MAM decision tool review Kenya, September 25, 2012
In attendance: WFP Kenya, MOPHS, UNICEF Kenya, CDC.
Unfortunately, the Cluster Coordinator did not attend the session. No contextual background was prepared for
use as an exercise. However we did discuss the 2011 situation, as well as the Wajir and Mandera situation. A CD
with the current version of the tool and powerpoint was shared with participants.
Key Feedback from the session

Cash and vouchering
o Cash and vouchering seem to be just added without any explanation or description of benefits.
It seems out of place. An objective of cash and vouchering must be included. Cash/vouchering
has not been shown to reduce or prevent malnutrition. A clarification is need on whether these
are conditional or unconditional vouchers/transfers. It is very difficult to design these programs
with a nutritional objective. If cash/vouchering is meant to improve dietary diversity that is one
aspect, but it you expect a nutritional improvement that is something different. Guidance needs
to be included with more detail.

Targeting for Preventive Programs
o Prioritization of lactating over pregnant
 There was some confusion on the rationale of prioritizing lactating women over
pregnant women. Perhaps further detail should be included in the guidance note. (We
had a discussion on the greater nutrient demand of lactating women and that by
enrolling lactating women we are protecting the infant until the age into the program.
The long-term benefit of protecting the mother and unborn child compared to only
enrolling lactating women was the question.)
o Elderly
 How do the elderly fit into the preventive programs? When should they be targeted? Do
they fit better into a safety net program?
o Disability
 A clearer definition of disability should be provided. What groups of disabled individuals
would benefit from BSFP? Who should be picked up by a safety net and whom by BSFP?

Risk deterioration
o Morbidity
 Is there guidance on what constitutes an outbreak or an increase in incidence per
disease? (I referred them to WHO. There are context and country specific rates of
incidence for the various diseases. Perhaps this is something that we should reference
within the text of the document. As it stands now, it is very subjective).
 Should the high category be an outbreak or epidemic?
 Is it acute watery diarrhea (i.e cholera) or diarrhea as a whole class of disease?
o Displacement
 Clarify displacement and that it does not include regular migration of pastoral
populations, nor does it include urban migration (economic migration).
o
o
Wording of risk categories
 With the risk categories, the levels are not worded the same. For example, morbidity
and food security are low, medium and high but displacement and density are yes, no.
there should be consistency. As well, grammatically the wording for density is not
correct- population density yes/no should be high low or rephrased to dense population
yes/no.
 The food security wording does not align. The risk of deterioration is: food availability
and/or access disrupted. The worst situation is high, but if you put high with the risk it
doesn’t make sense- high food availability.
Scoring
 The lowest possible score is 2, however the summed score categories include <3
 In the food security and morbidity risk groups, the user is forced to select a negative
starting point. It would be better to start at 0, then 1, 2 etc.
 The scoring of categories is not equivalent. It may be better to have consistent
categories across risk- 0,1,2.
 Subjective

Linkages
o How does this fit into the cyclic nature of emergencies- when do you use it if you are between
emergencies
o Better linkages to other sectors and programs
o How do risk factors for deterioration interlink
o How could this tool and risk of deterioration be used in conjunction with ongoing surveillance?
o Is it possible to ever reach <8% in Wajir and Mandera (or other pastoral populations)? In this
situation, would you always have to be running programs? Where does the strengthening of
existing programs fit into the model if populations with consistently high GAM

Use
o
o
o
Cyclic emergencies
 At what point is this tool designed to be used in countries where emergencies are cyclic?
Urban context
 Can this tool be applied to an urban context? Further clarification on chronic versus
emergency context in urban slums (ex: Kibera) should be included. (We discussed that
for use in a situation like Kibera, there would have to be an acute emergency on top of
the chronic situation. An example was following the displacement after the elections).
Nutritional data
 How should MUAC screening data be used? Do you use the same percentages as with
GAM based on WHZ?
 How were the GAM categories determined?
Follow-up action points
Reviewing IMAM guidelines. Currently treatment of MAM is included and preventive BSFP is an addendum. They
will review these and incorporate some aspects of the MAM tool.
Will review and present to the NTF
GNC to send out revised MAM tool with revisions in 2013
MAM decision tool review Somalia September 26, 2012
In attendance: Nutrition cluster coordinator, UNICEF, WFP, Trocaire, WRRS, JCC, Mulrany International,
Intergog, FAO/FSNAU, IMC, SAF, CDC
Key Feedback from the session

