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Integrating CTC in health care delivery systems in Malawi (Special Supplement 2)

By Kate Sadler & Tanya Khara (Valid International), Alem Abay (Concern Malawi)

In February 2002, the Malawi government declared a national nutritional emergency and the UN launched an international appeal for emergency assistance. The national Ministry of Health and Population (MoHP) and the humanitarian community began to develop strategies for the treatment of the large numbers of severely malnourished that were predicted. Nationally, a strategy of upgrading the 115 Nutritional Rehabilitation Units (NRUs) across the country was adopted, with the aim of each NRU being able to provide centre-based therapeutic treatment by the end of the year. UNICEF and several non-governmental organisations (NGOs) provided therapeutic products, training and support for this strategy. At the same time, the MoHP gave Concern Worldwide and Valid International (Valid) permission to pilot CTC in two districts in central Malawi.

In Dowa District, the CTC programme was set up for delivery through the existing health system, with Concern and Valid providing mobile CTC teams to deliver training and on the job support for health system staff. The programme consisted of:

Outcome Indicators

To date (Dec 2003), outcome indicators for this CTC programme compare reasonably well with the Sphere Project's international standards for therapeutic care (table 8).

Importantly, CTC programme coverage, a key determinant of impact in any humanitarian intervention, is high, approximately three times greater than TFC coverage achieved with international NGO support in the neighbouring District of Mchinji1, and far higher than the national average. These findings are summarized in table 9.

This combination of acceptable outcome indicators and high coverage has produced high impact for the emergency CTC programme. However, in the context of Malawi, where poverty and under-nutrition are long-term structural problems, this short term impact, achieved with high levels of external input, ultimately bears little relevance to the main problems facing the state and people. From the start, one of the main attractions of the CTC model has been the possibility that short-term emergency interventions may lay a foundation for longer term, more sustainable, benefits. The rest of this article focuses on the post-emergency measures that were taken to try and realise this potential.

Table 8: Interim monitoring results from Dowa District, Malawi, CTC project, Aug 2002-Dec 2003
  Stabilisation Centre OTP Combined
Exits n % N % N %
Discharged 1299 87 1160 69 1160 69
Death 101 7 47 3 148 9
Default 25 2 242 14 267 16
Referred to hospital/SC 50 3 217 13 50 3
Other 20 1 26 2 46 3
Total 1495   1692   1671  

 

Table 9: Direct estimations of CTC coverage in Dowa and TFC Mchinji districts, Malawi, March 2003
Project CTC in Dowa TFC in Mchinji
No. of severely malnourished identified 76 136
No. of children in feeding programme 46 29
Coverage (%) 61 21
95% Confidence interval (%) 48.7 - 71.6 14.8 - 29.2
Coverage WFP/UNHCR method (%) 73 28
95% Confidence interval (%) 63.6 - 80.1 20.8 - 35.8

 

Integrating CTC services into the district health system and community

One of the central principles of the CTC model is for CTC programmes to integrate with local health structures and services. This bridges the natural friction between the priorities of a short term, high input emergency intervention and those of a longer term, resource scarce development intervention. For this, a strong partnership at a District Authority management and supervision level is essential, if local services are to commit to CTC in the longer term. From the outset, the Dowa programme worked well with the existing MoPH and CHAM structures, supporting primary health care unit staff to carry out OTP and SC protocols. However, the majority of the day to day planning, problem solving and supervision was done solely by Concern, with very little input from District Authority managers. To some extent this has hindered the full integration of CTC services into Dowa health structures.

HSAs helped by Concern supervisors record the progress of OTP children in Malawi.

Although now in the process of trying to integrate all aspects of CTC delivery into the District health system and community structures in Dowa district, this is presenting further challenges and has highlighted some of the strengths and weaknesses of the initial CTC implementation in Dowa. The lessons learnt from this process will direct systems for the expansion of CTC into other Districts in Malawi.

Platform provided by the emergency programme

Several aspects of the emergency CTC programme are aiding the transition process:

Existing Challenges

In order to complete a successful handover, a scaled down Concern team are trying to focus on a number of key areas of weakness.

Supervision and monitoring of service delivery and impact

Both the District Health Officer (DHO) and the MCH coordinator for the District were consulted in the planning and implementation of the emergency programme. However the degree of collaboration needs to move from one of information sharing, to active involvement in the planning, supervision and reporting process. At present, the MCH coordinator makes ad hoc supervisory visits to health centres and NRUs implementing the CTC programme. The DHO (a clinician) makes monthly visits to each health centre as part of his existing work, during which time he reviews children in the OTP who are not responding well to treatment. However, all supervision and reporting implemented by Concern has, to date, happened in isolation of that implemented by DHO staff. This must be a focus for changeover in the coming months. Regular joint planning and problem solving meetings will give the DHO an opportunity to direct Concern to areas where they need extra support.

A traditional healer in Malawi.

Scheduling of joint field supervision visits with existing/established checklists will help the MCH co-ordinator to gradually take on responsibility for this role. This must be coupled with improvements in the sharing of programme monitoring statistics and reporting, both with the DHO and clinics. The strengthening of this system of information sharing is a prerequisite for development of the central reporting role of the DHO in the future (see section 5.3).

