Understanding barriers and facilitators of integrating management of Moderate Acute Malnutrition (MAM) into the Ethiopian primary health care system using Consolidated Framework for Implementation Research (CFIR)

Abstract

Existing studies focus on moderate acute malnutrition (MAM) management, with little attention to integrating MAM services into the health system. This study examines barriers and facilitators to integrating m (MAM) services into primary health care. We conducted a qualitative exploratory study at the policy, primary health care, and community levels in six regions of Ethiopia. We used the Consolidated Framework for Implementation Research (CFIR) to guide the development of the data collection tools and the analysis and presentation of the findings. We purposively selected participants and conducted in-depth interviews with 128 participants at the national, regional, district, and facility levels. Hybrid deductive-inductive analysis analysis was applied and the analysis was conducted using NVivo software version 14. Ratings were used to understand how strongly the constructs facilitated or hindered MAM integration, and patterns across levels were compared using heat maps. Integrating MAM management into the health system was considered useful and feasible, with a reliable and adaptable system in place. However, the absence of a dedicated government budget for supply chains, transport and storage services, and supervision creates heavy reliance on external donor funding, undermining government ownership. At the primary care level, understaffing and extensive paperwork and documentation requirements reduce self-efficacy and contribute to inconsistent implementation. These challenges are further compounded by community-level pressures, including misconceptions that the targeted medical supplement is a general food distribution, which increases demand beyond eligibility criteria. Additionally, access barriers such as distance, mobility constraints, and seasonal conditions, along with household dynamics such as sharing of supplements, affect utilization. Integrating MAM management into routine primary healthcare is perceived as valuable and adaptable, with support from existing policies. However, successful and sustained implementation remains constrained by context-specific health system challenges.