Decision Tree and programming determination
o More guidance is needed on preventive programming
o One half of scenarios lead to prevention and treatment
o Figure 1 was problematic. There are too many arrows and context was felt to me missing. There
should be another level of operational/contextual factors between the nutritional status and
risk of deterioration. At present, it was felt that the description of contextual factors being used
in the model was a bit deceptive.
o If you had a low GAM- you would not implement a true BSFP. You would integrate the program
with the health system and look at comprehensive programming to address nutrition. This is
different than a traditional BSFP. Clarity is needed here in the text.
o In areas with no access because of security, you may choose to improve existing service through
local partners rather than implement an additional program. This is not included in the tool.
o The process of working through the tree should be an iterative process. One would work
through the decision tree steps and come to a conclusion. Next, one would look at the decision
the operational context- security, funding, access, population, supply etc. Finally, one would
need to work back through the tree to determine what really can be implemented. AS it stands
now, these steps are not in the process.
o Operational context is the determining factor for the models, but it is not well represented.
o BSFP
 Lean season/post-harvest reference- There are differing lean seasons in Somalia. The
text in the document references to starting a program one month before the lean
season and running one month post-harvest. Perhaps an edit should be made to reflect
areas that have a lean season, but do not have a harvest- like the Riverine livelihood.

Distribution mechanisms
o Security will influence your distribution scheme. This should be included and addressed in the
text.
o Text regarding distribution frequency associated with product should be included. Rural and
scarcely populated areas may have different distributions schemes. (I think that we can expand
the section on different distribution schemes to clarify and give more guidance.)
o Distance will be a significant factor in your distribution scheme. This is not well addressed.

Product Selection
o Can a point be included that with the exception of very rare and exceptional situations can RUTF
be used outside of the treatment of SAM> There was concern that RUTF is being used outside of
the intended scope of the product.
o
o
o
o
o
o
Product selection should also include a discussion about transport and tonnage. The reference
was to the difference between transporting Supercereal versus RUSF by road and the issue of
lack of road infrastructure and cost for tonnage versus the number of children you could reach.
Can CSB be included as an option if Supercereal is not available in the pipeline?
The type of product can affect defaulting rates. An example was given that defaulting actually
increased when RUSF was introduced compared to CSB. The reason given was because of the
difference in the quantity of food received.
The product sheet was highly liked. One NGO stated that they sent it to all of their field offices
for posting as a quick reference. It is a good tool for lay people and for Logs officers.
Programmatically, it is very difficult and often not feasible to use different products for different
target populations within the same distribution (i.e. one product for PLW and another for U5s).
This should be addressed. In some situations, the policies of the government or governing body
may prohibit the use of multiple products.
Further clarification on the use of supercereal should be provided. There was concern over the
nutritional impact of supercereal versus RUFs. (We discussed the issues involving supply and cost
differences between the two categories, as well as approval of RUF’s in countries and for certain
target populations.)

Nutritional data
o How were the GAM categories chosen? They do not match to the WHO groupings and this
seemed to cause some confusion. Is it not possible to be consistent with WHO groupings? (I
cannot remember how we determined these groupings)

Targeting
o Where do the elderly fit in? (We had a discussion on the difficulty addressing the elderly
including identifying the underlying cause of malnutrition and the role of chronic disease.)
o IYCF-E is an important component for all programs. It is difficult to assess and use as a standalone program as it relies on behavior change.
Use
o The tool is good for program managers to assist in designing a program
o The tool cannot be used at a national level. The situation is too complex to use this tool.
o Existing national policies should be reflected and may contradict the programs selected by using
the tool. For example, in Somalia RUSF is used for PLW. This is not an option in the tool.
o The tool is good for highlighting linkages to the nutritional situation and programs which could
assist in improving the nutritional status
 There may be issues if 2 NGOs design different programs for the same areas and
approach “donors” (i.e. WFP).
Linkages
o Linkages to the underlying causes of malnutrition should be highlighted and strengthened within
the tool.
o The risk deterioration section can help identify the driving factors for MAM. There should be a
balance between the risks and focusing on programming Programming will not address the
underlying causes. Perhaps guidance on how to address other sectors would be useful.



Additional components
o Annex 4 for the evaluation of the tool is missing
o Inclusion of examples of working through the decision tree would be helpful, as well as
examples of actual programming.
o Community outreach should be included in the programming and text.
o There need to be a section on when to exit the program that has stronger guidance than the
current text.
o Where is reference to mental health in relation to the nutritional status of the child? Maternal
health influences the nutritional status of the child and this should be include in the tool
o Sphere standards for programming should be include in the tool
o Routine medical protocol should be included in the tool for the treatment of MAM (This is
perhaps beyond the scope as this tool is meant to assist in determining appropriate
programming- not the intricacies of the program. However it does reflect that there is a lapse in
the guidance on the actual implementation of programs once they have been determined.)
o How to calculate caseload for MAM programs should be included (Similar to the statement
above. We discussed that there is not consensus on the calculation of caseload for MAM and
that the factor used ranges from 1.6-6.)
o How to assess coverage should be included. (Similar to the 2 statements above. There is even
less known about coverage for the treatment of MAM. BSFP is more straight forward as all
individuals in the target group are eligible.)
For the last 2 points, perhaps a note that more research is needed should be included in the
manual.
Follow-up action points
A suggestion was made to have specific NGOs pilot the tool (not necessarily in Somalia). Perhaps the NGOs on
the Taskforce could use it in some of their programs and get feedback from the field.