Integrated Community Case Management Plus versus outpatient therapeu tic programs: a quasi-experimental study among children with severe acute malnutrition in Jowhar, Somalia

BACKGROUND: WHO guidelines endorse treatment of severe acute malnutrition (SAM) by community health workers as an alternative to facility-based care, but supportive evidence for this shift is low. OBJECTIVE: Among Somali children with uncomplicated SAM, we compared recovery between facility-based outpatient therapeutic programs (OTP) and integrated community case management (iCCM+) examining weight change, length of stay, discharge anthropometry and overall anthropometric change. METHODS: In a quasi-experimental study (January 3 to May 19, 2024), children with uncomplicated SAM (weight for height Z-scores, WHZ<-3SD and/or mid-upper arm circumference, MUAC≤115 mm) were enrolled for treatment in OTP (2 sites, 638 children) or iCCM+ (8 villages, 545 children). During weekly follow-up visits, children received nutritional assessments, ready-to-use therapeutic food, and routine medications until discharge (MUAC>115mm; WHZ > -3SD). Weight change and time to recovery were analyzed using generalized linear mixed-effects models and Cox proportional hazards models, respectively. To adjust for baseline differences in observed covariates, we used inverse probability weighting based on propensity scores. RESULTS: At enrolment, OTP children had more severe anthropometric deficits than their peers in the iCCM+ group ( WHZ<-3SD: 48% versus 42%, p=0.04; MUAC ≤110mm: 34% versus 18%, p<0.001). Recovery proportions were similar between groups (iCCM+: 89%; OTP: 91%). In adjusted analyses, no difference was observed in weight change over time. The iCCM+ group had a shorter median length of stay (by 7 days) and faster time-to-recovery (adjusted hazard ratio: 3.32, 95%CI: 2.70, 4.09). CONCLUSION: Treatment outcomes were similar between approaches; iCCM+ enabled earlier identification and shorter length of stays, suggesting improved efficacy and reduced burden on caregivers and health systems. It shows promise for expanding SAM treatment in settings with limited OTP access.