12):2895. Salam RA, Das JK, Bhutta ZA. Integrating nutrition into health systems: What the evidence advocates. Matern Child Nutr. 2019;15:e12738. Kim SS, et al. Understanding the role of intersectoral convergence in the delivery of essential maternal and child nutrition interventions in Odisha, India: a qualitative study. BMC Public Health. 2017;17:1–12. Fanzo J, et al. Integration of nutrition into extension and advisory services: a synthesis of experiences, lessons, and recommendations. FoodNutr Bull. 2015;36(2):120–37. Yousafzai AK, Aboud F. Review of implementation processes for integrated nutrition and psychosocial stimulation interventions. Ann N Y Acad Sci. 2014;1308(1):33–45. Heidkamp RA, et al. How are maternal-child nutrition activities integrated at the community level? Lessons from Haiti. Wiley Online Library; 2012. Sarfraz M, Hamid S. Exploring managers’ perspectives on MNCH program in Pakistan: a qualitative study. PLoS ONE. 2016;11(1):e0146665. Somassè YE, et al. Sustainability and scaling-up analysis of community-based management of acute malnutrition: lessons learned from Burkina Faso. FoodNutr Bull. 2013;34(3):338–48. Ireen S, et al. Challenges and opportunities of integration of community based Management of Acute Malnutrition into the government health system in Bangladesh: a qualitative study. BMC Health Serv Res. 2018;18:1–12. Kouam CE, et al. Perspectives for integration into the local health system of community-based management of acute malnutrition in children under 5 years: a qualitative study in Bangladesh. Nutr J. 2014;13:1–15. Kavita S, Doledec D, Begum F. Managing Acute Malnutrition: A Review of the Evidence and Country Experiences in South Asia and a Recommended Approach for Bangladesh. Washington DC: FANTA; 2014. Rowe AK, et al. The rise and fall of supervision in a project designed to strengthen supervision of Integrated Management of Childhood Illness in Benin. Health Policy Plann. 2010;25(2):125–34. Alé FG, et al. Mothers screening for malnutrition by mid-upper arm circumference is non-inferior to community health workers: results from a large-scale pragmatic trial in rural Niger. Archives Public Health. 2016;74:1–12. Blackwell N et al. M others U nderstand A nd C an do it (MUAC): a comparison of mothers and community health workers determining mid-upper arm circumference in 103 children aged from 6 months to 5 years. Archives of public health, 2015. 73: pp. 1–7. Donfouet HPP, et al. The impacts of task shifting on the management and treatment of malnourished children in Northern Kenya: a cluster-randomized controlled trial. Health Policy Plann. 2024;39(7):710–21. Smith S, et al. Task-shifting and prioritization: a situational analysis examining the role and experiences of community health workers in Malawi. Hum Resour health. 2014;12:1–13. Yadav P. Health product supply chains in developing countries: diagnosis of the root causes of underperformance and an agenda for reform. Volume 1. Health systems & reform; 2015. pp. 142–54. 2. Kraiselburd S, Yadav P. Supply chains and global health: an imperative for bringing operations management scholarship into action. Prod Oper Manage. 2013;22(2):377–81. Yadav P, Stapleton O, Van Wassenhove LN. Always cola, rarely essential medicines: comparing medicine and consumer product supply chains in the developing world. 2010. Donovan J, Gelli A. Designing interventions in local value chains for improved health and nutrition: insights from Malawi. World Dev Perspect. 2019;16:100149. Lippeveld T, Sauerborn R, Bodart C. Design and implementation of health information systems. Volume 281. World Health Organization Geneva; 2000. Simba D, et al. Perceived usefulness, competency, and associated factors in using District health information system data among District health managers in Tanzania: cross-sectional study. JMIR Formative Res. 2022;6(5):e29469. Bogale TN, et al. Barriers, facilitators and motivators of electronic community health information system use among health workers in Ethiopia. Front Digit Health. 2023;5:1162239. Mekonnen ZA, et al. Lessons and implementation challenges of community health information system in LMICs: a scoping review of literature. Online J Public Health Inf. 2022;14(1):e62639. Additional Declarations No competing interests reported. Supplementary Files SupplementaryTables.docx InterviewguideIMAMTAsNutritionfocals.docx InterviewguideFMOHWFP.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 22 Aug, 2025 Reviewers agreed at journal 16 Aug, 2025 Reviewers invited by journal 14 Aug, 2025 Editor assigned by journal 13 Aug, 2025 Editor invited by journal 24 Jul, 2025 Submission checks completed at journal 24 Jul, 2025 First submitted to journal 24 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7071162","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":502595651,"identity":"3dffdba3-c869-4a1e-8c36-23025790a689","order_by":0,"name":"Alinoor Mohammed Farah","email":"","orcid":"","institution":"Addis Ababa University","correspondingAuthor":false,"prefix":"","firstName":"Alinoor","middleName":"Mohammed","lastName":"Farah","suffix":""},{"id":502595652,"identity":"54961e9c-b569-4822-87e2-413d42a7dd8e","order_by":1,"name":"Yakob Desalegn","email":"","orcid":"","institution":"Addis Ababa University","correspondingAuthor":false,"prefix":"","firstName":"Yakob","middleName":"","lastName":"Desalegn","suffix":""},{"id":502595654,"identity":"d772a46b-2c3b-442b-8987-bfe304abcb4c","order_by":2,"name":"Beza Yilma","email":"","orcid":"","institution":"Addis Ababa University","correspondingAuthor":false,"prefix":"","firstName":"Beza","middleName":"","lastName":"Yilma","suffix":""},{"id":502595661,"identity":"55f3ba5d-2605-40c1-acec-1579e298d186","order_by":3,"name":"Sibhatu Biadgilign","email":"","orcid":"","institution":"Addis Ababa University","correspondingAuthor":false,"prefix":"","firstName":"Sibhatu","middleName":"","lastName":"Biadgilign","suffix":""},{"id":502595662,"identity":"e95cb4dc-26c3-4458-bf11-041cb9dc3fec","order_by":4,"name":"Aweke Kebede","email":"","orcid":"","institution":"World Food Programme (WFP)","correspondingAuthor":false,"prefix":"","firstName":"Aweke","middleName":"","lastName":"Kebede","suffix":""},{"id":502595664,"identity":"ced32eb5-5858-43d3-beec-51a499f9070d","order_by":5,"name":"Kemeria Barsenga","email":"","orcid":"","institution":"World Food Programme (WFP)","correspondingAuthor":false,"prefix":"","firstName":"Kemeria","middleName":"","lastName":"Barsenga","suffix":""},{"id":502595666,"identity":"b812ef3c-768d-48cb-b006-6b791c6420c4","order_by":6,"name":"Tafara Ndumiyana","email":"","orcid":"","institution":"World Food Programme (WFP)","correspondingAuthor":false,"prefix":"","firstName":"Tafara","middleName":"","lastName":"Ndumiyana","suffix":""},{"id":502595671,"identity":"61265508-0e24-4b45-b65d-0f813b105e09","order_by":7,"name":"Robert Ackatia-Armah","email":"","orcid":"","institution":"World Food Programme (WFP)","correspondingAuthor":false,"prefix":"","firstName":"Robert","middleName":"","lastName":"Ackatia-Armah","suffix":""},{"id":502595672,"identity":"945374ea-1665-42a4-a545-e78aef135677","order_by":8,"name":"Meron Tamirat","email":"","orcid":"","institution":"Addis Ababa University","correspondingAuthor":false,"prefix":"","firstName":"Meron","middleName":"","lastName":"Tamirat","suffix":""},{"id":502595673,"identity":"2661c2ee-47b3-4909-9d9c-0c676a150272","order_by":9,"name":"Feven Hailu","email":"","orcid":"","institution":"Addis Ababa University","correspondingAuthor":false,"prefix":"","firstName":"Feven","middleName":"","lastName":"Hailu","suffix":""},{"id":502595674,"identity":"c01c309d-f622-457d-98f0-4e44b11aeaac","order_by":10,"name":"Eskeziaw Abebe","email":"","orcid":"","institution":"Addis Ababa University","correspondingAuthor":false,"prefix":"","firstName":"Eskeziaw","middleName":"","lastName":"Abebe","suffix":""},{"id":502595675,"identity":"c6e1e79d-4df0-42e4-be94-41bebb02f82a","order_by":11,"name":"Genet Kiflemariam","email":"","orcid":"","institution":"Addis Ababa University","correspondingAuthor":false,"prefix":"","firstName":"Genet","middleName":"","lastName":"Kiflemariam","suffix":""},{"id":502595676,"identity":"5ff873df-b8f7-4898-82a1-e05483a9ad5d","order_by":12,"name":"Samson Gebremedhin","email":"","orcid":"","institution":"Addis Ababa University","correspondingAuthor":false,"prefix":"","firstName":"Samson","middleName":"","lastName":"Gebremedhin","suffix":""},{"id":502595677,"identity":"fa8e7f41-c144-4af2-afd5-980b55440e8b","order_by":13,"name":"Seifu Hagos Gebreyesus","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1UlEQVRIiWNgGAWjYFACxoYPjA02dvwMDGxEa2mcwdiQlizZQLwWBkaglsOMGw4Qq0W+vbmxgXEHM7PxjeRnDz5UMMjzix3Ar8XgzEGgljNsfGY30swNZ5xhMJw5O4GAFonE9geMbTzMZjcSzKR52xgSDG4T0CI//yHQljYJxs0z0r8Rp4XhBiNIiwHjBokcIm0xOJMI0pKQLHHmTZnkjDMShP0i3378IVDLfzv+9vRtEh8qbOT5pQk5DAiY/4BIAbBKCcLKEYD/ACmqR8EoGAWjYCQBAM2nQ+eM8mFdAAAAAElFTkSuQmCC","orcid":"","institution":"Addis Ababa University","correspondingAuthor":true,"prefix":"","firstName":"Seifu","middleName":"Hagos","lastName":"Gebreyesus","suffix":""}],"badges":[],"createdAt":"2025-07-08 06:23:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7071162/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7071162/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":89641658,"identity":"8b93022c-b430-45ed-943e-dda55b50b548","added_by":"auto","created_at":"2025-08-22 08:11:06","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":57675,"visible":true,"origin":"","legend":"\u003cp\u003eScreening for children 6-59 months and pregnant and lactating women\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7071162/v1/e7f360789a734b7d43adfc32.jpg"},{"id":89641660,"identity":"b79098ae-5fff-4510-80e7-8a4aac667572","added_by":"auto","created_at":"2025-08-22 08:11:06","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":69445,"visible":true,"origin":"","legend":"\u003cp\u003echildren 6-59 months identified through screening as MAM with those who were subsequently enrolled and followed biweekly\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7071162/v1/cefa41a921c0399f8abf6b04.jpg"},{"id":89641668,"identity":"04543e52-248b-467f-8335-04bffb0914f6","added_by":"auto","created_at":"2025-08-22 08:11:06","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":70569,"visible":true,"origin":"","legend":"\u003cp\u003ePLW identified through screening as MAM, with those who were subsequently enrolled and followed biweekly.