Working out the threshold will depend completely on the health system you are talking about. The example indicator of 30 would be reasonable in many places but that doesn't correspond to 3% SAM. The threshold should be based on actual numbers presenting not a % prevalence and should be worked out with the district/regional health team on the ground ahead of time to see what level they could manage before needing external assistance. It can be exactly same process for MAM - an agreed threshold where it no longer becomes manageable as part of routine activities.

Thank you for the question and referencing our paper. As Anne says the 3% and 30 children "thresholds" were used as an example to illustrate some of the points in the paper. The actual numbers depend on your particular circumstance. The same is true of your question about MAM programmes. A capacity assessment could be carried out at centre, district, or even national level depending on the decisions you need to make. To use a very simple one centre scenario, take a SFP implemented at a small scale through a health post or health centre with 50 children in the programme at any one time. They come for their check up and distribution every two weeks and it takes 2/3 government staff to distribute for a whole morning. One of the staff is more medically qualified. The programme has been running for 1 year and has occasional monitoring visits from the Government and NGO staff with a refresher training for the medical staff once a year. The hungry season is starting and a survey gives a GAM of 9% and predicts an increase of 100 children/month. Your baseline capacity assessment for a centre could, for example, look at the physical structure of the centre, the staff numbers and their technical capacity, the logistics capacity of the Government system to deliver supplies (other criteria could be used). The baseline findings set three thresholds >100, > 500 and > 1000 children with defined areas of support that would be required. Therefore in this example the baseline assessment concluded that if the caseload increases to 150 children there will be a need for 1. One more support staff, 2. External support to the government logistics system and 3. A mentoring support for the staff for 1 month by having NGO technical staff present at the first two distributions. 4. And of course increase in supplies The supporting organisation then provides this support until the number of children reduces to <100 again and external support can be phased down. If after the survey the situation was worse than expected and the numbers of children increased to 700 then the baseline assessment has already suggested that when the centre has over 500 children the supporting agency would need to provide the following support 1. 4 extra support staff on distribution days and 1 extra medical staff (these can be provided by the NGO or the government seconds people there and/or financial support is provided to the Government to increase HR numbers., 2. Take over the physical running supply chain for the period of the crisis 3. Supporting agency technical staff present at every distribution. 4. A tent with additional furniture and equipment 5. Increase in supplies An additional point of the paper was that during this phased up response the aim is that when the supporting agency withdraws or scales down the baseline assessment thresholds for the various types of external support are increased. In this case threshold one could be increased from 100 to 200 children. This is because of the mentoring work and the capacity built within the Governments supply chain mechanism. The paper also suggests that this approach provides a nutrition Disaster Risk Reduction (DRR) framework. Capacity building is a fundamental aspect of DRR. If an emergency response is triggered or is long running, and implemented using a capacity assessment approach then the objective of capacity building for DRR is added to the objective of saving lives. I firmly believe that his is true and possible even in my new stamping ground of Somalia. Incidentally this approach provides a possible framework for exit strategies for anyone who is old enough to remember all the debates we used to have about exit strategies or the days when we closed TFCs because they had less than 100 or 200 children in them. Without making the baseline too complicated this approach could be used for a livelihood zone or district, with the thresholds and suggested types of support being defined at a broader level allowing more specific centre assessment to be conducted using the same criteria once the response has been triggered. This approach also brings up another issue that Andre Briend has been talking to us about and which is very familiar to all of us but not always appreciated by others. Prevalence thresholds are an infectious disease approach to decision making for response management. A prevalence threshold for an infectious disease is used to estimate when the risk of transmission increases to a point where external support is required. Acute malnutrition is not an infectious disease. Andre added the following comment "Epidemiology was initially driven by infectious disease specialists. When you read early papers on nutrition epidemiology, this is quite clear, including the misleading idea that a child can be classified as being malnourished or not, whereas in reality, there is a continuum. Many misconceptions come from this confusion." In the scenario above the GAM was estimated to be 9%. Using the present WHO emergency thresholds the Government and supporting agencies would have a hard time to find resources to implement the light touch of phase 1 scaled up response described above. This would be true if the survey was conducted in a population of 5,000 children (e.g. a group of villages) suggesting that 450 children have GAM or if it was conducted in 500,000 children (e.g. an urban slum/refugee camp) suggesting 45,000 children have GAM. If a decision maker rejects the use of the prevalence thresholds and decides to only use estimated caseload they might decide to only respond to the 45,000 children problem, probably a big step forward from the prevalence approach presently used. However if the same decision maker has the knowledge of the number of children affected and the capacity of the underlying system to deal with this problem is able to decide that 450 children can be managed by the existing system with refresher training, but 45,000 severely malnourished children completely overloads the existing system and a full "traditional" response is required or vice versa. I am sorry for the long reply. These are ideas that we have been trying out but that require many more experienced inputs and suggestions and both Tewolde and I would be very happy if these ideas trigger a debate.

Thanks Anne and Peter for the Valuable response which clearly states that the thresholds (Actual numbers) need to be context specific depending on baseline capacity assesment conducted. Thanks Peter for elaborating on the areas that one one look into when conducting a baseline capacity assesment to define areas of support the health system will require. Am wondering how these approach will be presented to donors,as i think, donors often like to see a more uniform approach and perhaps a more standard "threshold" that can be used to assess a situation. Thanks