Module 4

MODULE 4
Governance
Resource Speaker
Designation
Module Learners
• LGU officials
• LGU Health Board members
• Nutrition Cluster members
• Hospital administrators, chiefs of clinics
• NGO leaders
Learning Objectives
At the end of the session, you will be able to:
○ Review how to assess the MAM and SAM situation in your LGU
○ Discuss an LGU best practice
○ Identify linkages and provider arrangements for MAM and SAM
○ Estimate annual MAM and SAM supplies and medicines
○ Cite performance indicators for monitoring and evaluating PIMAM
○ Discuss how to use bottleneck analysis
○ Review PIMAM protocols for disasters and emergencies
Module Sessions
4.1 Managing a PIMAM Program
Case Study: Davao City IMAM
4.2 Elements of a Successful PIMAM Program
4.3 Logistics & Supply Management
Exercise: Calculate Your Annual MAM and SAM
Procurement
4.4 PIMAM Monitoring & Evaluation
4.5 MAM and SAM In Emergencies
Severe Acute Malnutrition is a Critical Health Priority for LGUs
Session 4.1
Managing a PIMAM Program
A.O. No. 2015-0055
National Guidelines on the
Management of Acute
Malnutrition for Children
Under-5 years
PIMAM Program
“A multi-sectoral approach to ensure access to
evidence-based, effective and life-saving interventions
to prevent and treat acute malnutrition.”
•Public health strategy

•Integrated with other health and nutrition services
•Strong community component
•Linked to other sectors
•4 guiding principles
Photos Courtesy of Davao City Nutrition Office, June 2016

4 Components of
PIMAM
A.O. No. 2015-0055
General Objective
• To provide the policy, strategy, and
standards to health, nutrition, and social
service providers,
• including government partners, civil

society organizations, and donors
involved in the
• effective and efficient implementation of

the Philippine Integrated Management
of Acute Malnutrition (PIMAM)
A.O. No. 2015-0055
Specific Objectives
1. Provide evidence-based and standardized protocol to prevent,
identify, refer, and manage MAM and SAM
2. Ensure capacities, essential supplies and commodities, and

logistics to deliver quality services
3. Standardize and integrate indicators, reporting and monitoring

tools and systems and evaluation mechanisms (esp. for
emergencies)
4. Define roles and functions of all involved

A.O. No. 2015-0055
General Guidelines
1. Access to Information -- Mothers & caregivers have access to
information and PIMAM health services
1. 2. Integration in all health programs to ensure continuity and access
2. 3. PIMAM services are available in times of disasters and emergencies
4. Capacity Building – LGUs shall be responsible in enhancing capacities

of their communities to identify, refer, and treat MAM and SAM
5. Quality Care – Competent PIMAM service providers, at all levels, deliver

quality services
A.O. No. 2015-0055
General Guidelines
6. Supply Management and Utilization – Mechanisms, tools, and systems for
supplies management and monitoring & evaluation of service delivery
7. Information Management systems for appropriate, timely and evidence-
based information at all times and all levels.
8. Established mechanisms for coordination, advocacy, networking &
partnership.
9. PIMAM components operate in the “critical 1000 day window”
Exercise: Your PIMAM Role & Responsibility
Instructions
1.In your small group, review your role and responsibilities as directed in
A.O. No. 2015-0055, VIII. Implementing Mechanisms.
2.Review the Organizational Chart in the MAM and SAM Manual of