\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7071162/v1/751e154b24d800327549c648.jpg"},{"id":89643277,"identity":"7dca6464-ee6b-4114-9c1e-cde893c7ae0d","added_by":"auto","created_at":"2025-08-22 08:27:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1449400,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7071162/v1/223579ec-630c-425d-afe6-9ae12c0ade38.pdf"},{"id":89641659,"identity":"ab24572f-999d-4493-a78a-320f2c4d8160","added_by":"auto","created_at":"2025-08-22 08:11:06","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":28750,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTables.docx","url":"https://assets-eu.researchsquare.com/files/rs-7071162/v1/941c884212323fb7bbaac004.docx"},{"id":89642451,"identity":"8cfd1155-6b06-4e69-8749-eddb4ea2964e","added_by":"auto","created_at":"2025-08-22 08:19:06","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":30708,"visible":true,"origin":"","legend":"","description":"","filename":"InterviewguideIMAMTAsNutritionfocals.docx","url":"https://assets-eu.researchsquare.com/files/rs-7071162/v1/edb5e312b9cab696fb2dee08.docx"},{"id":89641664,"identity":"757f015f-b7fe-46a2-b810-106ce5bb9004","added_by":"auto","created_at":"2025-08-22 08:11:06","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":27046,"visible":true,"origin":"","legend":"","description":"","filename":"InterviewguideFMOHWFP.docx","url":"https://assets-eu.researchsquare.com/files/rs-7071162/v1/492f2794fefe7706904c5332.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Implementation Outcomes of Strategies to Integrate Management of Moderate Acute Malnutrition (MAM) into Ethiopia’s Primary Health Care System: Application of the RE-AIM Framework","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAcute malnutrition (wasting) is characterized by rapid deterioration in a child\u0026rsquo;s nutritional status, resulting in low weight-for-height, reduced mid-upper arm circumference (MUAC), and nutritional edema [\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e]. It manifests as severe acute malnutrition (SAM) or moderate acute malnutrition (MAM), with global acute malnutrition (GAM), and the combined prevalence of SAM and MAM serves as a critical indicator of population-level nutritional emergencies[\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e]. Globally, 14\u0026nbsp;million children under the age of five suffer from SAM, while 31\u0026nbsp;million experience MAM [\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e]. Despite Ethiopia\u0026rsquo;s progress in reducing childhood wasting by five percentage points between 2000 and 2019[\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e], the 2019 Mini Ethiopia Demographic and Health Survey (EDHS) revealed alarming rates: 1.2\u0026nbsp;million wasted children, including 170,000 with SAM and 1\u0026nbsp;million with MAM[\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e]. This trajectory falls short of Ethiopia\u0026rsquo;s 2025 Global Nutrition Targets[\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eAlthough SAM management has been integrated into Ethiopia\u0026rsquo;s health system since 2008 [\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e], MAM integration remains nascent. Unlike SAM, which benefits from standardized global guidelines enabling successful health system integration of MAM lacks scalable models for integration, creating a policy vacuum filled by fragmented, humanitarian-focused approaches [\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e]. A pivotal shift occurred in August 2019, when Ethiopia\u0026rsquo;s Ministry of Health (MoH) launched the Integrated Management of Acute Malnutrition (IMAM) guideline, mandating Health Extension Workers (HEWs) to screen, admit, and provide biweekly follow-ups with specialized nutritious foods (SNF) for children under five years of age and pregnant/lactating women [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e]. This replaced the previous emergency-led model overseen by the National Disaster Risk Management Commission (NDRMC) and the World Food Program (WFP) [\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e]. Currently piloted in 150 woredas, IMAM aims to transition MAM services from parallel humanitarian interventions to routine primary health care.\u003c/p\u003e\n\u003cp\u003eEvaluations of wasting programs in low-income settings highlight systemic challenges in terms of structural readiness, clinical capacity, and integration [\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e]. However, these assessments have focused almost exclusively on SAM, with little attention to MAM management or combined SAM/MAM approaches. As Ethiopia\u0026rsquo;s Ministry of Health and the World Food Program, supported by implementation research from Addis Ababa University, work to pilot MAM integration into primary health care, there is an urgent need to ensure that adding MAM services does not overwhelm already limited resources or compromise the quality of SAM care.\u003c/p\u003e\n\u003cp\u003eTo address this gap, our broader implementation research effort systematically designed and adapted context-specific strategies using the Expert Recommendations for Implementing Change (ERIC) taxonomy [\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e] and the RE-AIM framework to evaluate these strategies. The RE-AIM framework is a valuable tool for evaluating nutrition and health promotion programs in various settings. It assesses five dimensions: reach, effectiveness, adoption, implementation, and maintenance [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e]. RE-AIM has been widely applied in various health fields, including interventions to improve community-based management of possible serious bacterial infections (PSBI) in young infants[\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e]. The framework has also been used for systematic reviews of interventions to prevent eating disorders in adults[\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e] and the evaluation of physical activity interventions in children [\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e]. However, its use for evaluating MAM integration models remains undocumented. Therefore, this study aims to assess the implementation outcomes of MAM integration into primary healthcare using RE-AIM, evaluate the status of designed implementation strategies, and identify operational successes and challenges to inform improvements.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe present study was part of a broader implementation research project conducted by the School of Public Health at Addis Ababa University in collaboration with the World Food Program and the Federal Ministry of Health of Ethiopia (FMOH). The aim of the parent project is to develop, pilot, and evaluate context-adapted strategies for sustainably integrating the management of MAM into Ethiopia\u0026rsquo;s national primary health care (PHC) system. The program operates under the governance of a technical advisory committee (TAC) (including WFP, FMoH, NDRMC and implementing partners), which provides strategic oversight.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe present study was conducted in five selected districts in Amhara, Oromia, Sidama, Afar, Somali, and Southern Nations Nationalities and Peoples\u0026apos; Regions. The five districts selected for the implementation research were Girawa (Oromia region), Zala (SNNPR), Aleta Cheko (Sidama region), Mille (Afar Region), and Adadle (Somali Region).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy design and approach\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study employed a formative, mixed-methods evaluation guided by the RE-AIM framework[23]\u0026nbsp;to assess strategies for integrating MAM into primary health care. We evaluated four RE-AIM dimensions: Reach, Adoption, Implementation/Fidelity, and Acceptability. Quantitative and qualitative data were used to comprehensively identify program successes and areas for improvement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuantitative Component\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData collection methods and metrics were aligned with specific RE-AIM dimensions:\u003c/p\u003e\n\u003cp\u003e1. Reach:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eQuantified by the number of health posts providing MAM services.\u003c/li\u003e\n \u003cli\u003eCalculated as the proportion of the target population (children aged 6\u0026ndash;59 months and pregnant/lactating women [PLW]) enrolled in care.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e2. \u0026nbsp; Implementation/Fidelity:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eFacility Assessments: Evaluated health post infrastructure, staffing, and management practices to gauge fidelity of MAM service delivery.\u003c/li\u003e\n \u003cli\u003eChart Reviews: Analyzed MAM follow-up cards for children (6-59 months) and PLW to assess consistency and quality of care.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e3. \u0026nbsp; Adoption\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eMapped MAM integration across all six WHO Health System Building Blocks: service delivery, health workforce, information systems, medical products, financing, and leadership/governance.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e4. \u0026nbsp; Acceptability\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eSurveyed Health Extension Workers (HEWs) to capture their perceptions of MAM integration and the adequacy of available resources.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eQualitative component\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe qualitative component explored the implementation challenges in depth to also compliment the quantitative component of acceptability. Semi-structured interviews with woreda nutrition focal persons and HEWs identified barriers to fidelity, logistical constraints and contextual adaptations.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSample size and Sampling approach\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study employed a mixed purposive and random sampling design to recruit respondents from all levels of the health system. For the qualitative component, we purposively selected 12 key informants: five woreda nutrition focal persons (one per region), five IMAM Technical Assistants (one per region), one representative from the Ministry of Health, and one from the World Food Program, capturing diverse perspectives on implementation challenges and adaptations. Concurrently, for the quantitative component, we randomly chose 101 health posts for facility assessments and chart reviews.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOne IMAM-implementing woredas where the implementation research was conducted and the enhancement strategies were implemented was selected from each of the five regions: Girawa (Oromia), Adadle (Somali), Mille (Afar), Aleta Chuko (Sidama), and Zala (SNNP). Within these pilot woredas, we randomly selected 101 health posts for assessment, distributed as follows: Oromia (31), Somali (15), Afar (11), Sidama (18), and SNNP (26).\u003c/p\u003e\n\u003cp\u003eAll 101 health posts were visited for on-site facility assessment and chart review. At each site, we reviewed approximately 10 follow-up cards for children aged 6\u0026ndash;59 months (totaling 798 charts) and 10 cards for pregnant and lactating women (totaling 782 charts). These reviews provided quantitative measures of fidelity, such as record completeness, adherence to follow-up schedules, and the number of beneficiaries reached.