Community-Based Outpatient Therapeutic Program Implementation in Central Gondar Zone, Northwest Ethiopia: A Process Evaluation Using Access and Implementation Fidelity Frameworks.

Children with severe acute malnutrition have a 10-fold increased risk of death, diminished intellectual development and poor adult work capacity. Community-based outpatient therapeutic programs are among the key interventions designed to manage uncomplicated severe acute malnutrition at the community level in Ethiopia. Despite its implementation, evaluation involving multi-dimensional data sources such as health system level, service provider level and community level perspectives has not been made so far. A mixed-method evaluation was conducted in the central Gondar zone from January to May 2021. The OTP program is implemented by Ethiopian Ministry of Health. A total of 105 women/caregivers, 39 health posts, 171 health extension workers, and outpatient therapeutic program registration and reporting documents were included in the study. In-depth interview was conducted with seven HEWs and nine mothers/caregivers. Moreover, five key informants were selected from district officers and nutrition focal persons. Although more than half of the health posts had the required two HEWs, WHO weight-for-height reference cards, referral forms, length measuring boards and essential drugs were limited in most health posts. Close to a third (35.5%) of the HEWs were recording the routine-given medicine while the majority (98.8%) of them measured and recorded the children's Mid-Upper circumference. Sharing of RUTF for non-eligible children was the observed barrier to adherence to the program. The implementation status of the OTP program was poor. Some medicines were stocked out in all health posts. The majority of the mothers/caregivers didn't appropriately provide RUTF for their children. Improving resource availability, enhancing HEWs' compliance with the OTP protocol, and ensuring consistent counseling and regular home visits for mothers are recommended to improve recovery outcomes among children with malnutrition.