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

Abstract

Community-based management of severe wasting (CMSW) programs have solely focused on exit outcome indicators, often omitting data on nutrition emergency preparedness and scalability. This study aimed to document good practices and generate evidence on the effectiveness and scalability of CMSW programs to guide future nutrition interventions in South Sudan. A total of 69 CMSW program implementation documents and policies were authenticated and retained for analysis, complemented with the analyses of aggregated secondary data obtained over five (2016–2020 for CMSW program performance) to six (wasting prevention) years (2014–2019). Findings suggest a strong and harmonised coordination of CMSW program implementation, facilitated timely and with quality care through an integrated and harmonised multi-agency and multidisciplinary approach. There were challenges to the institutionalisation and ownership of CMSW programs: a weak health system, fragile health budget that relied on external assistance, and limited opportunities for competency-based learning and knowledge transfer. Between 2014 and 2019, the prevalence of wasting fluctuated according to the agricultural cycle and remained above the emergency threshold of 15% during the July to August lean season. However, during the same period, under-five and crude mortality rates (10,000/day) declined respectively from 1.17 (95% confidence interval (CI): 0.91, 1.43) and 1.00 (95% CI: 0.75, 1.25) to 0.57 (95% CI: 0.38, 0.76) and 0.55 (95% CI: 0.39, 0.70). Both indicators remained below the emergency thresholds, hence suggesting that the emergency response was under control. Over a five-year period (2016–2020), a total of 1,105,546 children (52% girls, 48% boys) were admitted to CMSW programs. The five-year pooled performance indicators (mean [standard deviations]) was 86.4 (18.9%) for recovery, 2.1 (7.8%) for deaths, 5.2 (10.3%) for defaulting, 1.7 (5.7%) for non-recovery, 4.6 (13.5%) for medical transfers, 2.2 (4.7%) for relapse, 3.3 (15.0) g/kg/day for weight gain velocity, and 6.7 (3.7) weeks for the length of stay in the program. In conclusion, all key performance indicators, except the weight gain velocity, met or exceeded the Humanitarian Charter and Minimum Standards in Humanitarian Response. Our findings demonstrate the possibility of implementing robust and resilient CMSAM programs in protracted conflict environments, informed by global guidelines and protocols. They also depict challenges to institutionalisation and ownership.

Pathways and approaches for scaling-up of community-based management of acute malnutrition programs through the lens of complex adaptive systems in South Sudan

“…The availability and wide dissemination of such evidence has led to unparalleled support for CMAM programs’ expansion by bilateral and multilateral donors. Similar findings have recently been reported in South Sudan [ 14 ], hence supporting their geographic and operational expansion.…”

“…These challenges continue to threaten the effectiveness of the operational expansion of CMAM programs, compounded by a high level of insecurity that triggers mass population displacements and hence affecting the speed of CMAM program inception and uptake as well as interrupting supply distribution and inhibiting qualified workers from accepting offers and postings. This could explain why, despite CMAM programs spreading to more than 80 countries and the number of children treated more than tripling since 2010, global acute malnutrition prevalence levels remain stubbornly high [ 14 ].…”

“…A deductive a priori template of codes approach was complemented by data-driven inductive approach to develop the second level of interpretive understanding [ 50 ]. Predetermined codes were generated in two ways: We carried out a study that examined the impact of CMAM programs in South Sudan and identified paths to CMAM program scalability [ 14 ]. Data from the study were complemented by RE-AIM framework [ 43 , 44 ].…”

“…These centres were labour intensive and effective in managing child malnutrition. However, admitted children were accompanied by one or both parents away from the rest of the family [14]. Such an approach led to a number of serious challenges including low coverage rates, late presentation and associated complications, overcrowding and the risk of cross-infection, limited capacity as well as paucity of skilled staff and associated heavy staff workloads, high default rates, and possibly high-risk behaviours among mothers to cover meals [14][15][16][17][18].…”

“…They get ready-to-use supplementary foods such as fortified blended foods or lipid-based nutrient supplements, which are dry take home supplementary rations [22]. The availability of ready to use therapeutic foods (RUTF) has made it possible to treat children in their homes [14,19]. CMAM programs have been extensively evaluated to establish their effectiveness in Asia [23], Africa [14,24,25], and South America [20].…”