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrategies under evaluation\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 1 provides an overview of the implementation strategies evaluated to enhance the integration of MAM management into Ethiopia\u0026rsquo;s primary healthcare system, organized by key thematic categories. These strategies span leadership and governance, service delivery, workforce development, financing, supply management, and strengthening health information.\u003c/p\u003e\n\u003cp\u003eTable 1. Implementation Strategies Evaluated for Integrating MAM Services\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategory\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSub-category\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eLeadership\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eConduct the advocacy workshop on IMAM program at kebele, woreda and regional levels.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eStrengthening woreda level multisectoral coordination\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eService delivery\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eSupportive Supervision and regular spot checks of IMAM protocol fidelity.\u003c/p\u003e\n \u003cp\u003eIntroducing the family MUAC approach.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eAvail implementation tools (Guidelines, follow-up cards, registration books, demonstration kits and other supplies).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eMaking MAM Day flexible (consider making it multiple days/routine)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eSupport in conducting monthly screening\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eStrengthen reviewing of IMAM activities at woreda level (Review Meeting)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eHealth workforce\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eProvide training on IMAM protocol\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eProvide training in logistics documentation \u0026amp; supply management\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eProvide training on DHIS-II, documentation, and reporting\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eImplement HEWs incentives and motivation mechanisms\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eProvide onsite mentorship for HEWs\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eFinance\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eIntroducing and developing matching fund allocation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eMap and integrate resources\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eSupplies\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eSupport HEWs in doing timely forecast, quantification, and request of nutrition supplies\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eEstablish nutrition supplies misuse controlling taskforce committee\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eMaintain and re-innovate existing storage facilities\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eHealth information\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eStrengthening PMT at woreda and health center level ensure data quality\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eIntroducing one channel reporting system (DHIS-II)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eData collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data collection period for both the quantitative and qualitative components spanned from November 25 to December 4, 2024.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuantitative Data Collection: tools and procedures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eChart Review:\u003c/em\u003e A retrospective chart review was conducted to examine the MAM follow-up cards for both children aged 6-59 months and pregnant and lactating women (PLW) at health facilities. This method provides insights into MAM implementation and fidelity.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFacility Assessments:\u003c/em\u003e Surveys and structured observations were used to assess the infrastructure, supplies, staffing, and management of health posts. This method provided insights into implementation/fidelity and acceptability.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eProgram Data Analysis:\u003c/em\u003e Program data, such as admission trends, service reach, and the proportion of health facilities implementing MAM management, were collected and analysed from routine program records.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAdoption tool:\u003c/em\u003e To evaluate the extent to which key health system functions support the integration of Moderate Acute Malnutrition (MAM) management into primary health care, we developed a structured adoption-assessment tool. This tool comprises six domains (elements), each with specific indicators scored on a three-level scale (full = 2, partial = 1, none = 0). The total scores reflect the degree of adoption and guide targeted strengthening activities.\u003c/p\u003e\n\u003cp\u003eWe developed the tool by first selecting six health system functions: Governance, Health Financing, Health Information, Health Workforce, Medical Products, and Service Delivery, based on the WHO\u0026rsquo;s health system framework. Each indicator was scored on a three-level rubric: Full (2 points) when all criteria were met with documented evidence, Partial (1 point) when some but not all criteria were satisfied, and No (0 points) when the indicator was absent or non-functional. Semi‑structured interviews were conducted with ministry of health IMAM focal and regional IMAM technical assistants to clarify the practical implementation of each function.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQualitative Data Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe in-depth interviews explored perceptions, challenges, and the impact of various strategies, and were semi-structured, allowing for in-depth exploration of the specific challenges and changes observed during implementation of strategies to enhance the MAM integration (Supplementary files). Data collection was conducted by proficient qualitative research assistants and investigators. They were conducted in local languages, transcribed, translated into English, and recorded. The interviewers also took notes during the sessions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMeasurement\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 2 shows the measurement framework used to evaluate the integration of MAM services across RE-AIM dimensions\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 2. Measurement Framework and Indicators for Evaluating MAM Integration Using the RE-AIM Framework\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"708\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 194px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDimension\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDescription \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIndicator(s)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 194px;\"\u003e\n \u003cp\u003eReach\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003e-Service access/level of institutionalization\u003c/p\u003e\n \u003cp\u003e-MAM service is available and integrated within primary health care.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-These include mainly biweekly supplementation and follow ups for children.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003e-% of HFs implementing MAM management routinely/biweekly\u003c/p\u003e\n \u003cp\u003e-Children accessing MAM management and follow up services\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 194px;\"\u003e\n \u003cp\u003eEffectiveness/Appropriateness\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003e-Intervention effects on target outcomes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003eIndicators under service and clinical outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 194px;\"\u003e\n \u003cp\u003eAdoption\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003e-Intention to try or uptake: the extent to which key health system functions support the integration of MAM management into primary health care.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003e- MAM integration across all six WHO Health System Building Blocks: service delivery, health workforce, information systems, medical products, financing, and leadership/governance.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 194px;\"\u003e\n \u003cp\u003eImplementation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003e-Quality of MAM program delivery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003e-% of HEWs on average trained/mentored on MAM management, logistics and documentation\u003c/p\u003e\n \u003cp\u003e-Mean percentage of materials/ equipment available\u003c/p\u003e\n \u003cp\u003e-Mean percentage of supplies available\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;-% of HEWs supervised on MAM Management\u003c/p\u003e\n \u003cp\u003e-% of health facilities with secure and enough storage for MAM commodities\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;-% U5 children who are followed by the MAM protocol\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 194px;\"\u003e\n \u003cp\u003eAcceptability\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003e-Satisfaction of MAM service delivery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003e-Perceptions of service providers on integrating MAM into primary health care.\u003c/p\u003e\n \u003cp\u003e-Ongoing implementation challenges\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eData management and analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe collected data were systematically managed and analyzed to ensure quality, accuracy, and reliability. Data collectors participated in a three-day training session to standardize the procedures and minimize inconsistencies. Data collection was conducted digitally using the KoboToolbox, which allowed for the application of real-time validation rules to reduce errors and identify missing or inconsistent responses. After collecting, the data were exported to Stata version 14.1 software packages for cleaning. Data cleaning involved addressing outliers, resolving inconsistencies, and managing missing data points.