To assess the effectiveness of facility-based care for children with severe acute malnutrition (SAM) in malnutrition treatment centres (MTC).

Early detection and treatment of SAM using locally adapted protocols; assessment of programme outcomes, including survival, default, discharge and recovery rates.

All forty-eight MTC in Jharkhand, India.

Children (n 3595) with SAM admitted to MTC (1 July 2009–30 June 2011).

Of children admitted, 55·0 % were girls, 77·7 % were 6–23 months old and 68·6 % belonged to scheduled tribes or castes; 34·4 % had oedema or medical complications. Of the 3418 programme exits, the proportion of children who died was 0·6 % (n 20), the proportion of children who defaulted was 18·4 % (n 628) and the proportion of children discharged was 81·0 % (n 2770). Children's average weight gain was 9·6 (sd 8·4) g/kg body weight per d and their average length of stay was 16·0 (sd 5·7) d. Among the 2770 children who were discharged from the programme, 39·4 % (n 1090) gained 15 % or more of their initial weight while 60·6 % (n 1680) gained less than 15 % of their initial weight.

MTC provide live-saving care for children with SAM as demonstrated by high survival rates. However, the protocols and therapeutic foods currently used need to improve to ensure the recovery of all discharged children. MTC should be reserved for children with complicated SAM; children with uncomplicated SAM should be admitted to a community-based programme for the management of SAM, at a lesser risk to children and a lesser cost to families and the health system.