guidelines for the integrated management of severe acute malnutrition

ACF-In Guidelines for the integrated management of SAM Monitoring and evaluation 119
MONITORING AND EVALUATION
Monitoring and evaluation is an integral part of all feeding programmes. Watching and plotting the
indicators on a graph can quickly highlight problems. This allows appropriate and prompt investigation
and action to be undertaken, and the effects of these changes to be evaluated in turn. On-going
analysis of the results allows adjustment and improvement of the programme to the prevailing
circumstances. Identification of seasonality and the quantification of its magnitude, prediction of
change in incidence of SAM, early identification of deviations from the usual pattern of seasonal
change give indications to scale up or down the programme in response and to order supplies and
other resources in time for anticipated changes. Without accurate monitoring, evaluation, adjustment
and timely identification of problems the programme is incomplete and will be less effective. Indicators
should be graphed to help in interpreting trends as the programme proceeds. Quite sophisticated
methods have been developed for examining the data from programmes and determining where the
problems lie. If the data are poor and the reasons are not easily determined from the data reported
then there should be a visit from someone highly experienced in these programmes.
1. The SAM number
A good registration and recording system is critical to the management. It allows both close monitoring
and successful management of the individual patient and also provides easily accessible information
that can be compiled to give the appropriate indicators and statistics to monitor the functioning of the
feeding programme.
It is important to use a registration book; individual records are often misplaced 186 or lost completely,
and it is very difficult and time consuming to compile a report from individual records, particularly when
large numbers of children attend an OTP.
It is important to be able to follow individual patients as they are transferred from one component of
the programme to another. With patients being referred from the community to OTP sites to In-patient
facilities and then back to the OTP, or transferred to another OTP nearer to their home as OTP sites
are opened and closed, it has become impossible to follow an individual’s progress.
The system used should ensure that a patient is neither lost from the system during transfer nor
registered multiple times as a new case of malnutrition. If each institution and OTP site acts
autonomously each arrival is recorded as a new admission (for them) and each transfer is counted as
a discharge, so that all patients that are transferred are registered multiple times as new cases 187 .
To overcome these problems each NEW case is given a SAM-number by the first programme that
starts treatment of the person. The patient then keeps this same number during ALL transfers. The
individual programme can also give a registration number to the patient for their own internal use and
filing – a site specific number – but they must use the SAM-Number on all transfer forms and
documents related to that patient.
186 Even in well run programmes about 10% of records are frequently “missing”; in poorly run centres there are many
missing records and the monthly report is consequently often wrong. In particular, the records for dead children are
frequently lost. This is because the staff know that the record will not be necessary for follow-up or readmission and the
records for dead children are separated from the other records and neglected: they are “finished” according to the staff and
do not need to be carefully preserved. The new admissions to each site should have consecutive numbers so that the total
number of patients can be verified from the numbers. Furthermore the outcome of patients in registration books and patient’
records are often not recorded properly or only marked in the column with an “x” or some other ambiguous mark instead of
“died”.
187 This is a major problem when the OTP and in-patient facility are controlled by different authorities or NGOs. Without
close cooperation between the agencies the data returned is inaccurate and can lead to false conclusions.