Operations. Is this applicable to your area? Are there any modifications
necessary to address concerns specific for your area?
3.In small groups, review A.O. guidelines, reorder them from Most
Challenging or “hardest to implement” to Least Challenging or easiest to
implement.
Exercise: Your PIMAM Role & Responsibility
Region
Mean Mean
General Guidelines
Area 1 Area 2 Area 3 Area 4 Area 5 Score Rank
1 Access to information
2 Integration in all health programs
3 Availability in times of disasters and emergencies
4 Capacity Building
5 Quality Care
6 Supply Management and Utilization
7 Information Management systems
8 Coordination, advocacy, networking & partnership
9 Operate in the “critical 1000 day window”
*1-hardest to implement
Session 4.2
Elements of a Successful
PIMAM Program
1 Community Assessment
Elements of 2 Advocacy & Stakeholders Mobilization
Successful PIMAM 3 Policy
Management 4 PIMAM Organization
5 Financing
6 Orientation/Training of Health Workers
7 Linkages
8 Continuous Supply of Medicine & Supplies
9 Implementation & Monitoring
10 Evaluation
1 2 3 4 5 6 7 8 9 10
5 Financing
7 Linkages
10 Evaluation
1 2 3 4 5 6 7 8 9 10
1. Conduct a Community Assessment
A. Gather Data to Assess Magnitude & Distribution of MAM and SAM
• Local health data
• Nutrition surveys
•1
• Consultations
• Case Finding:
▪ Active
▪ Active Adaptive
▪ Passive
B. Map & Report Data
• Transform the data from community assessment into useful information
(maps, tables, etc.) that will be made known to others
1 2 3 4 5 6 7 8 9 10
Elements of 1 Community Assessment
Successful PIMAM 2 Advocacy & Stakeholders Mobilization
Management 3 Policy
4 PIMAM Organization
5 Financing
7 Linkages
10 Evaluation
1 2 3 4 5 6 7 8 9 10
2. Advocate, Inform & Mobilize Stakeholders
▪ List Stakeholders in LGU
▪ Inform and Advocate
▪ Secure commitment
▪ Gain Support for LGU Policy, Resources, & Implementation
1 2 3 4 5 6 7 8 9 10
Management 3 Policy
5 Financing
7 Linkages
10 Evaluation
1 2 3 4 5 6 7 8 9 10
3. Develop PIMAM Policy for your LGU
Executive Order No. 20, Series of 2014

“An Order Integrating and
Operationalizing IMAM (Integrated
Management of Acute Malnutrition) in the
Local Health System of Davao City”
1 2 3 4 5 6 7 8 9 10
Management 3 Policy
5 Financing
7 Linkages
10 Evaluation
1 2 3 4 5 6 7 8 9 10
4. Organize the PIMAM Program Management
Team
A. Functions:
• Policy & Standards
• Financing
• Capacity Building
• Logistics Management
• Information
• Monitoring
• Evaluation
• Coordination
• Linkages
• Advocacy
1 2 3 4 5 6 7 8 9 10
B. Implementation Arrangements
Consider the Patient: Consider the Health Facilities:
1.Cost of access to service 1. Choose Supplementary Feeding Center - area
2.Time of travel to get care for the TSFP
3.Geographical or seasonal 2. Choose OTC/ITCs:
• OTCs: RHU or BHS
barriers
• ITCs: DOH-retained or LGU hospitals
4. Political
3. All facilities should be functional and
adequately equipped with trained personnel and
supplies and/or Mobile Teams, Home Visits*
PIMAM Organization
1 2 3 4 5 6 7 8 9 10
C. Making Your Service Delivery Network
(SDN) work for MAM and SAM
• Inter Local Health Zones (ILHZs)
• Service Delivery Network
• Provincial network
• Geo-political boundaries
PIMAM Organization
1 2 3 4 5 6 7 8 9 10
PIMAM Organization
1 2 3 4 5 6 7 8 9 10
PIMAM Organization
1 2 3 4 5 6 7 8 9 10
PIMAM Organization
1 2 3 4 5 6 7 8 9 10
PIMAM Organization
D. Integrate PIMAM into LGU Health

Systems & Programs
As Local Nutrition Committee
Members…
Engage to strengthen multi-sectoral

coordination targeted at removing
bottlenecks in quality nutrition and health
service delivery at facility, community,
and household levels.
- UNICEF 1000 Days Policy Brief
1 2 3 4 5 6 7 8 9 10
Management 3 Policy
5 Financing
7 Linkages
10 Evaluation
1 2 3 4 5 6 7 8 9 10
5. Financing
Sources of Funds Uses of Funds
• Budget Allocation for Health • Orientation & training of staff
• PhilHealth • Nutrition prevalence surveys
• Department of Health • Supply & Maintenance of Materials
• Local Financing • IEC materials
• External Donors • Program review & planning
• Reporting
• Transportation
• Communication
• Mobile Teams
1 2 3 4 5 6 7 8 9 10
Management 3 Policy
5 Financing
7 Linkages
10 Evaluation
1 2 3 4 5 6 7 8 9 10
6. Orientation & Training of Health Workers
Types of Training Available:
• Basic Training on the Management of MAM and SAM (5-day
TOT, 3-day Providers’ Course)
• IMCI Training (Midwife/Nursing/Physician & BHW/BNS)
• Proposed Five-in-1 course for community-based health
workers (IYCF – EBF, complementary feeding, Growth Monitoring, CB-IMCI, Nutrition
Emergencies)
*When you conduct trainings, always ensure availability of