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor adoption, health system domains (Governance, Health Financing, Health Information, Health Workforce, Medical Products, and Service Delivery) were assessed using predefined indicators scored as follows: 2 points for full achievement, 1 for partial, and 0 for none. For acceptability, provider satisfaction and perceived challenges were assessed using Likert scale responses from structured questionnaires. All quantitative analyses were conducted in Stata v14.1, with descriptive statistics (proportions) and stratification by region.\u003c/p\u003e\n\u003cp\u003eQualitative data from the in-depth interviews (IDIs) were transcribed and analyzed using Nvivo software version 14. Thematic analysis was conducted to identify key themes and insights related to ongoing integration challenges within the primary health care system. Thematic analysis followed Braun and Clarke\u0026rsquo;s six-step framework: (1) familiarization through repeated reading; (2) generation of initial codes in NVivo; (3) collating codes into candidate themes; (4) reviewing themes against the dataset; (5) defining and naming themes; and (6) producing a narrative report enriched with illustrative quotations. Analytical memos documented emerging patterns, researcher reflections, and coding decisions throughout the process. The findings were triangulated with quantitative results to enhance the depth and validity of the conclusions.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003ea.\u0026nbsp; Reach\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNearly universal access to MAM services was achieved across the 101 pilot health posts, with 99 percent (n=100) offering the service and 88 percent on a biweekly schedule (12 percent monthly) (Table 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 3: Health post providing MAM service (n=101)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 426px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;Frequency n (%) \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 426px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHPs providing MAM service\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e100 (99.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 426px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency of MAM service\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 426px;\"\u003e\n \u003cp\u003eRoutine (every 2 weeks)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e88 (88.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 426px;\"\u003e\n \u003cp\u003eRoutine (every month)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e12 (12.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eOver the 10-month evaluation, health posts screened an average of 66,921 children aged 6\u0026ndash;59 months per month (range: 60,760\u0026ndash;76,701) and 22,377 pregnant or lactating women (PLW) per month (range: 19,609\u0026ndash;26,399) (Figure 1).\u003c/p\u003e\n\u003cp\u003eRetention gaps between identification and sustained follow-up were substantial. On average, 28 percent of children and 24 percent of PLW identified with MAM did not complete the recommended biweekly visits. These gaps peaked in August (52 percent for children and 36 percent for PLW) and were lowest in May (13 percent for children) and the early months for PLW (7 percent) (Figure 2 and 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eb.\u0026nbsp; \u0026nbsp;Acceptability of MAM Services (Provider Perspective)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHEWs demonstrated strong readiness and confidence in delivering integrated MAM services. Nearly all respondents (96%) felt confident managing MAM in children aged 6\u0026ndash;59 months and pregnant or lactating women (PLW), and 94% agreed that their training adequately prepared them. District-level advocacy was also effective, with 92% of respondents recognizing its role in supporting service delivery. The commitment to integrating MAM screening and follow-ups into routine duties was equally high (95%) (Supplementary Table 1).\u003c/p\u003e\n\u003cp\u003eDespite this enthusiasm, HEWs reported mixed perceptions of resource adequacy. While 83% felt supported by their supervisors, fewer than half believed they had sufficient storage space (36%) or equipment (41%) for MAM commodities. Nearly half (49%) experienced frequent stock-outs of key supplies (RUSF and CSB++). Pressure from communities or local authorities to admit clients outside the eligibility criteria was reported by 42% of HEWs, although 48% reported minimal or no such pressure (see Supplementary Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ec.\u0026nbsp; \u0026nbsp;Implementation\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEssential equipment was largely available for anthropometry (94% MUAC tapes; 72% child spring scales), but fewer sites had functioning weighing scales (42%) or thermometers (53%) (Supplementary Table 3). Among essential nutrition commodities, 75.3 percent of health posts had ready-to-use supplementary foods (RUSF) in stock and 73.3 percent had CSB++ (corn-soy blend) available. Vitamin A capsules were present in 61.4 percent of posts, while deworming tablets were available in 59.4% of posts (Supplementary Table 3). Monitoring tools showed a high uptake of registration materials: 90.1 percent of the health posts maintained MAM registration books for children and 93.1 percent for pregnant and lactating women, but only 44.5 percent kept up-to-date stock cards for RUSF and CSB++ (Supplementary Table 4). Dedicated storage infrastructure existed at 88.1 percent of posts, with 23.6 percent rated as very good and 56.2 percent as good; 48.3 percent used pallets, 64.0 percent had secure perimeters, and 78.7 percent reported adequate ventilation (Supplementary Table 4).\u003c/p\u003e\n\u003cp\u003eOn average, each health post was staffed by 2.1 HEWs (SD = 1.2). External supervision was nearly universal, with 99% of posts reporting at least one supervisory visit; 76% occurred within the previous three months (Supplementary Table 5). However, over half of the HEWs (52.5%) felt that they had more work than they could manage, and 5.9% reported always feeling overworked. Training coverage in the past six months was highest for IMAM protocols (70.3%), followed by supply management (61.4%) and HMIS/DHIS-II (46.5%). Despite this, 84.2% of health posts experienced shortages of RUSF or CSB++ during this period (Supplementary Table 5).\u003c/p\u003e\n\u003cp\u003eChart review fidelity (Supplementary Table 6) demonstrated high adherence to age and MUAC admission criteria (\u0026gt;97%) and correct SNF distribution (90% of visits). However, only 33% of children received deworming, and 68% of child-visit records documented outcomes of each visit.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ed. Adoption of the MAM Program\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe overall adoption of IMAM varied across the six WHO health system building blocks (Table 4). Governance was fully established with dedicated Technical Working Groups and coordinated alignment of all nutrition actors under the MOH and Regional Health Bureau leadership. Service delivery has also achieved full integration: outpatient MAM admission and management now managed within the Health Extension Package at health posts.\u003c/p\u003e\n\u003cp\u003eIn contrast, health financing remains a gap: no regular pooled budget or costed action plans at the woreda level support IMAM activities, although HEWs are salaried on the Ministry of Health payroll. Health information systems showed partial adoption, with only selected MAM indicators incorporated into DHIS-II. Workforce adequacy is rated as full, sufficient HEWs cover child health, but competency gaps persist among health managers and HEWs in IMAM-specific technical and organizational skills. Finally, medical products and logistics are partially adopted: transportation and supply management rely on partner support, and woreda offices maintain limited storage capacity for MAM commodities.\u003c/p\u003e\n\u003cp\u003eTable 4: Adoption of MAM program across the WHO building blocks\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"600\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 152px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eElements\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 256px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIndicator\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLevel\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eScore\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 152px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealth system functions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 256px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGovernance\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 256px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTechnical leadership\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 256px;\"\u003e\n \u003cp\u003eA technical working group for IMAM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eFull\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRegulation and coordination\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 256px;\"\u003e\n \u003cp\u003eRegulation and coordination of nutrition actors (including INGOs, CSOs, UN agencies and donors) aligning with the IMAM guideline.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eFull\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealth financing\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 256px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRegular budget-pooled funding\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 256px;\"\u003e\n \u003cp\u003eRegular budget from pooled funds to support covering financing for IMAM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnnual costed action plans\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 256px;\"\u003e\n \u003cp\u003eAnnual costed action plans covering IMAM interventions (woreda level review meeting and supervision)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealth workers payroll\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 256px;\"\u003e\n \u003cp\u003eStaff in health facilities involved in IMAM on government payroll\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eFull\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealth information\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 256px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealth information system (HIS)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 256px;\"\u003e\n \u003cp\u003eNational DHIS-II includes moderate acute malnutrition (MAM) indicators\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003ePartial\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealth workforce\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 256px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdequate health workers\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 256px;\"\u003e\n \u003cp\u003eAdequate number of qualified health workers with geographic coverage for comprehensive child health care\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eFull\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCompetences of health managers and health workers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 256px;\"\u003e\n \u003cp\u003eAdequate technical and organizational management skills for IMAM implementation/IMAM rollout.