Evidence for Action: Coverage and Access gaps in Integrated Management of Acute Malnutrition in Kapilvastu District of Nepal

Abstract

Background: Acute malnutrition remains a critical public health problem in
Nepal, contributing substantially to under-five morbidity and mortality. Despite
the nationwide expansion of the Integrated Management of Acute Malnutrition
(IMAM) program, evidence on coverage and access gaps at the sub-national
level is limited. This study assessed program coverage and explored barriers and
boosters of Integrated Management of Acute Malnutrition (IMAM) program in
Kapilvastu District.
Methods: A Semi-Quantitative Evaluation of Access and Coverage (SQUEAC)
was conducted between 10–22 November 2024 following the standard threestage
methodology. The study comprised children aged 6–59 months residing in
the program catchment areas who met the criteria for severe acute malnutrition,
including both those enrolled in and those not accessing IMAM services. Stage I
involved analysis of routine IMAM data and qualitative inquiry to identify highand
low-coverage areas and to determine barriers and boosters to service uptake.
Stage II tested hypotheses through small-area surveys, and Stage III conducted a
wide-area Bayesian survey to estimate coverage. Data were analyzed thematically
and triangulated across sources, methods, and locations.
Results: Routine program data revealed inconsistent admission trends and
delayed case detection, with median length of stay of nine weeks among recovered
cases. Fourteen boosters and twenty-four barriers were identified, including
strong community trust in Female Community Health Volunteers (FCHVs) and
adequate RUTF supply as key facilitators, and cultural restrictions, long travel
distance, limited awareness, and stock-outs as major barriers. The Bayesian
analysis estimated overall program coverage at 22.9% (95% CI: 14.3–34.8), with
point coverage of 6.7% and period coverage of 12.5%. A gender gap was evident,
with 86% of uncovered cases being female.
Conclusion: Despite a decade of IMAM implementation, program coverage in
Kapilvastu remains below the Sphere minimum standard of 50%. Addressing
systemic bottlenecks, particularly community awareness, gender and social
inclusion, health worker capacity, and supply consistency—is critical to improving
access and treatment uptake. Strengthened community engagement and sustained
local government commitment are essential to close the coverage gap and advance
progress toward national and SDG nutrition targets.