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

Abstract

Background Funds for community-based management of acute malnutrition (CMAM) programs are short-term in nature. CMAM programs are implemented in countries with weak policies and health systems and are primarily funded by donors. Beyond operational expansion, their institutionalisation and alignment with governments’ priorities are poorly documented. The study aimed to identify pathway opportunities and approaches for horizontal and vertical scaling up of CMAM programs in South Sudan. Methods The study was conducted in South Sudan between August and September 2021 using an online qualitative survey with 31 respondents from policy and implementing organisations. The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework guided the study’s design. It was self-administered through the Qualtrics platform. We used Qualitative Content Analysis supported by the Nvivo coding process. A deductive a priori template of codes approach was complemented by a data-driven inductive approach to develop the second level of interpretive understanding. Results Findings from the study demonstrate that the emphasis of CMAM programs was horizontal scaling up, characterised by geographic distribution and coverage as well as operational expansion. Main challenges have included unsustainable funding models, the inadequacy of existing infrastructure, high operational costs, cultural beliefs, and access-related barriers. Factor impacting access to CMAM programs have been geographical terrains, safety, and security concerns. Vertical scaling up, which emphasises institutional and ownership strengthening through a sound policy, regulatory, and fiscal environment, received relatively little attention. Nutrition supplies are not part of the government’s essential drug list and there is limited or no budgetary allocation for nutrition programs by the government in national budgets and fiscal strategies. Factors constraining vertical scalability have included weak government systems and capacity, a lack of advocacy and lobbying opportunities, and an apparent lack of exits strategies. Conclusion Addressing the scalability problems of CMAM programs in South Sudan demands a delicate balancing act that prioritises both horizontal and vertical scalability. Government and political leadership that harness multidisciplinary and multi-sectoral coordination are required. There is a need to increase policy commitment to malnutrition and associated budgetary allocation, emphasise local resource mobilisation, and ensure financial sustainability of integrating CMAM programs into the existing health and welfare system.

Impact of COVID-19 program adaptations on costs and cost-effectiveness of community management of acute malnutrition program in South Sudan

“…Compared with pre-COVID period, RUF costs increased overall. NGOs reported that providing RUF for longer durations of time introduces risks of misuse and damage at the household level due to poor storage conditions ( 28 ) , leading to longer stays and using higher quantity of RUF to treat one child. This poor adherence when treatment follow-up duration is increased was reported in a study in Nigeria ( 29 ) .…”

The implementation of health operational cost management in reducing stunting in the Kalisat Community Health Centre, Jember Regency

“…The outcomes of mini-workshops that the community health centre has regularly held have guided the use and distribution of BOK funds in the Kalisat Community Health Centre. This is in accordance with the operational policy of using BOK in the 2015 BOK Technical Guidelines, which states that the use of BOK funds is for community health centre activities and their networks, and Community-Based Health Efforts must be based on the planning results agreed upon in t h e c o m m u n i t y h e a l t h c e n t r e m i n iworkshops, which are held routinely or periodically in accordance with the conditions of the community health centre work area (15).…”