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003ePartial\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedical products\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 256px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLogistic management system\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 256px;\"\u003e\n \u003cp\u003eNational logistic management system for drugs and medical supplies including for IMAM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003ePartial\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStorage\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 256px;\"\u003e\n \u003cp\u003eAdequate storage for MAM product available and managed by woreda health office\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003ePartial\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eService delivery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 256px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMAM admission and management\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 256px;\"\u003e\n \u003cp\u003eOutpatient management of moderate acute malnutrition (MAM) as part of the health extension program (HEP)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eFull\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eQualitative component\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQualitative evaluation examined the achievements of implementation strategies and ongoing challenges across six themes: Leadership and Governance, Service Delivery, Health Workforce, Financial Planning, Supply Chain and Resource Management, and Health Information Systems.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLeadership \u0026amp; Governance\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAdvocacy workshops and stakeholder engagement were pivotal in shifting perceptions and securing local commitments. Advocacy sessions attended by woreda leaders, community elders, and partners clarified that IMAM was a targeted treatment program rather than general food distribution program. As one woreda nutrition focal explained,\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Advocacy was conducted in the presence of woreda leaders and other stakeholders. There are changes in terms of increased awareness among the community not only among the community but also among the leaders.\u0026rdquo; (Afar IMAM TA)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eLocal authorities pledged matching funds, improved security for storage sites, and collaborated on road repairs, although regular coordination meetings often fell short because of competing priorities.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;There should be a regular meeting every 15 days or every month, but because there are a lot of other agendas, there is a gap in the regularity of meetings\u0026hellip; There is also a gap in fulfilling their mandates and an issue of budget.\u0026rdquo; (Afar IMAM TA)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eCommunity leaders, particularly women\u0026rsquo;s groups and traditional elders, mobilized households for screening, repaired roads to support supply transport, and helped minimize the misuse of therapeutic foods. However, religious leaders were largely excluded from orientation workshops due to a lack of resources, which limited their potential influence.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ea. Service Delivery\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSupportive Supervision:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eRegular, MAM-specific supervisory visits improved HEW adherence to admission/discharge criteria, data documentation, and supply management. One nutrition focal person described how supervisory checklists corrected earlier errors:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Some HEWs used to register only 12.5 cm of MUAC as discharge criteria. But now, with MAM-specific supportive supervision, we have solved these errors by supporting them to work according to the MAM guideline.\u0026rdquo; (Afar Woreda Nutrition Focal)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eStrong supervision correlates with faster recovery times and higher cure rates. In areas with inconsistent oversight, recovery took longer and documentation gaps persisted.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eOnsite Mentorship:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eImmediate on-the-job coaching helped HEWs to correct errors in real time. In regions where mentorship was implemented, HEWs reported greater confidence and fewer protocol deviations:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We use a standardized checklist during visits\u0026mdash;if there is a gap, we develop an action plan on the spot. If it\u0026rsquo;s a minor error, like admission/discharge criteria, we mentor them immediately.\u0026rdquo; (Afar Woreda Nutrition Focal)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHowever, resource and staffing shortages have prevented the widespread rollout of mentorship. Many woredas lack trained personnel and budgets for regular visits.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFlexible Service Delivery Models:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFlex-day MAM services, which allow beneficiaries to attend any day, were viewed as a means to reduce overcrowding and defaulter rates. However, HEWs cautioned that without additional manpower and clear guidance from the MOH, flexible schedules risk overburdening staff and confusing communities.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Although flexible days could help manage large crowds, the workload for HEWs will increase significantly. They are already managing services for over 200 beneficiaries every two weeks.\u0026rdquo; (Afar Woreda Nutrition Focal)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFamily MUAC Approach:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTraining mothers to use MUAC tapes was recognized as a low-cost, high-impact strategy for early malnutrition detection and for reducing HEW workload. One respondent highlighted its simplicity and community acceptability:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026rsquo;s very easy. It needs resources to give orientation. Then the women will start screening at home\u0026mdash;our community is very interested in nutrition programs.\u0026rdquo; (Oromia Nutrition Focal)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHowever, sporadic training, limited coverage, and lack of orientation materials hampered scale‐up; only two or three woredas had piloted Family MUAC at the time of evaluation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eb.\u0026nbsp; Health Workforce Development\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCapacity Building:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFormal IMAM training, which combines protocol instruction and logistics management, significantly improved HEW performance. HEWs learned to maintain bin cards and manage supplies effectively:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;There was a big issue in this woreda related to bins and cards, but now there is no health post without a functioning bin card or model. This is the result of training and refresher courses.\u0026rdquo; (Oromia Nutrition Focal)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFrequent refresher sessions during review meetings further reinforced adherence, although the high turnover among trained staff necessitated repeated training. Documentation gaps persisted because many newly posted HEWs lacked prior IMAM training.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWorkload Management:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHEWs\u0026rsquo; workloads remained heavy, and engaging additional staff (e.g., Food Distributing Agents, health center personnel, and Woreda staff) helped only where incentives and coordination existed. Food Distributing Agents are often illiterate or unpaid, limiting their usefulness:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;FDAs cannot measure MUAC or register properly; most are illiterate. They cannot help reduce HEWs\u0026rsquo; workload in any meaningful way.\u0026rdquo; (Afar Woreda Nutrition Focal)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHealth center and woreda staff sometimes assisted, but competing responsibilities and budget constraints restricted sustained support.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIncentivizing and Motivating HEWs:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNon-monetary recognition, such as certificates for top-performing health posts, boosts morale. As one respondent noted,\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We could not give money, but we give certificates. Certificates were given to health posts ranked 1\u0026ndash;3 for their accomplishments.\u0026rdquo; (Aleta Cheko Nutrition Focal)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHowever, monetary incentives remained largely unmet due to budget shortfalls and HEWs often felt overworked without commensurate compensation for their efforts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ec. Financial Planning \u0026amp; Budget Integration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWoredas lacked dedicated budgets for IMAM activities, and nutrition partners covered the transportation and commodity costs. Advocacy was needed to integrate IMAM into annual costed plans and leverage the newly formed\u003cem\u003e\u0026nbsp;kabine\u003c/em\u003e structure at the kebele level for budget allocation.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;But allocating matching fund just for nutrition is difficult at the woreda level... currently, there is resource scarcity at the woreda level due to different reasons.\u0026rdquo; (Afar IMAM TA)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ed.\u0026nbsp; Supply Chain \u0026amp; Resource Management\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe misuse of RUSF and CSB++ has declined due to community advocacy and engagement with legal authorities. However, intermittent stockouts persisted, and warehousing conditions varied. Storage infrastructure was often inadequate, with only a minority using pallets or secure perimeters. Logistics documentation improved waybills became nearly universal, but ledger books, stock cards, and distribution pads remained unevenly available.