Hi Syed,
This is an interesting question. I wonder why there was the creation of an exit category called "moved out without supply". It appears that this would be a category specifically for IDPs who are thought to have relocated without notice and without completing treatment. I assume therefore that 'defaulters' are then either IDPs or host community members who do not relocate but have stopped attending treatment.

In my opinion I think that when treatment is terminated without notice and the beneficiary has not been transferred deliberately to another programme site or hospital then this is a 'default'. The distinction between those who remain in the programme area and default and those who relocate (and thus also default) is worth noting but should be part of "additional information". Keeping track of this information may assist in redesigning the programme to meet beneficiary needs so is definitely worth collecting. What we shouldn't do is try to make our outcomes look better by hiding defaulters. We should always produce 'honest' figures and seek to address the reason for it.

So, instead of reading: Cured = 20 / 26 = 77%
Defaulted = 6/ 26 = 23%

I think your report should read something more like:

Exits Additional information on defaulters
---------------------------------------------------- ------------------------------------------------------------------
Cured Died Default Non-Cured Host Community Relocated IDPs

20 0 10 0 6 4

The outcomes are calculated:

Cured 20 / 30 = 66.7%
Died 0 / 30 = 0%
Default 10 / 30 = 33.3%
Non-cured 0 / 30 = 0%

Defaulters remaining in programme area = 6 / 10 = 60%
Defaulters Relocating without supply = 4 / 10 = 40%

In either instance there is a need to address both reasons for default. Perhaps do some stage 1 SQUEAC type investigations. Ask defaulters who remain why they are defaulting. If the areas where IDPs are relocating to are safe is there scope to set up programme sites there and do planned transfers instead?

Perhaps (and i stress that this may not be an ideal solution) you include information on planned relocation in your sensitisation information for the IDPs then they can relocate WITH supply and take a MUAC strap with them to monitor their own child's progress (See the paper on Mothers Understand And Can do it - MUAC by Nikki Blackwell et al.). They will then at least know to seek medical help if the child's MUAC does not turn to yellow or green within a few weeks.

You may also try to look for information on programme learning in Pakistan where there were similar problems with IDPs 'relocating without supply' back to the SWAT valley area.

I hope this helps,
Paul

My apologies, the figures for the table did not come out as I had formatted them in the reply. It should read:

Exits
============
Cured: 20
Died: 0
Default: 10
Non-cure: 0

Additional information on defaulters
=============================

Defaulters in host community: 6
Defaulters relocating without supply: 4

Paul

Dear Paul Binns,

Thank you so much for your precious Reply on the above query but kindly let me know that to we do further for those beneficiaries who went back to their origin where are no any organization work on CMAM Program and we are unable to access to them.simply you said that we will included these Moved Out beneficiaries in the category of Defaulters.And what about those beneficiaries who still not cured and want to go back their origin/District Village.if we given Two months of supply to those beneficiaries and mark them Exit As moved then what about these beneficiaries Are they come on the status Of defaulters OR not and which category of the exit we put these beneficiaries? And here one thing are clear with us that if a beneficiary missed their visit then we will mention them As defaulter As exit.

waiting for your prompt Response.

Thank you much

Hi Syed,
It is debatable whether this should be a new discharge category or whether the discharge should be as 'non-cured'. I tend to favour the latter, as in general I am against creating new discharge categories.

If you categorise them as non-cured, you could then have a section on 'further information' which would distinguish between non-cured because they have not responded to treatment after 4 (?) months or whether they were a planned discharge and were not cured at the time of leaving.

In any case I think this needs to be considered a negative outcome. I think there needs to be very careful thought before introducing planned discharges before cure and should be an action of last resort when nothing else can be done. Efforts should be made to convince them to stay until the child is cured involving other family or local traditional leaders within the IDP community or even religious leaders . They should clearly understand that relocating while the child is still SAM puts the child at great risk. If they are absolutely determined to leave perhaps negotiate that the child stays until at least they are no longer SAM or stays in treatment and / or for a minimum of 1 month. The MUAC should at the very least be in the MAM range if the child started as SAM. Perhaps the caregiver and affected child can delay relocation while the rest of the family relocate (security / protection considerations may make this unlikely).

If you do discharge a child with RUTF and a MUAC tape you must be sure to give training in the use of MUAC and careful messages. MUAC responds in a similar way to weight changes without any lag effect. MUAC also responds in exactly the same way as weight when there is an illness (these will be the subject of a peer reviewed paper being published imminently). It is important to tell the caregiver to take the child to a health facility if the MUAC does not increase each week.

The child with MAM is also at a slightly elevated risk but the physiology is less deranged than that of a SAM child. A planned discharge could be done more immediately and the child discharged with RUSF along with all of the appropriate key messages for the caregiver.

In all cases there should be an emphasis on
- IYCF messaging
- WASH considerations, hygienic food preparation etc.
- Specific messaging regarding the underlying cause of the malnutrition
- Messaging on any medications which must be continued after discharge

On discharge you should provide a detailed discharge slip which explains the treatment given so that the caregiver can give this to a health care provider in the new location if necessary (include your contact phone number). Take the phone number of the caregiver or a close relative, if possible, so that you can follow up the child remotely. You should ensure that any planned discharge must be certified by the programme manager to ensure that as much is done as possible to prevent the early discharge. It is important that this does not become the de facto method of discharge.

I am sure that these thoughts on the topic are not exhaustive and others will have more to contribute to the discussion. Whatever is decided, the safety of the child remains the number one consideration.