training materials, manuals, job aids
1 2 3 4 5 6 7 8 9 10
Management 3 Policy
5 Financing
7 Linkages
10 Evaluation
1 2 3 4 5 6 7 8 9 10
7. Mobilize Linkages
✓ Ensure a Continuum of Care
✓ Ensure maximum compliance with treatment.
✓ Linkages are critical to:
▪ IYCF
▪ EPI
▪ Micronutrient supplementation
▪ DSWD
▪ Agriculture
▪ Education
✓ Link with private sectors
1 2 3 4 5 6 7 8 9 10
Session 4.3
Logistics &
Supply Management
Management 3 Policy
5 Financing
7 Linkages
10 Evaluation
1 2 3 4 5 6 7 8 9 10
8. Logistic Management of MAM and SAM Supplies
Your Goal: Ensure Continuous Supplies & Medicines
Select
Products
Supply Management Cycle Quality Quality
Monitoring Monitoring
▪Follow Government
Procurement policies (R.A.
9184) Rational Use
Management
Support Estimate
▪ Policy, legal, and Systems Procurement
regulatory framework
Quality Quality
Monitoring Inventory Monitoring
Management &
Storage
1 2 3 4 5 6 7 8 9 10 Reference: DOH National Guidelines Manual of Operations. 2015
8.1 Product Selection
RUTF F-75 F-100 ReSoMal Therapeutic RUSF
(OTC) Therapeutic Therapeutic (ITC) CMV (MAM)
milk (ITC) milk (ITC)
(ITC)
Ready-to-use Phase 1/ Phase 2/ Oral Use to Ready-to-use

therapeutic Stabilization Transition for rehydration prepared supplementary
food (RUTF) for SAM with SAM with solution for ReSoMal, (F- food (RUSF)
complications complications severe acute 75), (F-100)
malnutrition
8.2 Inventory Management
Follow Guidelines for Supply Management
• Procurement
o Based on utilization rate, projected increase and buffer stocks
o Based on standards/product specifications (PIMAM Guidelines)
• Receiving supplies
• Storage
• Maintaining Records
• Supply Delivery and Tracking
• Disposal of Supplies
• Allocate buffer stock for emergencies
1 2 3 4 5 6 7 8 9 10
8.3 Logistics Monitoring & Evaluation
• Maintain proper records
• Perform a physical stock check at least monthly
• Identify any supplies which will expire within three months of
the stock check and alert CHO/PHO
• Encode and update in NOSIRS/Supply Database/Logbook
monthly.
1 2 3 4 5 6 7 8 9 10
8.4. Quantification and Procurement:
Estimate Caseload and Supplies
Step 1: Calculate Caseload
CASELOAD = N x P x K x C
N = size of population aged 6 to 59 months or 12.15% of general population

P = estimated prevalence of SAM or 20% of GAM of the area;
estimated prevalence of MAM (or 80% of GAM)
K = correction factor to account for incident cases over 1 year (constant of 1.6)
C = mean program coverage in 1st year or 50%.
*Complicated cases for ITC = 10% of SAM Caseload
1 2 3 4 5 6 7 8 9 10
Estimate Caseload (SAM): N x P x K x C
For Example in Batangas: Lets Calculate:
Total Population: 2,922,637 Total Population: 2,922,637
Children 6-59 months: 12.15% of total N = 2,922,637 x 12.15% = 355,100.40
population P = 8.1% x 0.2 = 1.62%
Wasting Prevalence (GAM): 8.1% K = 1.6
SAM Prevalence: 20% of GAM C = 50%
K = 1.6
355,100 (N) x 0.0162 (P) x 1.6 (K) x 0.5
Coverage = 50% (for start-up yr)
(C) = 4,602
SAM Caseload in Batangas is 4,602

SAM with Complications (10%) is 460
Estimate Caseload (MAM): N x P x K x C
population P = 8.1% x 0.8 = 6.48%
K = 1.6
Wasting Prevalence (GAM): 8.1%
C = 50%
SAM Prevalence: 20% of GAM
K = 1.6 355,100 (N) x 0.0648 (P) x 1.6 (K) x 0.5
Coverage = 50% (for start-up yr) (C) = 18,409
MAM Caseload in Batangas is 18,409

Estimate Caseload: N x P x K x C
population P = 8.1%
K = 1.6
C = 50%
K = 1.6 355,100 (N) x 0.081 (P) x 1.6 (K) x 0.5 (C)
Coverage = 50% (for start-up yr) = 23,011
SAM Caseload = 23,011 x 0.20 = 4,602