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;We found Plumpy\u0026rsquo;Nut in shops, but it was due to a gap in monitoring; once corrective action was taken, some shops were closed\u0026quot; (Sidama IMAM TA).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ee. Health Information \u0026amp; Data Systems\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChallenges in the health information system remain significant barriers to effective program implementation. One major issue is the lack of comprehensive training for HEWs and other frontline staff on the proper use of reporting tools, such as the District Health Information System (DHIS). Moreover, the presence of parallel reporting systems remains a persistent challenge. Various stakeholders and partners often require different reporting formats and indicators, leading to duplication of effort and an increased workload for health workers.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;We have reported the gaps repeatedly to the MOH. The reporting should be one channel, the HMIS is online and easy to use, and WFP can also get reports from that. So, we have asked, and it has started, but it has gaps\u0026quot; (Sidama IMAM-TA).\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe study indicated that while MAM services have achieved near-universal geographic coverage, 99 percent of health posts offer MAM management. Population-level reach remains uneven, with substantial gaps between case identification and follow-up. Health Extension Workers express strong confidence in delivering integrated MAM services and generally welcomed the program; however, persistent concerns about resource adequacy and recurrent stockouts highlight ongoing operational barriers. Although governance and service delivery show robust adoption, critical shortfalls in health financing, information systems, and supply chain management threaten the sustainability of gains.\u003c/p\u003e\u003cp\u003eHEWs demonstrated strong readiness and confidence in delivering integrated MAM services despite mixed perceptions of resource adequacy. Although essential equipment and commodities were generally available, gaps persisted in the monitoring tools and storage infrastructure. studies indicated that integrating nutrition services into existing health programs is generally well-accepted by communities and health workers, leading to increased service utilization and efficiency[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Properly trained and supervised community health workers can effectively manage cases of severe acute malnutrition[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]; however, persistent challenges, such as inadequate staffing, insufficient training, and broader health system constraints, often hinder integration efforts[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Successful integration requires strengthening health systems, optimizing task allocation, and synchronizing work schedules across sectors[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Frontline workers adopt various practices that both facilitate and impede nutrition integration, influenced by societal, organizational, and individual factors[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Despite these challenges, integrated approaches have shown potential for improving service coverage and treatment outcomes in countries such as Malawi, Ghana, and Zambia[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAdoption of the MAM program varied across the six WHO health system building blocks: governance and service delivery were fully established, whereas health financing, information systems, and logistics were only partially adopted. Integrating nutritional interventions into health systems and community programs can enhance maternal and child health outcomes. Studies have demonstrated positive impacts when nutrition is incorporated into extension services, health systems, and intersectoral programs[\u003cspan additionalcitationids=\"CR32\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Key factors for successful integration include clear leadership, shared priorities, adequate workforce training, and strong coordination across sectors and administrative levels[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Community-based integrated programs that utilize local workers can deliver cost-effective, multifaceted services, such as nutrition education, health care, and family planning[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. However, fully integrating nutrition across all health system functions remains challenging, particularly in financing and supply management[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Careful program design, active community participation, and ongoing evaluation are essential for developing sustainable, context-specific integrated nutrition interventions [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eQualitative findings highlighted that advocacy and multisectoral coordination have successfully shifted perceptions and fostered local ownership, while targeted supervision and on-site mentorship bolstered HEW performance. Although the Family MUAC approach holds promise, its effectiveness depends on sustainable funding, consistent training, and clear policy support. Addressing persistent gaps in human resources, logistics, and data systems is essential for sustaining and scaling up IMAM integration. These findings align with evidence from other studies that emphasize the value of such strategies not only for MAM but also for broader maternal, newborn, and child health (MNCH) programs[\u003cspan additionalcitationids=\"CR37\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIntegrating community-based management of acute malnutrition (CMAM) into health systems requires more than technical guidelines; it demands strengthened coordination, targeted training for frontline workers, and a consistent and reliable supply of essential commodities[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Supervision is a key driver of improved health worker performance; however, studies highlight the difficulty of maintaining high-quality and regular supervision amidst systemic constraints such as limited resources, competing priorities, and geographic inaccessibility[\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTask shifting and family MUAC have shown promise in improving community nutrition programs and reducing the workload of health workers. Studies have demonstrated that mothers can effectively screen their children for malnutrition using MUAC tapes, with a sensitivity and specificity comparable to that of community health workers[\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Integrating the treatment of acute malnutrition by community health volunteers into existing programs has led to better outcomes, including higher recovery and lower default rates[\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Task shifting is a viable option for improving health system efficiency and access to care in low-resource settings[\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSupply chain effectiveness is essential for ensuring uninterrupted service delivery; however, health product supply chains in developing countries face numerous challenges, including ineffective distribution networks, stock-outs, and coordination problems among stakeholders [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. These issues significantly affect access to essential medicines and health technologies. [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. Addressing both supply and demand constraints in local value chains is crucial for improving nutritional outcomes in developing countries[\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFinally, information systems are increasingly important for measuring and improving the quality and coverage of health services[\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. However, the implementation of health information systems, such as DHIS, in low- and middle-income countries faces several challenges. While these systems can improve data timeliness and completeness[\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e], barriers include inadequate infrastructure, unreliable Internet, and lack of training[\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. Parallel reporting systems and unintegrated tools create duplication and increase the workload [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. To improve DHIS implementation, recommendations include integrating systems, providing regular training and supervision, enhancing infrastructure, and promoting local ownership[\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis study had several limitations. First, facility assessments and chart reviews provide only a snapshot in time and cannot capture long-term maintenance or evolving trends in service quality without repeated measurements. By design, the evaluation focused on early implementation; therefore, long-term sustainability (maintenance) remains unassessed and will require follow-up studies to understand institutionalization over time. Finally, our reliance on routine data means that chart review findings depend entirely on the completeness and accuracy of MAM follow-up cards; any documentation gaps or data quality issues directly undermine the validity of our fidelity and effectiveness measures.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn conclusion, the integration of MAM services into Ethiopia\u0026rsquo;s primary healthcare system has achieved remarkable geographic coverage and strong frontline engagement; however, it continues to struggle with resource constraints and supply chain inefficiencies. Moving forward, securing sustainable financing and reinforcing policy frameworks will be essential to sustain high-quality and equitable MAM care within Ethiopia\u0026rsquo;s primary health care system.