This is the first study reporting on the performance of nutritional services for children in Arua district. The assessment shows that, even though some positive aspects were observed, there are substantial deficiencies in the quality of nutrition services at health center level in Arua district. Significant gaps were observed both by using the national tool for Nutrition Service Delivery Assessment (NSDA) and by reviewing key indicators of health outcomes, case management and data quality in the official records.
The observed health facility cure rate of 52.9% was far below the international SPHERE standards target set at above 75% [28], while the defaulting rate of 38.3%, was significantly higher than the standard’s target set at below 15% (28). One of the possible reasons for this low cure rate may be the lack of adherence to guidelines for case management as observed in this study. Important clinical practices such as triage, screening of all children for malnutrition, history taking, detailed examination, diagnosis of SAM and MAM, individual counselling, complementary treatment and assignment of exit outcomes were not being performed according to the IMAM guidelines [2]. Additionally, laboratory screening for HIV and TB was not routinely conducted, despite the availability of laboratory diagnostic kits. Such poor performance of quality of health service delivery has also been reported in other studies both in routine settings in Uganda [13, 15, 29, 30] and in refugee settings such as in Ethiopia [31,32,33,34].
Another key reason explaining the poor performance of case management, in addition to inadequate human resource, is the substantial lack of training of heath facility staff, both frequently observed challenges in low and middle income countries [35]. The impact of targeted training on both health workers performance and children outcomes is relatively well documented. For example, a systematic review examining the effectiveness of nutritional training of health workers showed a clear benefit in improving feeding frequency, energy intake, and dietary diversity of children [36].
Notably, almost all the assessed health facilities had basic nutritional equipment such as digital weighing scales, length/height measuring boards, MUAC tapes and essential job aids. However, the frequent stock out of RUTF, an essential nutrition management commodity, was a significant issue, a finding in line with two earlier studies conducted in other regions in Uganda [29, 30].
The observed challenges such as stock out of RUTF, poor organisation of services including irregular working hours and long waiting times and weak community linkages re-affirm some of the underlying factors explaining the very high defaulting rate observed [29]. The poor performance of VHTs especially regarding case-identification and referral of cases is an observation that deserves further scrutiny because this study was not designed to identify the causes of this occurrence. However, evidence from a systemic review on factors that influence performance of community health workers (CHWs) such as VHTs found that lack of supervision, lack of training and lack of financial incentives were the main barriers to achieving an acceptable performance from CHWs [37]. Minimizing such barriers would improve access to care and ultimately the achievement of better health outcomes. Evidence shows that barriers to access for service users may increase mortality, especially among children with SAM who actually requires urgent medical attention [38].
Poor data quality is another important but frequently reported problem in low income countries, including Uganda [39, 40]. Good quality data is the basis for evidence based decision making and two suggested approaches for improvement in such settings include better training on data quality assurance procedures and intensive supportive supervision [38,39,40,41].
As already documented, the influx of refugees into a community negatively affects the performance of health services in such settings [31, 32]. However it is also true that poor performance has been reported in settings experiencing no refugee crisis [29, 30], indicating that refugee circumstances is not the sole explanation for such a performance. This study did not aim at comparing the performance of nutritional service before and during the most recent refugee crisis In Arua, but rather at collecting baseline data for service delivery evaluation. Future studies should aim at monitoring health system performance over time while exploring the influence of different factors on key outcomes.
Limitations of this study included the relatively small sample size in terms of health facilities, however, the study sample population captured over 45% of cases of children admitted to nutritional services in Arua district. Even though most of the assessment was conducted by direct evaluation using the NSDA tool [26], health outcomes and case management were assessed using recorded data, which, by nature, are exposed to a risk of recall bias. We tried to minimised this bias in different ways such as choosing the official documents as data sources with the expectation that all information of each child with malnutrition was recorded, using trained data collectors, using pre-defined data collection variables, developing standard operating procedures and transparency during reporting of study findings.
Recommendations for policy makers derived from this study may include: hiring and training of health facility staff to fill the human resource gap; strengthening supportive supervision to improve performance at different levels (case management, timely requests of RUTF, data quality, community linkages); and conducting regular NSDA assessments to monitor progress over time. More studies are needed to identifying effective approaches to enhance adherence to national guidelines and ultimately improve health outcomes of children.