MAM Decision-making Tool

1. MAM Decision-making Tool

2. MAM Taskforce • Formed by the Global Nutrition Cluster • UNHCR • UNICEF • WFP • OFDA • ACF • Save the Children • CDC • WHO • ECHO

3. Tool Objectives Decision making process grounded by data, but is subjective on some levels • Guide practitioners to identify most appropriate and feasible strategies to address MAM • Prevention • Management (treatment) • Harmonize nutrition programme decision-making on MAM in emergency situations • Incorporate contextual situational factors into the decision making process • Beyond nutritional status • Engage in discussion

4. Caveats of Tool • Limited to emergency contexts • Rapid/sudden onset • Slow onset • Protracted emergencies • Acute emergency within a chronic emergency setting • Local or large-scale emergencies • Not for refugee contexts • UNHCR/WFP Guidelines for Selective Feeding: The Management of Malnutrition in Emergencies 2011 http://www.unhcr.org/4b7421fd20.pdf

5. Caveats of Tool • Primary objective: prevent morbidity and mortality associated with MAM • Linkages: MAM cannot be addressed in isolation • SAM • IYCF-E • Other sectors (WASH, health, food security) • Re-assessment

6. MAM decision tool steps Prevention/treatment Prevention Treatment No additional programme Step 1: Programme Type/Objective Step 2: Modality Supplementary feeding Cash/voucher Infant and Young Child Feeding Target group Product Duration Delivery Step 3: Programme Operation Step 4: Review and Revise Regularly throughout the emergency

7. Programme Recommendations

8. UPDATE • Development of facilitation guide • Translation of the tool and guide into French • Country level tool review through Cluster • Yemen conducted by WFP with WFP office • Kenya and Somalia conducted in September 2012 • Other countries pending (Afghanistan, Chad, DRC, Mali, Niger, Sudan, Yemen)

9. Tool Review • Review the MAM decision-making tool • Work through country situation • Provide feedback on • Content • Usability • Layout

10. Feedback on Tool • Frequency of use and target users: Unclear throughout the document who should be involved and in what way in the process, nor at what point in the emergency can this tool be used (e.g. emergency onset versus at the end of the acute emergency phase versus in pre-emergency preparedness). • 8% cut-off: there is a clear need to explain the rationale -> agreed, so this has to be clearly justified or changed. • MUAC screening data: This is raised as one potential second choice type of information- but it isn’t clear whether it refers to non-representative data such as rapid screening or MUAC information from a nutrition survey.

11. Feedback on Tool • Morbidity: Need for greater clarity in terms of thresholds and risk of deterioration, and where this information can be found (e.g. data sources such as WHO country offices), which can be added into the revision. • Displacement: Clarification that this does not refer to regular seasonal migration (e.g. pastoralists and seasonal migration for water) but that this refers to physical displacement that is not normally seen, which can be added into the revision.

12. Feedback on Tool • Outcomes: Over half of the outcomes result in both prevention of acute malnutrition and treatment of MAM, though this does not appear to reflect programming reality. Suggestions on what is realistic are welcome. • Targeting when there is a need to prioritise: Clarify that it is more often pregnant women rather than lactating women (as written) that are targeted in the context of limited resources. • Older persons and disabled persons: how to assess and deliver nutrition programming to older persons and the disabled is an outstanding technical issue. In future, this tool can be harmonised with updated guidance when it is available. Older persons would more generally be targeted with food security programmes in terms of prevention as opposed to through nutrition programming.

13. Feedback on Tool • Linkages with other programmes and cash & vouchers: Need for practical level of guidance and where to look for further guidance is limited, as well as clarity on differences between conditional and unconditional cash transfers. • Operational issues: The situation analysis may suggest a programme recommendation that is not in fact possible in the context. Operational issues of how to modify programme recommendation and programme design based on context are not reflected, though they had been discussed and included in the foundational discussions on the tool. • Case studies: developed and will be included in the annex to show some of the complexity of applying the tool in practice.

14. Feedback on Tool • Use of RUTF: It was requested to clarify that Ready to use Therapeutic Foods should not be used in treatment of MAM programming. It was agreed to mention the product recommendations are the recommendations that should be followed. • Products: Clarification on how to incorporate the previous formulation of CSB into the tool. WFP clarified that the previous formulation should not be in use in the field and not part of product planning from this point onwards. In addition, operational constraints will also be modified to reflect product choices may be influenced by context – first choice and second choice • There is a request to haveMAM guidelines from country offices consolidated. UNICEF and WFP and the CMAM forum are doing different parts of this. The two agencies are discussing how best to consolidate and ensure that they are accessed and vetted.

15. Next Steps Completion of country reviews Revision of tool in 2013