MAM Caseload = 23,011 x 0.80 = 18,409
Estimate Caseload: N x P x K x C

population P = 8.1%
K = 1.6
C = 50%
K = 1.6 355,100 (N) x 0.081 (P) x 1.6 (K) x 0.5 (C)
Coverage = 50% (for start-up yr) = 23,011
SAM Caseload = 23,011 x 0.20 = 4,602

MAM Caseload = 23,011 - 4,602 = 18,409
EXERCISE!
PROVINCE XYZ: CALCULATE:
▪ GIVEN: N=?
▪ TOTAL Population: 3,000,000 P=?
▪ Wasting Prevalence: 7.1% K=?
C=?
1. MAM Caseload = ?
2. SAM Caseload = ?
EXERCISE!
PROVINCE XYZ: CALCULATE: MAM CASELOAD
▪ GIVEN: N= 3,000,000 x 0.1215

▪ TOTAL Population: 3,000,000 P= 7.1% x 0.80 (MAM)
▪ Wasting Prevalence: 7.1% K= 1.6
C= 0.50
MAM Caseload = 364,500 x 0.0568 x 1.6

x 0.50 = 16,563
EXERCISE!
PROVINCE XYZ: CALCULATE: SAM CASELOAD
▪ GIVEN: N= 3,000,000 x 0.1215

▪ TOTAL Population: 3,000,000 P= 7.1% x 0.20 (SAM)
▪ Wasting Prevalence: 7.1% K= 1.6
C= 0.50
SAM Caseload = 364,500 x 0.0142 x 1.6

x 0.50 = 4,141
Agusan del Apayao Marinduque Nueva Ecija Oriental Romblon
Norte Mindoro
Population 354,503 119,184 234,521 2,151,461 844,059 292,781
Children 6-59
months
GAM
SAM prevalence
MAM prevalence
K
C
GAM Caseload
MAM Caseload
SAM Caseload
% expected ITC
Note: Wasting Prevalence from 2013 NNS, FNRI-DOST

Norte Mindoro
Population 354,503 119,184 234,521 2,151,461 844,059 292,781
Children 6-59
months
GAM 5.4% 10.30% 13.80% 7.4% 7.3% 6.5%
SAM prevalence
MAM prevalence
K
C
GAM Caseload
MAM Caseload
SAM Caseload
% expected ITC

Norte Mindoro
Population 354,503 119,184 234,521 2,151,461 844,059 292,781
Children 6-59 43,072 14,481 28,494 261,403 102,553 35,573
months
GAM
SAM prevalence
MAM prevalence
K
C
GAM Caseload
MAM Caseload
SAM Caseload
% expected ITC

Norte Mindoro
Population 354,503 119,184 234,521 2,151,461 844,059 292,781
Children 6-59 43,072 14,481 28,494 261,403 102,553 35,573
months
GAM 5.4% 10.30% 13.80% 7.4% 7.3% 6.5%
SAM prevalence
MAM prevalence
K
C
GAM Caseload
MAM Caseload
SAM Caseload
% expected ITC

Norte Mindoro
Population 354,503 119,184 234,521 2,151,461 844,059 292,781
Children 6-59 43,072 14,481 28,494 261,403 102,553 35,573
months
GAM 5.4% 10.3% 13.8% 7.4% 7.3% 6.5%
SAM prevalence 1.1% 2.1% 2.8% 1.5% 1.5% 1.3%
MAM prevalence
K
C
GAM Caseload
MAM Caseload
SAM Caseload
% expected ITC

Norte Mindoro
Population 354,503 119,184 234,521 2,151,461 844,059 292,781
Children 6-59 43,072 14,481 28,494 261,403 102,553 35,573
months
GAM 5.4% 10.3% 13.8% 7.4% 7.3% 6.5%
SAM prevalence 1.1% 2.1% 2.8% 1.5% 1.5% 1.3%
MAM prevalence 4.3% 8.2% 11.0% 5.9% 5.8% 5.2%
K
C
GAM Caseload
MAM Caseload
SAM Caseload
% expected ITC

Norte Mindoro
Population 354,503 119,184 234,521 2,151,461 844,059 292,781
Children 6-59 43,072 14,481 28,494 261,403 102,553 35,573
months
GAM 5.4% 10.3% 13.8% 7.4% 7.3% 6.5%
SAM prevalence 1.1% 2.1% 2.8% 1.5% 1.5% 1.3%
MAM prevalence 4.3% 8.2% 11.0% 5.9% 5.8% 5.2%
K 1.6 1.6 1.6 1.6 1.6 1.6
C 50% 50% 50% 50% 50% 50%
GAM Caseload 1,861 1,193 3,146 15,475 5,989 1,850
MAM Caseload 1,489 955 2,517 12,380 4,791 1,480
SAM Caseload 372 239 629 3,095 1,198 370
% expected ITC 37 24 63 310 120 37

