An Assessment of the Coverage, Boosters and Barriers of the Out-patient Therapeutic Care for Severe Acute Malnutrition in Albay Province, Philippines

Background: Severe acute malnutrition prevents a child from developing
normally and increases mortality risk. It remains to be a major global health
problem in children under 5 years of age. The community-based management
of acute malnutrition (CMAM) is a nutrition intervention aimed at the early
diagnosis and management of these children at the community level through
the provision of therapeutic foods coupled with facility-based management for
those with medical complications. In 2015, the Philippine Integrated
Management of Acute Malnutrition (PIMAM) program was established to
manage acute malnutrition in Filipino children of less than 5 years of age.
Evaluating coverage which is one of the important indicators of CMAM
program performance as well as identifying its boosters and barriers were
imperative. The study aimed to assess the coverage, boosters, and barriers of the PIMAM Out-patient Therapeutic Care (OTC) in the province of Albay,
Philippines.

Methods: This is a mixed method explanatory sequential research design
adopting the Semi-Quantitative Evaluation of Access and Coverage
(SQUEAC) tool. Accrual period was from January 2019 to present. Collection
and analysis of quantitative routine program data from all the cities and
municipalities of Albay followed by qualitative data collection through
community assessment, key-informant interviews, informal group discussions
and directly observing OTC processes were done. A small area survey to
validate hypotheses regarding areas with high or low coverage was
subsequently conducted.

Results: Analyses of secondary routine program data showed that only two
out of the 18 cities and municipalities in Albay had complete program data
where Municipality C had high coverage and Municipality K had low coverage
in 2019. Qualitative methods identified the main boosters to program
coverage which include (1) support from the Local Government Unit and the
Municipal Health Officer; (2) presence of a well-trained OTC personnel; (3) OTC services are made available at the barangay level; (4) provision of door-
to-door screening, follow-up and dispensing of nutrition commodity; (5) community health workers’ willingness to learn and be trained; (6) supervision
of the community health workers by the OTC personnel; (7) presence of
community mobilization practices; (8) support of the barangay council; (9)
acute malnutrition is not stigmatized; and (10) caregivers’ awareness and
acceptance of the PIMAM program. Barriers on the other hand appeared to
be more significant which include (1) limited budget from the Local
Government Unit; (2) Ready-to-Use Therapeutic Food (RUTF) stockouts; (3)
inadequate number of trained OTC personnel; (4) gaps in anthropometric
measurements; (5) insufficient community mobilization; (6) community health
workers’ lack of knowledge and training on PIMAM; (7) community’s lack of
knowledge on malnutrition and the PIMAM; (8) caregivers’ laziness and
indifference on their child’s condition; (9) RUTF feeding difficulties; and (10)
COVID-19 pandemic stopped community mobilization and OTC admissions.
The small area survey results showed low coverage in both near and far
barangays in Municipality C.

Conclusions and Recommendations: The study was able to present the
level of PIMAM implementation in the different municipalities in Albay and was
able to evaluate program data completeness and accuracy. Boosters can be
considered as groundworks where opportunities to strengthen program
access coverage rest. Barriers which validate coverage failure shall be
addressed such that bridging gaps and augmenting inadequacies, together
with adaptations to program protocols must be prioritized for an effective
program implementation. The unavailability of RUTF and the COVID-19
pandemic could have explained the low coverage in both near and far
barangays in Municipality C in the small area survey. The study therefore
recommends the following: (1) provide measures to improve program data
quality; (2) strengthen ownership of the PIMAM program by the Local
Government Unit; (3) increase the number of PIMAM-trained personnel; (4)
intensify OTC services at the barangay level together with the training of the
community health workers on PIMAM; (5) increase the number and quality of
community mobilization activities; (6) address shortage of RUTF; (7) consider
program adaptations to PIMAM implementation during the COVID-19
pandemic; and (8) more research on the evaluation of the PIMAM in other
regions of the country.