Implementation Outcomes of Strategies to Integrate Management of Moderate Acute Malnutrition (MAM) into Ethiopia’s Primary Health Care System: Application of the RE-AIM Framework

Abstract Background: In August 2019, Ethiopia's Ministry of Health launched the Integrated Management of Acute Malnutrition (IMAM) guideline, mandating Health Extension Workers (HEWs) to screen, admit, and provide biweekly follow-ups with specialized nutritious foods for children under five years of age and for pregnant/lactating women. This replaced the previous emergency-led model overseen by the National Disaster Risk Management Commission (NDRMC) and the World Food Program (WFP). Objective: This study aimed to assess the implementation outcomes of MAM integration into primary healthcare using the RE-AIM framework, evaluate the status of the designed implementation strategies, and identify operational successes and challenges. Method: We employed a mixed-methods approach to evaluate the outcomes of Moderate Acute Malnutrition (MAM) integration strategies using the RE-AIM framework. Implementation outcomes were assessed using indicators including reach, acceptability, adoption, fidelity, and implementation effectiveness/appropriateness. We conducted facility assessments on 101 randomly selected health posts and, conducted a retrospective chart review of MAM follow-up cards for children aged 6–59 months and pregnant and lactating women to assess implementation fidelity. Additionally, a structured adoption-assessment tool was developed to evaluate health system support for MAM integration across six WHO health system domains. We also conducted 12 in-depth interviews with the program implementers to explore the contextual factors and perceptions of the implemented strategies. Quantitative data were analyzed descriptively in Stata version 14.1, and qualitative transcripts underwent thematic analysis in NVivo version 14 using Braun and Clarke’s six-phase approach. Results: In terms of Reach, MAM services were nearly universal across 101 pilot health posts; 99 percent offered the service (88 percent biweekly) screening 66,921 children aged 6–59 months and 22,377 pregnant or lactating women monthly. Regarding effectiveness, chart reviews showed high fidelity to admission criteria (> 97 percent) and correct supplement distribution (90 percent). For Adoption, governance and service delivery integrated fully into primary healthcare, while health financing, information, workforce competencies, and logistics showed partial uptake. Under Implementation, equipment (MUAC tapes at 94 percent, scales at 42 percent) and commodities (RUSF in 75 percent of posts) were broadly available, though storage quality (23.6 percent) and HEW workload remained challenging. Qualitative findings indicated that advocacy, supervision, and mentorship improved HEW adherence to protocol, yet persistent equipment shortages, stockouts, and heavy workloads constrained service delivery. Budget constraints, parallel reporting systems, and staff turnover hindered MAM management integration into primary health care. Conclusion: The integration of MAM services into Ethiopia's primary healthcare system has achieved strong geographic coverage and frontline engagement; however, it faces resource constraints and supply chain inefficiencies. Securing sustainable financing and reinforcing policy frameworks are essential to sustain quality MAM care within Ethiopia's primary health care system.