Stock movement and accountability

At present, Concern moves both supplementary food and RUTF to health centres and NRUs. In June 2004, the supplementary feeding programme will phase out. This will reduce the weight of food commodities requiring delivery by over 72%, leaving only RUTF requiring transport from the district production site to the local distribution points.

The CTC support team will focus on two potential systems for RUTF delivery in Dowa:

  1. Integrating delivery into community-based systems. A Valid anthropologist will explore possible mechanisms for community-based transport systems in Dowa.
  2. It is feasible that RUTF, along with F100 and F75, be included on the list of essential medicines for Malawi. In this case, it could be delivered through the existing drug delivery mechanism in Malawi.

Local health staff at the health centres and NRUs are currently implementing Concern's systems of stock control and Concern is collecting data and monitoring stock usage. Many centres have already implemented WFP SFP distributions according to WFP guidelines. Thus, similar modified stock control systems could be developed, presenting little change from those already familiar to centre staff. At a higher level, the Concern CTC team is increasing support to the DHO for central stock control and reporting, in order to facilitate their future accountability to MoH/donor agencies.

Delivery of CTC from health centres and NRUs

All health centres and NRUs are now implementing CTC with little input from Concern. At the centre level, however, the need for support is very variable according to each centre's staff capacity, caseload and motivation. To better focus inputs, the CTC support team is conducting capacity assessments at each site to identify areas that require strengthening. It is likely that strengths at some centres can provide lessons to address weaknesses in others. At this stage, it will be important to look at centres individually and come up with flexible strategies for these issues. This is somewhat of a departure from the previous focus on general protocols. A general challenge at this level is systems of communication. Good follow up of children referred between NRUs and health centres requires some rigour and a functional communication system. Communication is also difficult between health structures and the DHO. Improving communication would improve feedback and enhance the ability of the system mangers to learn and solve problems.

Community-based support systems

From the start of the programme, HSAs have been very involved in the delivery of treatment from health centres, in working with the Traditional Authorities on community sensitisation, following up those in the programme, and tracing defaulters. However, HSAs already have a high workload in Malawi, being responsible for all vaccination, growth monitoring, community outreach and education. The CTC programme in Dowa is now in the process of strengthening links with the non formal sector, as an alternative mechanism for sustaining referral follow up and support at community level. Experience suggests that the high levels of 'positive feedback' associated with recovery from acute malnutrition provide a potent force to generate enthusiasm and motivate individuals at the community level to get involved (see section 5.12)

The evidence is that referrals can be maintained through mother-to-mother networking and the Traditional Authority structures. In addition, HSAs are now beginning to strengthen and, to some extent, formalise their links with networks of volunteers, already active at community level. Volunteers include community growth monitors, traditional birth attendants, agricultural extension workers, village health committee members and mothers that have been in the programme. These volunteers are helping to maintain case finding and referral at village level. However, it is being found that volunteers do require some small incentives if their role is to include assisting the HSAs in the follow up of children in the programme and of those that default from treatment. With the DHO, the team are considering the suitability of providing materials that help communities associate these volunteers with the programme.

Changing perceptions

The success of the consolidation and handover process is not just reliant on the relationship Concern manages to build with the DHO, MoH health staff and HSAs. Communities' understanding of the handover process and of the increased responsibility of the MoH are vital if they are to remain committed to and engaged in the programme. Communities have recently expressed their concern with the lack of transport for referrals between NRU's and OTP sites, as this was carried out during the old programme. Using existing communication channels, it will be important, throughout the handover process, to inform and involve community leaders in programmatic changes (see section 5.12)

Multi-sectoral programming

The close links between Concern's food security programme and CTC are providing an opportunity to tackle some of the root causes of malnutrition in Dowa District CTC (see section 5.21). In principle, CTC is also well suited to providing support for those affected by HIV/AIDS in Malawi, for example:

Conclusions

The Dowa CTC programme achieved good short term impact. It saved lives and reduced morbidity by achieving high coverage and good cure rates. It also achieved a level of integration at village and health centre level, by implementing the programme through local staff from the Dowa health structure and linking with HSAs in the community. However by its nature, the emergency programme was largely a vertical one and the relationships and links made with existing infrastructure were essentially imposed from the outside. The challenges ahead lie in modifying and further developing these relationships. At a district health level, this involves moving the collaboration that exists from simple information sharing to active involvement in the planning, supervision and reporting processes for CTC. At a community level, it means rooting CTC implementation further into the non formal community health systems of Dowa. Initial signs are that the challenges of transiting smoothly towards local management and sustainable case finding and follow up are being gradually met. Consequently it is believed that this programme holds great opportunities in Malawi, not only for the long term treatment of acute malnutrition, but also for the provision of support to those living with HIV/AIDS.

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Kate Sadler, Tanya Khara and Alem Abay (2004). Integrating CTC in health care delivery systems in Malawi (Special Supplement 2). Supplement 2: Community-based Therapeutic Care (CTC), November 2004. p19. www.ennonline.net/fex/102/3-2

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