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We are Working Against "Default Definition, Aren't we?

This question was posted the Prevention and treatment of severe acute malnutrition forum area and has 3 replies. You can also reply via email – be sure to leave the subject unchanged.

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Tammam Ahmed

H&N Project Manager/Relief International

Normal user

21 Jun 2016, 11:45

With some health workers we may notice high number of defaulters in the CMAM program. Without consultation and follow up, this issue continues for months and years and may be reflected in the central databases, donors databases and gives a false impression that there is high number of defaulters.

And if you go back to search the cause of this high number of defaulters you will anticipate it is due to "no food commodities, difficulty of access to the health facilities and so on".
This is against the definition of "defaulter"...
Real Defaulter means "the service is available but the child is absent". Otherwise it is pseudo-default (false default)

I hope you all the best

Paul

Technical expert

21 Jul 2016, 13:45

Hi Tammam,
this is an interesting point and I think it is worthwhile expanding on the discussion.

The general 'definition' of default in CMAM programs is usually something like 'absent for 2 weeks' or 'absent for 3 weeks'. In normal circumstances this makes the assumption that the service is available and that the 'default' is due to some 'non-programmatic' barrier to access. Since the programme is providing the service, the inference is that it is not a deficiency in the programme that is to blame.

Where a deficiency arises in the programme (such as a stock out of RUTF or other food commodity) and the beneficiaries still attend the 'programme', but do not receive treatment, there is a need to capture that deficiency in some way, and respond to it appropriately. How to capture that information has been the subject of discussion in other en-net discussions.

http://www.en-net.org/question/2223.aspx

http://www.en-net.org/question/650.aspx

We could reasonably use a different category (such as "others" or discharged due to "unplanned service interruption") as suggested by other contributors. Rather than recording an 'absence' on the treatment card it should be ensured that 'RUTF stockout' is recorded and there is a prioritised effort to restore RUTF supply before discharging cases under the new category.

I (personal opinion) wouldn't advocate for a category called 'pseudo default' or 'false defaulters' since this does not adequately convey the programme failure that is occurring. Certainly a beneficiary that defaults due to "difficulty of access to the health facilities" is the very definition of a 'true defaulter' and should not be included as a 'pseudo defaulter'.

Whichever category is used it is important to:

1. Refer SAM cases to the nearest health facility offering appropriate treatment (if available). This should be done as a priority when RUTF supplies are not available and no there is no immediate prospect of getting a new supply. We should not wait for 2 to 3 weeks to classify the beneficiary as a 'defaulter' (or under some new category) before transfer.

2. Where transfer to another health facility is not an option, we should ensure regular follow up of registered and newly identified cases . Follow up may include the provision of first line antibiotics, deworming and any other medical care required in addition to continued monitoring in the community and referral to other services such as IYCF counselling, the provision of micronutrients etc.

3. The return to the treatment programme after 'default' (or other category) when supplies have been re-established should NOT require the 'defaulter' to satisfy normal admission criteria, readmission to the programme is automatic.

3. The new category should be included in the denominator for total number of discharges when calculating programme outcomes.

Alternatively.....

In your example you define default as "the service is available but the child is absent". I agree that this is the general perception, however the dictionary definition of default is "a failure to fulfil an obligation". This could arguably be interpreted in such a way that the term 'default' should not be associated with assuming that it is the beneficiary that is to blame; it can equally apply to a programme deficit such as RUTF stock out. The common underlying feature is that the child is not receiving treatment.

A Sphere standard of < 15% default which is inclusive of programme deficits (such as 'default' due to stock out) would still be a reasonable measure of minimum performance by which to evaluate a programme.

The use of the category of 'defaulter' could therefore also be argued to be a reasonable approach, although it should be used with the same caveats as identified above which focus on offering the child the best treatment that is available and continuing monitoring during the service interruption.

The Sphere handbook states:

"Causes of re-admission, deterioration of clinical status, defaulting and failure to respond should be investigated and documented on an ongoing basis. The definition of these should be adapted to guidelines in use."

The guidance notes also indicate that when assessing performance, the participation of the population and external factors (such as the capacity to deliver the programme) should be considered.

In summary, whichever category is used to classify the treatment outcome, there is a need to ensure an appropriate response to the stock out which prioritises the safety of beneficiaries and that this category is included when assessing programme performance.

Cheers
Paul

Tammam Ahmed

H&N Project Manager/Relief International

Normal user

23 Jul 2016, 19:31

Thanks Paul for your reply. I meant in my question details two scenarios:
1. Default in the health facilities.. accused to RUTF/RUSF stock out...they write in the report"defaulter"
2. Mobile teams who find it very difficult to access to Children because of insecurity or geography.... they write the report"defaulter"

in both the two scenarios it is not real default.
Best

Shafiqullah Bashari

Sr. Nutrition Adviser - SCI in Afghanistan

Normal user

25 Jul 2016, 07:56

If the child doesn’t receive services it is ‘default’ whatever is the cause, program failure to provide services or shortfall from beneficiary side (it doesn’t mean to blame the beneficiary). For the program assessment further investigation should be done – even some of the shortfalls from beneficiary side referring back to the program e.g. it might due inadequate planning for follow up visits, nutrition education and awareness rising for the continuation of the treatment.

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