Thank you very much, dear partner, for this great service. These children are both failing and non-responsive. For what ? Because the number of sessions must be considered as the only means that determines the barometer of community reintegration. In this case, the scenario must be repeated to enable it to be properly required to respond to the PCMA. A child at one month old without receiving supplies before their readmission are new, who must be monitored very carefully to avoid relapse and the development of chronic acute malnutrition.

For our experience we avoid stock shortages, we follow up on admitted children and we monitor the progress of each child.

Dieudonné KEBA

Designer of the SOMMAC food supplement in the Democratic Republic of Congo

+243817542406

diedonnesommac@gmail.com

Dear,

it is the same in Ethiopia, mot facilities record them as defaulters. Discussion is underway on how to record the group.

I personally prefer to record them separately as "program / operational defaulter". 

there shall another column or remark to differenciate this group from the usual defaulters.

thanks,

Dear Elijah,
Thank you for sharing your ground experience with us. The situation you've described, where there are stock-outs of supplies for Targeted Supplementary Feeding Programs (TSFP) and Outpatient Therapeutic Programs (OTP) for an extended period in South Sudan, raises some important considerations regarding the discharge and readmission of children. Addressing your specific questions. Yes, as you haev said, according to the CMAM guidelines, children who have missed two consecutive visits are typically discharged as defaulters, while those who do not meet the discharge criteria after three months in OTP are classified as non-responders. However, in the scenario you've described, where the stock-out is beyond the control of the caregivers and the facility, it may not be appropriate to discharge these children as defaulters or non-responders. Instead, it might be more suitable to use a different discharge category, such as "temporarily discharged due to stock-out," or something similar. This would acknowledge the unavoidable circumstances and prevent unfairly penalizing the children or the program's performance indicators. As you have thought, if these children were discharged as defaulters or non-responders, it could indeed negatively impact the program's performance indicators and the Sphere standards. The high rates of defaulters and non-responders would suggest issues with program implementation or adherence, when in reality, the challenge is the stock-out situation. If your program would be affected by length of stay and good to provide the justification of your stock-out status or using a new terminology to address your situation like "temporary discharges due to stock-outs" can provide a more accurate representation of the program's performance and avoid skewing the indicators.

Thank you again for sharing your ground experience.

Alemshet 

The same has happened in Zimbabwe, especially around the COVID-19 pandemic time where the supply chain was interrupted. From the program outputs, we saw an increase in defaulters and non-respond cases which were only because of stock outs of nutrition supplies. Having a new group as you stated would assist in evaluating the program better.

Dear,

I am sharing my experience from Pakistan context, where we also faced stockout situation in OTP & TSFP while working in different complexities.

Children who were enrolled but did not receive supplies due to stockouts should not be classified as defaulters or non-respondents. Instead, they may need to be categorized based on the specific circumstances that led to their lack of treatment. Therefore, those who are reached or nearby to program exit criteria by 1 or 2 points may be counselled well for family foods, proper IYCF practices, observe for few follow up visits without stock and discharged as CURED if progressing, if the enrolled children spend more than 2 months in program they may be exit as MOVED OUT without supplies. However, they may not be discharged as Defaulters as the interruption was due to programmatic challenges rather than the children's absence or lack of response to treatment.

In response to question 2, while adhering to the given scenario, it is evident that the performance indicators do not impact the program's performance metrics. Nonetheless, it is imperative to precisely record the reasons for discharge to accurately represent the program's actual performance and the challenges encountered.

For the new terminology, it should be described, such as "Moved out without Supplies" to differentiate these cases from standard Moved out, defaulters or non-respondents. This would help in maintaining the integrity of the program's performance metrics and provide a clearer picture of the challenges faced.

Regards

Addressing Stock-Outs in CMAM Programs: A Nutrition Supply Chain Management  Solution

Dear Elijah Boh Alier and other Forum members here! 

Thank you for raising this pertinent issue which l would like to address as a nutrition supply chain management problem and here to propose a solution to prevent all this. 

The challenges you raise regarding stock-outs in CMAM programs in South Sudan highlight a critical issue: a nutrition supply chain problem. Fortunately, this can be addressed through implementing robust inventory management policies/models. I have shared this at one of the USAID/BHA conferences, a paper title "A Programming strategy for addressing stock-outs of nutrition commodities: An Inventory Management Policy Case-study" published here: 

Inventory Management for Improved CMAM Performance

By adopting data-driven inventory management models, you can calculate safety stock levels. This ensures sufficient supplies are readily available to cover uncertainties like the COVID-19 pandemic, accessibility challenges or unforeseen delays etc, preventing stock-outs that disrupt treatment.

In my research paper link, I delve deeper into how these models can be applied to optimize CMAM program supply chains. Coupled with my past experience is nutrition supply chain management for Sudan, Pakistan and Zimbabwe. 

Putting Solutions into Practice

I'd be happy to assist you further by demonstrating a practical implementation of these models. Depending on the data available, a short call (15-30 minutes) can showcase how to calculate safety stock levels specific to your program's needs and would be happy to see the results of this. Especially how this will contribute to reduced number of children "discharged due to stocks". 

By implementing these simple and effective inventory management policies/models you can ensure your CMAM programs continue providing life-saving treatment to children in South Sudan, even during challenging circumstances.

