Evaluation of Access and Coverage of Integrated Management of Acute Malnutrition Program

Abstract

Background: Wasting remains a critical public health concern in Nepal, with many children unable to access timely treatment despite national efforts. Evidence on program coverage is lacking in Syangja district. The objective of this study is to identify the underlying factors supporting and hindering the program and to estimate its coverage.
Methods: The Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) approach was implemented in three stages using a mixed-method design. Stage I involved qualitative data collection through key informant interviews (KII), Focus Group Discussions (FGD), and direct observations (DO) in seventeen different locations. Stage II tested a hypothesis about proximity and coverage via small-area surveys using active and door-to-door case finding. Due to inconclusive results, Stage III was not executed. Quantitative data from DHIS-2 and IMAM registers were analyzed for trends and performance indicators, while qualitative data were thematically analyzed and triangulated across participants, types and methods. A Barriers, Boosters, and Questions (BBQ) scoring exercise informed prior coverage estimation.
Results: Twelve boosters and twenty-five barriers affecting program access and coverage were identified. Boosters included strong family support, motivated frontline workers, and local government initiatives. Barriers involved stigma, logistical challenges, inconsistent protocol adherence, limited training, and stockouts. The estimated prior coverage was 34.3%. Hypothesis testing on distance-related coverage was inconclusive, halting progression to a wide-area survey. Additional qualitative investigation confirmed gaps in health worker capacity, community engagement, and IMAM protocol compliance.
Conclusions: The IMAM program in Syangja district faces systemic and community-level challenges. To improve coverage, targeted interventions are needed to strengthen service delivery, enhance staff capacity, ensure supply availability, and increase community awareness and engagement.
Keywords: Access; barriers; boosters; coverage.