“When they stop coming, we lose them”: a qualitative study assessing health workers’ experiences on treatment default during outpatient therapeutic care for severe acute malnutrition at Gulu regional referral hospital, Uganda

Background Outpatient therapeutic care (OTC) programs are essential for managing severe acute malnutrition (SAM). However, default rates in northern Uganda remain high- reaching up to 21.9%. This study explored the experiences of health workers delivering OTC services on outpatient therapeutic care treatment default at Gulu regional referral hospital (GRRH). Methods This was a qualitative descriptive study that employed phenomenology. Semi structured interviews were conducted with nine purposively selected health workers. All interviews were transcribed verbatim and analyzed thematically. Results Six core themes were developed: organization of the OTC program, causes of treatment default, consequences of default, management and prevention strategies, programmatic challenges, and recommendations for program improvement. Many health workers described multiple drivers of default, including health system constraints (e.g., long distances, transport costs, RUTF stockouts, staff absenteeism, and seasonal farming), caregiver-level challenges (e.g., Domestic violence, family separation, poverty, inadequate social support, and cultural beliefs), health literacy gaps (e.g., misinformation, misconceptions and negligence), and child-level clinical complications (comorbidities e.g., HIV, TB, cerebral palsy). Conclusions Outpatient therapeutic care treatment default is driven by a complex intersection of health system limitations, caregiver socio-economic challenges, and child-related factors. Addressing these requires a coordinated, multi-sectoral approach to strengthen service delivery, caregiver support, and program monitoring.