Step 2. Calculate Your Annual Supplies for
MAM and SAM
SAM Supplies MAM Supplies Other Supplies

•RUTF •RUSF •MUAC tapes
•F-75 •Amoxicillin
•F-100 •Mebendazole
•ReSoMal •Micronutrient powder
1 2 3 4 5 6 7 8 9 10
Ready-to-Use Supplementary Food (RUSF)
1 patient = 1 sachet/day = 90 sachets in 3 months
Estimated Supply Requirement:

1 Case= 90 sachets*
(*but will depend how soon a child becomes normal)
Ready-to-Use Therapeutic Food (RUTF)
F-75 Therapeutic Milk
Sachet Grams Total Grams Tin

Reqts in 1 Grams in new Require-
sachet per child Tin ments
(12 prepa- per child
sachets) rations
F75 12 102.5 1230 400 3.075
F100 4 114 456 400 1.14

F-100 Therapeutic Milk
Sachet Grams Total Grams Tin

Reqts in 1 Grams in new Require-
sachet per child Tin ments
(12 prepa- per child
sachets) rations
F75 12 102.5 1230 400 3.075
F100 4 114 456 400 1.14

ReSoMal
Combined Mineral and Vitamin Mix (CMV)
ESTIMATED SUPPLY REQUIREMENT
1 CMV Tin per ITC facility/Hospital
Inpatient Therapeutic Care Requirement

1 levelled measuring scoop can be used to prepare 2 liters of
F75 therapeutic milk (See SAM MOP Alternative F75 Recipes)
Other Supplies
• MUAC Tapes: 10 packs per health facility
• Amoxicillin 125mg/5ml: 1-2 bottles per child
• Mebendazole/Albendazole: 1 tablet per child
• Micronutrient powder (MNP) *
• Vitamin A* capsules
• Safe drinking water and drinking cup
* Vit A and MNP are NOT GIVEN when RUSF/RUTF is available; Given only when RUSF is not
available and MAM child is treated with locally available food.
1 2 3 4 5 6 7 8 9 10
Considerations in Establishing a ITC/OTC
Regardless
Tools and
of GAM Location Structure Staffing
materials
prevalence
1 2 3 4 5 6 7 8 9 10
Considerations in Establishing a TSFP
When to implement TSFP:
Prevalence of
GAM + Tools and
Location Structure Staffing
Aggravating materials
Factors
1 2 3 4 5 6 7 8 9 10
1. GAM Prevalence and Aggravating Factors:

Factors:
When GAM rate is
WHO-UNICEF-WB 2018 Classification for GAM: HIGH to VERY HIGH
Very Low: < 2.5%
Low: 2.5% to < 5%
for children under 5
Medium: 5 to < 10%
High: 10 to < 15%
Very High: 15% and above When GAM rate is
MEDIUM
Aggravating Factors/Risk of Deterioration:
for children under 5
1.Increased morbidity
2.Food insecurity plus established
3.Significant population displacement presence of
4.Population density aggravating factors
1 2 3 4 5 6 7 8 9 10
2. Location:
▪ Situated at/near a local health facility to
avoid duplication of services
▪ Consider:
▪ Site’s accessibility to beneficiaries
▪ Personal safety of caretakers and
children, especially in insecure areas
▪ Climate in the area
1 2 3 4 5 6 7 8 9 10
3. Structure:
Distributions can be run by the Supplementary Feeding

Center (SFC) on a weekly or bi-weekly basis.
Weekly Bi-Weekly Monthly
(recommended)
Weekly Bi-weekly Monthly
distributions have distributions entail distributions are
the benefit of less opportunity usually not
more frequent cost for caretakers possible as the
follow-up on premix given turns
health and rancid after 2
nutrition status weeks.
1 2 3 4 5 6 7 8 9 10
4. Staffing*:
Health Center Staff (Doctor, Nurse,
or Midwife trained on IMCI)
▪ Presence of at least one health center

staff to perform medical assessment on
children who are sick or those who need
further evaluation.
BNS, BHW, or Community

Volunteers Prerequisite: trained on PIMAM
1 2 3 4 5 6 7 8 9 10
MAM Treatment Supervisor

