Dropouts due to stockouts

Dear Editor,

I recently read an interesting discussion on the en-net.org forum about the issue of ready-to-use therapeutic food (RUTF) stockouts causing high defaulter rates in community management of acute malnutrition (CMAM) programmes (en-net, 2024). The original poster was working in South Sudan and reported regular stockouts of supplies that can last approximately one month or more. They asked how they should record the discharge of all of the children in the programme who can no longer be supplied with treatment until new supplies reach the clinic.  

The Sphere Handbook for humanitarian response provides several indicators for assessing the performance of CMAM programmes (Sphere, 2018). These have dictated the standard data that most clinics record. The handbook recommends that programmes should meet the following standards: fewer than 10% deaths, more than 75% recovered, and fewer than 15% defaulted. They recommend that the following exit categories are recorded for children leaving treatment: recovered, died, defaulted, non-recovered (which includes non-responders plus medical referrals). Additionally, some programmes also have a category for “transferred” or “moved out”, which concerns those who move home and subsequently join a different treatment programme. The “Defaulting rate” is calculated as = (number of defaulters / total number of discharges) *100

However, a problem arises when you have children who have been admitted but upon discharge do not fit into any of these categories: such as those who exit a programme due to there being no supply of RUTF remaining. Many responders to the en-net.org question reported facing a similar issue, indicating that this as an important topic to consider. A different en-net.org post from 2012 discussed whether programmes are managing to achieve Sphere standards in non-emergency contexts.

“Sphere minimum standards for cure rates are usually met and exceeded. A big problem is defaulter rates. There are many reasons for this. The most common reasons that I have observed are periodic stockouts of RUTF (reflecting poor supply chains common in many settings), excessive waiting times, and highly judgemental attitudes of staff towards carers” – A poster, responding on the en-net forum

In the many responses to the original question regarding which category to record these children in, respondents from Pakistan, Zimbabwe, Ethiopia, and other settings reported facing the same issue. They suggested work-around options, such as recording these children as “moved out”. This example would not interfere with either the nominator or denominator of the defaulter rate, or other important Sphere metrics. Others stated that they have created their own unique category for this group, such as “operational defaulters” or “temporary discharges”. However, many CMAM record sheets do not allow for recording children in this category. The Save the Children’s CMAM guidance (2015) recommends having an admission and exit category of “other” to capture these circumstances. Alternatively, it gives the example of a situation in which a caregiver has lost the patient’s health record (these children are discharged under “other” and then a new record is started).

Save the Children also recommends that the defaulter category include two options: confirmed and unconfirmed (if the outcome is unknown). Defaulter “unconfirmed” refers to children who are absent for two consecutive visits and for whom the final outcome is not known (since no defaulter tracing was done, or the defaulter tracing was not successful). It is possible that this child has died at home and that is why they have missed their visits. Defaulter “confirmed” refers to children who are absent for two consecutive visits and for whom a home visit has confirmed that the beneficiary is alive and is a “true” defaulter. In any instance, children who must be discharged from the programme due to stockouts should not be recorded as defaulters. This interferes with programme quality assurance and potentially masks the issue of stockouts.

Ensuring that all CMAM records have an “other” option where discharges due to stockouts can be recorded is important for CMAM programme data quality. There is an argument that having a new category or using the “other” category for discharges due to stockouts adds unneeded complexity to what should be a very simple form. This may also normalise poor supply chain management. The same argument about ‘normalising’ or ‘permitting’ poor supply chain management has been made about a document from the Global Nutrition Cluster (GNC, 2022) which gives advice on “programming in the absence of nutritional product”.  However, stockouts will always occur, even when robust local and national systems are in place. For example, there have been cases of stockouts due to the COVID-19 pandemic, localised flooding, or conflict, which all make the delivery of supplies temporarily impossible.

While implementing effective stock management systems to prevent stockouts is a very important part of solving this problem, there is also a need to support those working on the frontline to accurately reflect the issues that occur in clinics today. Hopefully this discussion can also bring attention to the apparently frequent stockouts in multiple global locations. Addressing this issue will require better management and more funding.

Two facts are both true. First, we need to support frontline workers who are facing stockouts NOW. Second, we need to bring greater attention to, and find solutions for, the causes and frequency of RUTF stockouts, to make them more of an exception in the future.

Sincerely,

Natasha Lelijveld, Senior Nutritionist, Emergency Nutrition Network