Feel free to reach out Elijah Bol Alier and forum members to discuss further details or schedule a call to delve into the practical application of these solutions l shared here.

Sincerely, W.G Dube

Adding this information note, prepared by the GNC to outline potential options when RUTF and RUSF are unavailable, which could be useful to your situation.

https://www.nutritioncluster.net/resources/programming-absence-nutritional-products

Hi everyone,

I think children in this situation should be categorized as PROGRAM/POLICY FAILURE. I know there are serious challenges to the RUTF/RUSF supply chain (I mean I know Upper Nile and it is really hard to reach), but any stock-out is an abject failure of programmers, policy makers, and donors.

And I don’t mean to be too harsh, but I personally find the GNC document “Management of wasting during a shortage or absence of specialized nutritious food products” to be counter-productive. We can’t manage wasting in the absence of SNPs!!! We can, however, get angry. Angry at those responsible for such stock-outs (normally it is because there is insufficient funding).

We are too timid in the nutrition community. Currently, there are 28 million people living with HIV/AIDS on antiretroviral treatment. 28 million people on a lifelong medicine! While we in the nutrition community struggle to reach 4 million kids with SAM each year while functioning MAM programs are the exception rather than the norm.

We need to be more demanding. We need to demand that resources for SNPs are commensurate with the needs. I am so frustrated with the stock-out/near stock-out situation this year in so many of our health care facilities while RUTF manufacturers report full warehouses. This is unacceptable and requires dramatic change.

Kevin

I doubt there is anyone involved in programming that doesn't empathise with Kevin's frustration at the shortages / stock outs that are experienced in many programmes. There is an awful lot that could and should be done to improve management throughout the supply chain. I have visited too many programme sites without RUTF for several months for various reasons - in one case when large volumes of RUTF were available at a warehouse only a 10-minute drive from the treatment site - certainly funding wasn't the issue in that case. I'd be interested to know more about production / supply updates - the most recent one i could find was from 2023. Some of the procurement considerations were also presented in this forum from 2022. 

The reality is that this keeps happening and from 2020 the GNC were presented with repeated requests for advice on how to cope with shortages or outages. The current document referenced by Kevin was developed as an update to programming adaptations during covid, and there was a lot of concern about whether such a note could be misused as a way of mitigating poor programme management. In the absence of a silver bullet to fix the logistic supply chain, the alternative was to ignore the requests coming through the GNC help-desk. 

In defence of the GNC document, while it is pragmatic it does not take the position that poor supply chain management is acceptable. It starts by laying out conditions that prioritise a return to normal programming and emphasises preparedness actions to avoid shortages / stock outs to the care delivery point in the first place. It is meant to be used with the involvement of government / cluster partners at the highest levels to emphasise accountability for addressing the underlying issues and not by individual programme managers to paper over poor management. However none of that should undermine or be counter-productive to continuing to demand dramatic change. 

In response to the original questions:

1. From your two available options you would classify them as a 'defaulter' rather than non-cured / non-respondent. The latter refers to a non-response to treatment which does not apply if treatment is not being given. The child would normally remain registered and contacted to return when stocks are available and the reasons for the high default rate explained in the narrative report. The term defaulter merely implies absence for 2 or 3 consecutive visits. It does not in itself blame the caregiver - it is however often used to say 'the child defaulted' which implies blame on the caregiver. But this shouldn't be the case . There are many reasons / barriers to access why a child may default from treatment on both the supply and demand side of the programme. It important to investigate and react to the reasons for default in all cases through follow up or a coverage survey. If additional categories are used, be sure that they don't artificially suggest that programme performance is 'good' and that its 'just a supply problem' - without the supply there is no functioning treatment programme and likely poor outcomes for the affected children. 

2. Yes, the performance of the programme is down. If there's no RUTF and no treatment then treatment coverage is zero. However there should be less concern about the actual number and more focus on ensuring the reasons for poor programme performance are identified and appropriately addressed, e.g. through improved supply chain management in this case, and in mitigating any impact on the individual children through some of the measures outlined in the GNC document referenced in previous answers.

3. I'm not in favour of new terminology for reporting purposes. High default or low programme coverage should be addressed no matter the cause - we shouldn't (IMO) create special categories for poor supply chain management. Reporting should be kept as simple as possible and all of the data explained in the narrative report or though the relevant staff coordination meetings. 

Hi Paul, Thanks for this reply. I apologize if in my frustration I unintentionally disparaged any initiatives out of the GNC. And I totally get that we cannot simply ignore practical requests coming in from colleagues around the world. But the frustration - especially this year - points to a serious problem with RUTF supply/delivery/financing that requires urgent solutions. And from my perspective, demanding predictable financing commensurate with global needs is a place to start. Cheers, and good luck everyone... Kevin 

Dear KEVIN,

I completely agree with you. The constant challenges around RUTF supply,delivery and financing point to a deeper issue in nutrition supply chain management that often gets overlooked. It's more important, especially now with the increased nee and gaps.

On the bright side, I'm happy to discuss this further with anyone interested in exploring how effective supply chain management solutions can address these issues. I believe we can make a significant impact by optimizing RUTF supply, delivery and financing models.

Best