▪ Prerequisite: trained in
PIMAM
▪ Activities:
a) Manages the food and non-food items (stock control)
b) Prepares monthly reports
c) Manages human resources
d) Supervises MAM treatment
e) Organizes health and nutrition education/counseling
1 2 3 4 5 6 7 8 9 10
5. Tools and Materials:

Measurement
Registration
Medicines
Health- Ration
Nutrition Preparation/
Education Distribution
1 2 3 4 5 6 7 8 9 10
For Measurements
MUAC tapes
Length board/
Scales CGS tables /WFL/H charts
Height board
1 2 3 4 5 6 7 8 9 10
For Registration
Posters for admission and discharge,
failure to respond criteria
Registration book (Annex 6)
Key messages about the products
(RUSF/porridge) in local languages
Ration Card, ECCD Cards (Annex 7
and 8)
OPT forms for master-listing
Monitoring Tools (Annex 9 and 10)
1 2 3 4 5 6 7 8 9 10
Session 4.4
PIMAM Monitoring &
Evaluation
MAM and SAM Performance Indicators & Reports
5 Financing
7 Linkages
10 Evaluation
1 2 3 4 5 6 7 8 9 10
9. Implementation & Monitoring
Why do we monitor PIMAM services?

1.Ensure patients are treated appropriately and effectively
2.Evaluate what is working well and not working
3.Supervise and support health care providers
4.Interpretation of program trends
5.Use data for planning
6.Part of the nutrition surveillance system
1 2 3 4 5 6 7 8 9 10
9. Implementation & Monitoring
Two major components
1. Effectiveness of treatment
2. Program coverage
Monitoring and reporting

3. Monitors the individual child
4. Monitors effectiveness service delivery
5. Monitor and supervise the health care providers
6. Reporting system should be simple
7. Provide timely & relevant information
1 2 3 4 5 6 7 8 9 10
Monitoring
1. Community Level
2. Facility Level
1 2 3 4 5 6 7 8 9 10
TSFP Chart
(TSFP)
(TSFP) TSFP Chart

5 Financing
7 Linkages
10 Evaluation
1 2 3 4 5 6 7 8 9 10
10. Evaluate
Performance Indicators and Standards:
1. 1. Number of admissions
2. 2. Cure rate
3. 3. Death rate
4. 4. Default rate
5. 5. Non-cured rate
6. 6. Health Resources Coverage
7. 7. Treatment Coverage
8. 8. Geographic Access/Coverage
1 2 3 4 5 6 7 8 9 10
Performance Indicators
The number of patients successfully discharged as cured, as a
Cure rate percentage of all discharges during the reporting month
The number of patients who died during treatment, as a

Death rate percentage of all discharges during the reporting month
The number of patients who defaulted, as a percentage of all
discharges during the reporting month (default is defined as
Default rate absent for 3 consecutive visits)
SAM visit= every week
MAM visit= every 2 weeks
The number of patients discharged as non-cured, as a
percentage of all discharges during the reporting month.
Non-cured rate Non-cured is defined as not reaching discharge criteria after
4 months in the program
Performance/ Outcome Indicators
Cure Rate # of Cured x 100 %
Total # of Discharges
Defaulter Rate
# of Defaulter x 100 %
Death Rate
# of Deaths x 100 %
Non-Responder Rate
# of NR x 100 %
1 2 3 4 5 6 7 8 9 10
Minimum Performance Standards
Indicator Management of MAM and SAM
Cure rate Greater than 75%
Death rate Less than 10% (SAM)

Less than 3% (MAM)
Defaulter rate Less than 15%
Coverage Greater than 50-70%*
SPHERE Standard: Rural areas >50%, urban centers >70%, resettlement/refugee camps >90%
1 2 3 4 5 6 7 8 9 10
Coverage Assessment
1. Trends in Admission Do cases appear around a certain time?
2. Spread of MUAC on What are the MUAC measurements of

admission patients upon identification? Are they
near the cut-off?
3. Location Are cases coming from areas expected
to have high cases?
4. Default rate and What are the reasons for defaulting?
reasons for default
1 2 3 4 5 6 7 8 9 10
Support & Supervision Visits for
Health Workers
Continuous support and motivation improves performance
• Identify and follow up issues on
o service delivery
o follow-up home visits
o management of individual cases
• Conduct regular scheduled meetings
o Invite supervisors, health care providers and outreach workers
• Review treatment cards, reports, tally sheets
• Review of deaths and defaulters, non-responders
• Resources: Supplies and Manpower
1 2 3 4 5 6 7 8 9 10
Session 4.5
PIMAM in
Emergencies
Managing MAM and SAM in
Emergencies
1 PIMAM Team Responsibilities
2 Rapid and Comprehensive Nutrition Assessments
3 Coordination and Information Management
4 Interventions where PIMAM is implemented
5 Interventions where PIMAM is NOT implemented
6 Logistics
7 Reporting
8 Transition to Post Emergency
1. Responsibilities During Emergencies
• All Responses are Coordinated through Nutrition Cluster

