Assessing the reach of the IMAM program in a remote setting: Evidence from Bajura district, Nepal

BackgroundWasting remains a major public health concern in Nepal, contributing to preventable morbidity and mortality among children under five. The Integrated Management of Acute Malnutrition (IMAM) program has been implemented in Bajura district since 2014/15, yet evidence on its coverage and accessibility has been lacking. This study assessed program coverage, identified barriers and enablers, and proposed strategies to improve reach and effectiveness. MethodsA Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) approach was employed in three stages. Stage I combined routine HMIS data review with qualitative data from key informant interviews, focus group discussions, and direct observations to identify barriers and boosters. Stage II tested the hypothesis that coverage was higher near Outpatient Therapeutic Care Centres (OTCCs) and lower in distant areas, using active and adaptive case-finding. Stage III conducted a wide-area survey, applying Bayesian analysis to estimate coverage. ResultsThe assessment identified 14 boosters, including OTCC expansion and integration of SAM screening into growth monitoring and immunization services, and 25 barriers, notably RUTF stockouts, inadequate health worker capacity, and low community awareness. Coverage was estimated at 23.5% (95% CI: 14.5-36.0%), well below the SPHERE standard of [≥]50% for rural settings. Point coverage was 11.53%, indicating very limited reach at any given time. Female children constituted the majority (69%) of uncovered cases, suggesting possible gender-related disparities. ConclusionIMAM coverage in Bajura is substantially below international benchmarks, constrained by both service delivery gaps and socio-cultural barriers. Strengthening health worker capacity, ensuring uninterrupted RUTF supply, enhancing community engagement, improving data systems, and addressing gender-related inequities are critical to expanding access and improving treatment outcomes.