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Community-based management of acute malnutrition

This question was posted the Management of wasting/acute malnutrition forum area and has 5 replies.

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Elijah Bol Alier

Assistant Director for Nutrition-MOH

Normal user

6 Jun 2024, 10:21

 Dear members of the forum,

I would like to bring the following question to your attention so that we can share our experiences together. These are some of the questions one could ask himself/herself after implementing the CMAM programme in the most difficult part of Upper Nile, Unity and Jonglei state where supplies accessibility is limited due to lack of roads in South Sudan.

In most cases, in South Sudan the Targeted supplementary feeding programmes (TSFP) or outpatient feeding programmes (OTP) sometimes went out of stock for a period of one month and beyond. With this lack of supplies, many children 6-59 months who were admitted at the OTP or TSFP facility and waiting for supplies each week to be supplied. Then, after one month, supplies have been provided to the facility. As an officer, according to the CMAM guidelines you will be forced to discharge all these children before readmitting them to the programme as new.  According the CMAM guidelines as mentioned above, the following discharges: Defaulters refer to the Child that was absent for 2 consecutive visits from the programmes and non-Respondent refers to the Child that did not meet discharge criteria (But the child was receiving the supplies) after 3 months in OTP

1. When you discharged those children 6-59 months after one month without receiving the supplies before readmission as new. Do you discharge those children as defaulters or non-respondent?  If any of two, give reasons.

2.If you discharged those children as defaulters or non-respondents. Won’t they bring down the performance of the programme. I mean the Sphere standard will be affected.

3. If your programme is using a new terminology. Kindly share with us your experience on this. What do you call the discharged children?

Aweke Kebede


Normal user

6 Jun 2024, 13:32


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.



Health and nutrition Manager

Normal user

6 Jun 2024, 14:45

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.


Anonymous 45350

District Nutritionist

Normal user

6 Jun 2024, 14:47

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.

Fahdullah Shakir


Normal user

7 Jun 2024, 07:56


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.


Wisdom G. Dube

Nutrition Supply Chain Management Expert

Normal user

7 Jun 2024, 08:42

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

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