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eCMAM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003eCommunity Management of Acute Malnutrition\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eCSB++\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003eCorn-Soy Blend Plus Plus\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;CSOs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003eCivil Service Organizations\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eDHIS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003eDistrict Health Information System\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eDRMC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003eDisaster Risk Management Commission\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eEDHS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003eEthiopia Demographic and Health Survey\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eHEP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003eHealth Extension Program\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eHEW\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003eHealth Extension Workers\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eIDI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003eIn-depth Interview\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eIMAM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003eIntegrated Management of Acute Malnutrition\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eINGOs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003eInternational Non-Profit Organizations\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eMAM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003eModerate Acute Malnutrition\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eMNCH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003eMaternal, Newborn, and Child Health\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eMOH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003eMinistry of Health\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eMUAC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003eMid-Upper Arm Circumference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003ePLW\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003ePregnant and Lactating Women\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eRE-AIM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003eReach, Effectiveness, Adoption, Implementation, and Maintenance\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eRUSF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003eReady-to-Use Supplementary Food\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eSAM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003eSevere Acute Malnutrition\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003eStandard Deviation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eSNF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003eSpecialized Nutritious Food\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eUN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003eUnited Nations\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eWFP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003eWorld Food Programme\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eWHO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003eWorld Health Organization\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted according to the guidelines laid down in the Declaration of Helsinki, and all procedures involving research study participants were approved by the Institutional Review Board (IRB) of the College of Health Sciences, Addis Ababa University. Additionally, the necessary permissions were obtained from the relevant federal and local government offices/authorities. Participants were provided with a detailed explanation of the study’s purpose, procedures, potential benefits, and risks before they provided their written informed consent. Throughout the process, participants were assured of their right to decline or refuse to answer any or all questions without facing any consequences. Privacy was strictly maintained, and all the information collected was kept confidential. To ensure data security, all audio recordings were stored on a password-protected computer accessible only to the researchers involved in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe transcripts are available from the corresponding author on reasonable request\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was funded by WFP Ethiopia. The views expressed herein are solely those of the authors and do not reflect the views of the WFP or any other stakeholder.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contribution\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAM, SH conceived the study. AM analyzed the data and wrote the first draft with inputs from SH, YD and SB. All authors have read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors wish to thank the study data collectors, the woreda health office, HEWs and IDIs participants\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWHO. Supplementary foods for the management of moderate acute malnutrition in infants and children 6\u0026ndash;59 months of age. World Health Organization Geneva; 2012.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eForce MT. Moderate acute malnutrition: a decision tool for emergencies. Global Nutrition Cluster; 2017.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWHO. Levels and trends in child malnutrition child malnutrition: UNICEF/WHO/World Bank Group Joint Child Malnutrition Estimates: Key findings of the 2023 edition. World Health Organization; 2023.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCSA and ICF. Ethiopia demographic and health survey 2011. Maryland, USA: Central Statistical Agency of Ethiopia and ICF International Addis Ababa, Ethiopia and Calverton; 2012.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCSA and ICF. Ethiopia demographic and health survey 2011. Maryland, USA: Central Statistical Agency and ICF International,: Addis Ababa, Ethiopia and Calverton; 2012. p. 430.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCSA. and ICF, \u003cem\u003eEthiopia demographic and health survey, Addis Ababa, Ethiopia and Calverton, Maryland, USA\u003c/em\u003e. 2016.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEthiopian Public Health Institute (EPHI). [Ethiopia] and ICF, \u003cem\u003eEthiopia Mini Demographic and Health Survey 2019: Final Report. Rockville, Maryland, USA: EPHI and ICF.\u003c/em\u003e 2019.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eUNICEF. \u003cem\u003eGlobal action plan on child wasting: a framework for action to accelerate progress in preventing and managing child wasting and the achievement of the Sustainable Development Goals.\u003c/em\u003e 2021.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHall A, Blankson B, Shoham J. The impact and effectiveness of emergency nutrition and nutrition-related interventions: a review of published evidence 2004\u0026ndash;2010. Emerg Nutr Netw; 2011.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLenters LM, et al. Treatment of severe and moderate acute malnutrition in low-and middle-income settings: a systematic review, meta-analysis and Delphi process. BMC Public Health. 2013;13:1\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShoham J, McGrath M. Editorial perspective on the continuum of care for children with acute malnutrition. Field Exch. 2019;60:2.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLenters L, Wazny K, Bhutta ZA. \u003cem\u003eManagement of severe and moderate acute malnutrition in children.\u003c/em\u003e Reproductive, maternal, newborn, and child health: disease control priorities. 3rd edition. Washington, DC: World Bank, 2016: pp. 205\u0026ndash;223.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDeconinck H, et al. Review of community-based management of acute malnutrition in the postemergency context: synthesis of lessons on integration of CMAM into national health systems in Ethiopia, Malawi and Niger. Washington: FANTA AED; 2008.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDeconinck H, et al. Review of community-based management of acute malnutrition implementation in West Africa: summary report. Washington: FANTA AED; 2011.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAguayo VM, et al. Community management of acute malnutrition (CMAM) programme in P akistan effectively treats children with uncomplicated severe wasting. Matern Child Nutr. 2018;14:e12623.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRenzaho AM, et al. Assessing the impact of integrated community-based Management of Severe Wasting Programs in conflict-stricken South Sudan: a multi-dimensional approach to scalability of nutrition emergency response programs. Int J Environ Res Public Health. 2021;18(17):9113.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMaleta K, Amadi B. Community-based management of acute malnutrition (CMAM) in sub-Saharan Africa: case studies from Ghana, Malawi, and Zambia. FoodNutr Bull. 2014;35(2suppl1):S34\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePowell BJ et al. \u003cem\u003eA refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project.\u003c/em\u003e Implementation science, 2015. 10: pp. 1\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGlasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health promotion interventions: the RE-AIM framework. Am J Public Health. 1999;89(9):1322\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTiruneh GT, et al. Effect of community-based newborn care implementation strategies on access to and effective coverage of possible serious bacterial infection (PSBI) treatment for sick young infants during COVID-19 pandemic. PLoS ONE. 2024;19(3):e0300880.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNacke B, et al. A systematic review of reach, adoption, implementation and maintenance of Internet-based interventions to prevent eating disorders in adults. Eur J Pub Health. 2021;31(Supplement1):i29\u0026ndash;37.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMcGoey T, et al. Evaluation of physical activity interventions in children via the reach, efficacy/effectiveness, adoption, implementation, and maintenance (RE-AIM) framework: a systematic review of randomized and non-randomized trials. Prev Med. 2016;82:8\u0026ndash;19.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGlasgow RE, et al. RE-AIM planning and evaluation framework: adapting to new science and practice with a 20-year review. Front public health. 2019;7:64.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRyman TK, et al. Community and health worker perceptions and preferences regarding integration of other health services with routine vaccinations: four case studies. J Infect Dis. 2012;205(suppl1):S49\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eP\u0026eacute;rez-Escamilla R, Engmann C. Integrating nutrition services into health care systems platforms: Where are we and where do we go from here. Matern Child Nutr. 2019;15:e12743.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOgobara Dougnon A, et al. Impact of integration of severe acute malnutrition treatment in primary health care provided by community health workers in rural Niger. Nutrients. 2021;13(11):4067.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePuett C, et al. Sometimes they fail to keep their faith in us\u0026rsquo;: community health worker perceptions of structural barriers to quality of care and community utilisation of services in B angladesh. Matern Child Nutr. 2015;11(4):1011\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePhuka J, et al. A job analysis of community health workers in the context of integrated nutrition and early child development. Volume 1308. Annals of the New York Academy of Sciences; 2014. pp. 183\u0026ndash;91. 