• Established links with corresponding LGU Disaster Risk Reduction
Management Committee (LGU DRRMC)
• LGU DRRM Committee takes lead
• LGU nutrition cluster coordinates with Regional and/or National Nutrition
Cluster
• Regional and National Nutrition Clusters on standby to assist
• PIMAM Management Team oversees management of the program or
requests technical assistance from higher levels
GAM in Emergencies
1 2 3 4 5 6 7 8 9
2. Rapid & Comprehensive Nutrition
Assessments
1. Determine risks and future scenarios
2. Rapid nutrition assessment should include MAM and SAM
identification
3. Cross-check results with MAM and SAM data base
4. Use data to identify gaps and necessary interventions
5. List stakeholders and assign roles and responsibilities
GAM in Emergencies
1 2 3 4 5 6 7 8
3. Coordination and Information
Management
• The Philippine Nutrition Cluster is part of the over-all Health Cluster
(Health, Mental Health, Nutrition, WASH) led by the DOH; it is active in
emergency and non-emergency situations (per cluster guidelines, NNC is
default Nutrition cluster lead)
• The Cluster should identify Designated Cluster Coordinator and Information
Management Officer as focal points
• Their role is to:
• Intra-cluster coordination: Coordinate all nutrition-related assistance by
local or international NGOs
• Inter-cluster coordination: Health, WASH, Shelter, Food Security, etc.
GAM in Emergencies
1 2 3 4 5 6 7 8
4. Interventions for Areas where
PIMAM is Implemented
PIMAM services should continue to function and prioritize:
○Support for BNS/BHW to continue screening for cases in

affected areas
○Mobilize teams to access remote communities
○Ensure that displaced in evacuation centers have access to
PIMAM services
○Mobilize buffer stocks
○PIMAM services should link with other nutrition programs
GAM in Emergencies
1 2 3 4 5 6 7 8
5. Interventions for Areas where
PIMAM is not implemented
PIMAM services should avail external help to set up PIMAM
services and prioritize:
• Coordination with relevant local authorities and the Nutrition

Cluster under the LDRRMC to identify which nearby PIMAM-
implementing areas can be tapped
• Prioritize Community Mobilization and OTC
• For MAM, a MAM-decision tool shall be utilized
• Anticipate if PIMAM services need to continue beyond the
emergency/disaster
GAM in Emergencies
1 2 3 4 5 6 7 8
MAM Decision Tool
(Global Nutrition Cluster)
• For Areas where MAM is not implemented, decision to do
TSFP shall be governed by GAM prevalence and Risk Level
(risk factors)
• 3 GAM Prevalence Categories: ≥ 15%, 10 to < 15%, < 10%
• 3 Risk Level Categories: High, Medium, Low
• Increased morbidity level (Acute Watery Diarrhea, measles, ARI)
• Food Insecurity
• Significant Population Displacement
• Population density
GAM in Emergencies
1 2 3 4 5 6 7 8
MAM Decision Tool
*Note: GAM labels and prevalence adapted from UNICEF-WHO-WB Group Joint Child Malnutrition Estimates 2018
Risk of Deterioration Analysis Score Sum Risk Category
(Aggravating Factors) Score
Increased Morbidity (Acute High (Epidemic) 3
Watery Diarrhea (AWD),
Medium 2
measles, ARI
(Increasing incidence/ high levels)
Low 1
(Stable incidence/low levels)
Food Insecurity High (Severe food insecurity) 4 Score:
Medium High (Moderate) 3 7-9: HIGH
4-6: MEDIUM
Medium Low (Minimal) 2
≤ 3: LOW
Low (Food Secure) 1
Significant Population Yes (Concentrated) 1
Displacement
No (No displacement) 0
Population Density Yes (Urban) 1
No (Other) 0
6. Logistics During Emergencies
• Follow same logistic management flow during
emergencies to ensure availability of supplies and
equipment (buffer stocks)
• Procurement should still follow standards and guidelines
in supply management
• When supplies are limited or scarce, use innovative and
flexible strategies
• Link with partners in provision of logistics
GAM in Emergencies
1 2 3 4 5 6 7 8
7. Reporting in Emergencies
• Use the same indicators for regular PIMAM programs
• Ensure that MAM and SAM data are shared and

included in emergency surveillance systems such as
HEARS and SPEED
GAM in Emergencies
1 2 3 4 5 6 7 8
8. Transition to Post-Emergency
Make a transition plan to treat MAM and SAM children after emergency
• If PIMAM program previously existed in the area before the disaster –

resume regular operations
• If PIMAM program did not exist in the area:

