Renzaho Andre M N, Dachi Gilbert, Ategbo Eric, Chitekwe Stanley, Doh Daniel
Translational Health Research Institute, School of Medicine, Western Sydney, University, Sydney, Australia.
Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, VIC, 3004, Australia.
Arch Public Health. 2022 Sep 5;80(1):203. doi: 10.1186/s13690-022-00934-y.
Funds for community-based management of acute malnutrition (CMAM) programs are short-term in nature. CMAM programs are implemented in countries with weak policies and health systems and are primarily funded by donors. Beyond operational expansion, their institutionalisation and alignment with governments' priorities are poorly documented. The study aimed to identify pathway opportunities and approaches for horizontal and vertical scaling up of CMAM programs in South Sudan.
The study was conducted in South Sudan between August and September 2021 using an online qualitative survey with 31 respondents from policy and implementing organisations. The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework guided the study's design. It was self-administered through the Qualtrics platform. We used Qualitative Content Analysis supported by the Nvivo coding process. A deductive a priori template of codes approach was complemented by a data-driven inductive approach to develop the second level of interpretive understanding.
Findings from the study demonstrate that the emphasis of CMAM programs was horizontal scaling up, characterised by geographic distribution and coverage as well as operational expansion. Main challenges have included unsustainable funding models, the inadequacy of existing infrastructure, high operational costs, cultural beliefs, and access-related barriers. Factor impacting access to CMAM programs have been geographical terrains, safety, and security concerns. Vertical scaling up, which emphasises institutional and ownership strengthening through a sound policy, regulatory, and fiscal environment, received relatively little attention. Nutrition supplies are not part of the government's essential drug list and there is limited or no budgetary allocation for nutrition programs by the government in national budgets and fiscal strategies. Factors constraining vertical scalability have included weak government systems and capacity, a lack of advocacy and lobbying opportunities, and an apparent lack of exits strategies.
Addressing the scalability problems of CMAM programs in South Sudan demands a delicate balancing act that prioritises both horizontal and vertical scalability. Government and political leadership that harness multidisciplinary and multi-sectoral coordination are required. There is a need to increase policy commitment to malnutrition and associated budgetary allocation, emphasise local resource mobilisation, and ensure financial sustainability of integrating CMAM programs into the existing health and welfare system.
基于社区的急性营养不良管理（CMAM）项目资金本质上是短期的。CMAM项目在政策和卫生系统薄弱的国家实施，主要由捐助者资助。除了业务扩展外，其制度化以及与政府优先事项的契合度记录不足。该研究旨在确定南苏丹CMAM项目横向和纵向扩大规模的途径机会和方法。
2021年8月至9月在南苏丹进行了这项研究，对来自政策和实施组织的31名受访者进行了在线定性调查。可及性、有效性、采用率、实施情况和维持情况（RE-AIM）框架指导了研究设计。通过Qualtrics平台进行自我管理。我们使用了由Nvivo编码过程支持的定性内容分析。代码方法的演绎先验模板辅以数据驱动的归纳方法，以发展第二层解释性理解。
研究结果表明，CMAM项目的重点是横向扩大规模，其特点是地理分布和覆盖范围以及业务扩展。主要挑战包括不可持续的资金模式、现有基础设施不足、运营成本高、文化信仰以及与获取相关的障碍。影响获取CMAM项目的因素包括地理地形、安全和安保问题。纵向扩大规模，即通过良好的政策、监管和财政环境强调加强机构和所有权，受到的关注相对较少。营养用品不属于政府基本药物清单，政府在国家预算和财政战略中对营养项目的预算分配有限或没有。制约纵向可扩展性的因素包括政府系统和能力薄弱、缺乏宣传和游说机会以及明显缺乏退出战略。
解决南苏丹CMAM项目的可扩展性问题需要精心平衡，优先考虑横向和纵向可扩展性。需要政府和政治领导层进行多学科和多部门协调。有必要增加对营养不良问题的政策承诺和相关预算分配，强调当地资源调动，并确保将CMAM项目纳入现有卫生和福利系统的财政可持续性。
