**Background:** Severe acute malnutrition (SAM) remains a major contributor to child morbidity and mortality in low- and middle-income countries, with poor quality of care at health facilities being a key factor. Globally, approximately 17 million children suffer from SAM, and case fatality rates in hospitals treating SAM remain at 20–30% in most underdeveloped countries. In Ethiopia, the 2019 EDHS reported that 7% of under-five children were wasted, 37% were stunted, and 21% were underweight. Despite integrated pediatric healthcare initiatives in most Ethiopian hospitals, the quality of SAM management remains a concern, and evidence on perceived quality of care is limited.
**Methods:** This institution-based convergent mixed-method study was conducted from 15 February to 20 May 2022 in all four public hospitals providing inpatient SAM management in Addis Ababa, Ethiopia: Yekatit 12 Medical College Hospital, Menelik II General Referral Hospital, Zewditu Memorial General Hospital, and Tirunesh Beijing General Hospital. For the quantitative survey, 181 caregivers of under-five children with SAM were recruited using stratified sampling. The sample size was originally calculated as 413, but fewer SAM cases were encountered during the study period. Data were collected using a validated HEALTHQUAL model questionnaire (32 items, 5-point Likert scale) covering five dimensions: tangibility (5 items), empathy (7 items), efficiency (6 items), safety (6 items), and improving service delivery (8 items). Cronbach's alpha for the total scale was 0.71. For the qualitative component, 15 healthcare providers were purposively selected and interviewed until data saturation. Quantitative data were analyzed using STATA version 16 with binary logistic regression; variables with p<0.25 in bivariable analysis were entered into multivariable analysis. Qualitative data were analyzed using deductive thematic analysis in ATLAS.ti version 9.1.
**Key Results:** Among 181 caregivers, 74.03% were female, mean age was 30.80 ± 5.72 years, 62.43% were from rural areas, and 44.75% were housewives. Of the 181 children admitted with SAM, 77.35% were female, 60.22% were newly admitted, and 51.38% were aged <12 months (mean age 14.59 months). The overall perceived quality of care for SAM management was 55.80% (95% CI: 48.50–63.10%). Across dimensions, the lowest quality level was for empathy (25.41% good quality) and the highest was for safety (70.17% good quality). The mean Likert scale score for overall items was 3.44 ± 0.27. Factors significantly associated with lower perceived quality in multivariable analysis included: urban residence (AOR = 0.32, 95% CI: 0.16–0.66, p=0.002), college and above education (AOR = 4.42, 95% CI: 1.41–13.86, p=0.011), government employee occupation (AOR = 2.72, 95% CI: 1.05–7.05, p=0.039), readmission to hospital (AOR = 0.47, 95% CI: 0.23–0.94, p=0.036), and length of hospital stay >7 days (AOR = 2.1, 95% CI: 1.01–4.27, p=0.046). Qualitative findings from 15 healthcare providers (10 BSc nurses, 4 MPH in Nutrition, 1 general practitioner; age range 25–35 years; experience 2–10 years) identified four main themes: management process, factors affecting quality of care, outcomes of management, and quality improvement strategies. Key barriers included lack of support and attention from higher-level institutions (AAHB and MOH), supplement insufficiency, lack of training for healthcare providers, lack of diagnostic materials and laboratory facilities, and absence of separate units for SAM management.
**Clinical Implications:** The perceived quality of SAM management services in Addis Ababa public hospitals is low (55.80%) against national quality improvement goals, with empathy being the weakest dimension (only 25.41% rated as good quality). This indicates that patient-centered care and emotional support for caregivers require urgent attention. The study identifies specific groups at higher risk of perceiving poor quality—urban residents, caregivers with higher education, government employees, newly admitted patients, and those with prolonged hospital stays (>7 days)—who may benefit from targeted communication and service improvements. Healthcare providers reported systemic barriers including inadequate supplies, lack of separate SAM units, insufficient laboratory facilities, and limited training opportunities. Addressing these gaps through improved logistic supply chains, enhanced training programs, establishment of dedicated SAM units, and stronger institutional support from higher-level health authorities could improve both perceived and actual quality of care. The findings underscore that achieving universal health coverage requires not only access but also quality improvements in SAM management to reduce the 20–30% case fatality rates still seen in many low-income settings.