▪ Explore ways to integrate PIMAM into LGU health services
▪ Ensure continuity of services for patients (links, referrals)
GAM in Emergencies
1 2 3 4 5 6 7 8
Summary
As you organize and implement your PIMAM program to ensure that
children with MAM/SAM are treated and do not leave the program,
seek to ensure that:
• Your PIMAM adheres to the guidelines in A.O. No. 2015-0055
• Your PIMAM is integrated into other health programs in your LGU
• You have the capacity to implement the ten elements of good
PIMAM management: community assessment, stakeholder
mobilization, policy & protocols, financing & linkages,
organization with clear roles & functions, training of personnel,
logistics & supply management, monitoring, and evaluation.

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MODULE 4

•Public health strategy

Photos Courtesy of Davao City Nutrition Office, June 2016

• including government partners, civil

• effective and efficient implementation of

2. Ensure capacities, essential supplies and commodities, and

3. Standardize and integrate indicators, reporting and monitoring

4. Define roles and functions of all involved

1. 2. Integration in all health programs to ensure continuity and access

2. 3. PIMAM services are available in times of disasters and emergencies

4. Capacity Building – LGUs shall be responsible in enhancing capacities

5. Quality Care – Competent PIMAM service providers, at all levels, deliver

2.Review the Organizational Chart in the MAM and SAM Manual of

Executive Order No. 20, Series of 2014

D. Integrate PIMAM into LGU Health

Engage to strengthen multi-sectoral

*When you conduct trainings, always ensure availability of

Ready-to-use Phase 1/ Phase 2/ Oral Use to Ready-to-use

N = size of population aged 6 to 59 months or 12.15% of general population

*Complicated cases for ITC = 10% of SAM Caseload

SAM Caseload in Batangas is 4,602

MAM Caseload in Batangas is 18,409

SAM Caseload = 23,011 x 0.20 = 4,602

For Example in Batangas: Lets Calculate:

SAM Caseload = 23,011 x 0.20 = 4,602

PROVINCE XYZ: CALCULATE:

PROVINCE XYZ: CALCULATE: MAM CASELOAD

▪ GIVEN: N= 3,000,000 x 0.1215

MAM Caseload = 364,500 x 0.0568 x 1.6

PROVINCE XYZ: CALCULATE: SAM CASELOAD

▪ GIVEN: N= 3,000,000 x 0.1215

SAM Caseload = 364,500 x 0.0142 x 1.6

Note: Wasting Prevalence from 2013 NNS, FNRI-DOST

Note: Wasting Prevalence from 2013 NNS, FNRI-DOST

Note: Wasting Prevalence from 2013 NNS, FNRI-DOST

Note: Wasting Prevalence from 2013 NNS, FNRI-DOST

Note: Wasting Prevalence from 2013 NNS, FNRI-DOST

Note: Wasting Prevalence from 2013 NNS, FNRI-DOST

Note: Wasting Prevalence from 2013 NNS, FNRI-DOST

SAM Supplies MAM Supplies Other Supplies

1 patient = 1 sachet/day = 90 sachets in 3 months

Estimated Supply Requirement:

Sachet Grams Total Grams Tin

F75 12 102.5 1230 400 3.075

F100 4 114 456 400 1.14

Sachet Grams Total Grams Tin

F75 12 102.5 1230 400 3.075

F100 4 114 456 400 1.14

Inpatient Therapeutic Care Requirement

When to implement TSFP:

1. GAM Prevalence and Aggravating Factors:

Distributions can be run by the Supplementary Feeding

▪ Presence of at least one health center

BNS, BHW, or Community

MAM Treatment Supervisor

5. Tools and Materials:

5. Tools and Materials:

Why do we monitor PIMAM services?

Monitoring and reporting

(TSFP) TSFP Chart

The number of patients who died during treatment, as a

Death rate Less than 10% (SAM)

Coverage Greater than 50-70%*