1.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDeconinck H, et al. Integrating acute malnutrition interventions into national health systems: lessons from Niger. BMC Public Health. 2016;16:1\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNamugumya BS, et al. Integrating Nutrition actions in Service Delivery: the practices of Frontline workers in Uganda. Int J health policy Manage. 2022;11(12):2895.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSalam RA, Das JK, Bhutta ZA. Integrating nutrition into health systems: What the evidence advocates. Matern Child Nutr. 2019;15:e12738.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKim SS, et al. Understanding the role of intersectoral convergence in the delivery of essential maternal and child nutrition interventions in Odisha, India: a qualitative study. BMC Public Health. 2017;17:1\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFanzo J, et al. Integration of nutrition into extension and advisory services: a synthesis of experiences, lessons, and recommendations. FoodNutr Bull. 2015;36(2):120\u0026ndash;37.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYousafzai AK, Aboud F. Review of implementation processes for integrated nutrition and psychosocial stimulation interventions. Ann N Y Acad Sci. 2014;1308(1):33\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHeidkamp RA, et al. How are maternal-child nutrition activities integrated at the community level? Lessons from Haiti. Wiley Online Library; 2012.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSarfraz M, Hamid S. Exploring managers\u0026rsquo; perspectives on MNCH program in Pakistan: a qualitative study. PLoS ONE. 2016;11(1):e0146665.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSomass\u0026egrave; YE, et al. Sustainability and scaling-up analysis of community-based management of acute malnutrition: lessons learned from Burkina Faso. FoodNutr Bull. 2013;34(3):338\u0026ndash;48.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eIreen S, et al. Challenges and opportunities of integration of community based Management of Acute Malnutrition into the government health system in Bangladesh: a qualitative study. BMC Health Serv Res. 2018;18:1\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKouam CE, et al. Perspectives for integration into the local health system of community-based management of acute malnutrition in children under 5 years: a qualitative study in Bangladesh. Nutr J. 2014;13:1\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKavita S, Doledec D, Begum F. Managing Acute Malnutrition: A Review of the Evidence and Country Experiences in South Asia and a Recommended Approach for Bangladesh. Washington DC: FANTA; 2014.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRowe AK, et al. The rise and fall of supervision in a project designed to strengthen supervision of Integrated Management of Childhood Illness in Benin. Health Policy Plann. 2010;25(2):125\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAl\u0026eacute; FG, et al. Mothers screening for malnutrition by mid-upper arm circumference is non-inferior to community health workers: results from a large-scale pragmatic trial in rural Niger. Archives Public Health. 2016;74:1\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBlackwell N et al. \u003cem\u003eM others U nderstand A nd C an do it (MUAC): a comparison of mothers and community health workers determining mid-upper arm circumference in 103 children aged from 6 months to 5 years.\u003c/em\u003e Archives of public health, 2015. 73: pp. 1\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDonfouet HPP, et al. The impacts of task shifting on the management and treatment of malnourished children in Northern Kenya: a cluster-randomized controlled trial. Health Policy Plann. 2024;39(7):710\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSmith S, et al. Task-shifting and prioritization: a situational analysis examining the role and experiences of community health workers in Malawi. Hum Resour health. 2014;12:1\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYadav P. Health product supply chains in developing countries: diagnosis of the root causes of underperformance and an agenda for reform. Volume 1. Health systems \u0026amp; reform; 2015. pp. 142\u0026ndash;54. 2.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKraiselburd S, Yadav P. Supply chains and global health: an imperative for bringing operations management scholarship into action. Prod Oper Manage. 2013;22(2):377\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYadav P, Stapleton O, Van Wassenhove LN. \u003cem\u003eAlways cola, rarely essential medicines: comparing medicine and consumer product supply chains in the developing world.\u003c/em\u003e 2010.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDonovan J, Gelli A. Designing interventions in local value chains for improved health and nutrition: insights from Malawi. World Dev Perspect. 2019;16:100149.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLippeveld T, Sauerborn R, Bodart C. Design and implementation of health information systems. Volume 281. World Health Organization Geneva; 2000.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSimba D, et al. Perceived usefulness, competency, and associated factors in using District health information system data among District health managers in Tanzania: cross-sectional study. JMIR Formative Res. 2022;6(5):e29469.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBogale TN, et al. Barriers, facilitators and motivators of electronic community health information system use among health workers in Ethiopia. Front Digit Health. 2023;5:1162239.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMekonnen ZA, et al. Lessons and implementation challenges of community health information system in LMICs: a scoping review of literature. Online J Public Health Inf. 2022;14(1):e62639.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7071162/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7071162/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e In August 2019, Ethiopia's Ministry of Health launched the Integrated Management of Acute Malnutrition (IMAM) guideline, mandating Health Extension Workers (HEWs) to screen, admit, and provide biweekly follow-ups with specialized nutritious foods for children under five years of age and for pregnant/lactating women. This replaced the previous emergency-led model overseen by the National Disaster Risk Management Commission (NDRMC) and the World Food Program (WFP).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e This study aimed to assess the implementation outcomes of MAM integration into primary healthcare using the RE-AIM framework, evaluate the status of the designed implementation strategies, and identify operational successes and challenges.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod:\u003c/strong\u003e We employed a mixed-methods approach to evaluate the outcomes of Moderate Acute Malnutrition (MAM) integration strategies using the RE-AIM framework. Implementation outcomes were assessed using indicators including reach, acceptability, adoption, fidelity, and implementation effectiveness/appropriateness. We conducted facility assessments on 101 randomly selected health posts and, conducted a retrospective chart review of MAM follow-up cards for children aged 6–59 months and pregnant and lactating women to assess implementation fidelity. Additionally, a structured adoption-assessment tool was developed to evaluate health system support for MAM integration across six WHO health system domains. We also conducted 12 in-depth interviews with the program implementers to explore the contextual factors and perceptions of the implemented strategies. Quantitative data were analyzed descriptively in Stata version 14.1, and qualitative transcripts underwent thematic analysis in NVivo version 14 using Braun and Clarke’s six-phase approach.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eIn terms of Reach, MAM services were nearly universal across 101 pilot health posts; 99 percent offered the service (88 percent biweekly) screening 66,921 children aged 6–59 months and 22,377 pregnant or lactating women monthly. Regarding effectiveness, chart reviews showed high fidelity to admission criteria (\u0026gt; 97 percent) and correct supplement distribution (90 percent). For Adoption, governance and service delivery integrated fully into primary healthcare, while health financing, information, workforce competencies, and logistics showed partial uptake. Under Implementation, equipment (MUAC tapes at 94 percent, scales at 42 percent) and commodities (RUSF in 75 percent of posts) were broadly available, though storage quality (23.6 percent) and HEW workload remained challenging. Qualitative findings indicated that advocacy, supervision, and mentorship improved HEW adherence to protocol, yet persistent equipment shortages, stockouts, and heavy workloads constrained service delivery. Budget constraints, parallel reporting systems, and staff turnover hindered MAM management integration into primary health care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e The integration of MAM services into Ethiopia's primary healthcare system has achieved strong geographic coverage and frontline engagement; however, it faces resource constraints and supply chain inefficiencies. Securing sustainable financing and reinforcing policy frameworks are essential to sustain quality MAM care within Ethiopia's primary health care system.\u003c/p\u003e","manuscriptTitle":"Implementation Outcomes of Strategies to Integrate Management of Moderate Acute Malnutrition (MAM) into Ethiopia’s Primary Health Care System: Application of the RE-AIM Framework","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-22 08:11:02","doi":"10.21203/rs.3.rs-7071162/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"205511717086433862497428105894340966768","date":"2025-08-22T05:33:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"107145960444934816331551194567515362329","date":"2025-08-16T08:56:44+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-14T08:46:22+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-13T06:45:54+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-24T11:26:49+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-24T08:30:24+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-07-24T08:26:30+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d3f0670d-cedc-4641-8743-97f201c998df","owner":[],"postedDate":"August 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-08-22T08:11:02+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-22 08:11:02","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7071162","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7071162","identity":"rs-7071162","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}