CTC from Scratch - Tear Fund in South Sudan (Special Supplement 2)

By Ed Walker (Tearfund)

Beneficiaries collecting their general ration in South Sudan.

Tearfund has been working in Northern Bahr el Ghazal, southern Sudan, in the nutrition sector since 1998. In 2002, drought, in combination with the effects of the 20 year war, led to a serious situation, with the population of Northern Bahr el Ghazal most affected. By the end of 2002, the WFP Annual Needs Assessments, Tearfund's feeding programme experiences, and nutritional surveys all suggested that the hunger gap in 2003 would be severe and prolonged. Furthermore, base-line nutritional surveys, conducted in February 2003, found rates of 25% Global Acute Malnutrition and 5% Severe Acute Malnutrition, reinforcing the expectation of high numbers of malnourished children. An outbreak of measles at this time also heightened fears of an increase in numbers.

For some time Tearfund had been questioning the effectiveness of the traditional, centralised Therapeutic Feeding Centre (TFC) approach to treating severe malnutrition. Issues of concern were the low levels of coverage TFCs generally achieved, the large distance mothers and children needed to travel to reach services, the length of time mothers spent in centres, and the long term dependency impact on the community. However, exploring the potential of community based therapeutic care (CTC) as an alternative, raised as many questions as it provided answers. Was this approach appropriate in the southern Sudan setting? Would it work? And would the level of care ensure that children gained weight and recovered? After lengthy deliberations, we decided to incorporate CTC into our plans for the nutritional programme in 2003.

Preparation and Planning

Carers and children wait for food at the SFP and OTP distribution tree, South Sudan.

In preparation, the Tearfund nutrition co-ordinator visited the Concern/Valid implemented CTC project in Malawi (see section 3.2) to learn how CTC was adopted there. As a result, a very decentralised approach was developed, based on the Malawi model. The field teams established many more distribution points than in previous years, often in more remote areas, with a greater emphasis on the 'community' to supply the labour and materials for the construction of the centres. There was, however, concern that although this decentralised approach, which aims to maximise coverage, was working successfully in Malawi, it would be difficult or impossible to maintain access to sites during the wet season in the swamps of South Sudan. There were also potential issues regarding field staff, who had worked for many years in a traditional therapeutic feeding centre, and whether they would adopt and accept the CTC approach.

Other NGOs working in the nutrition sector raised concerns about the effectiveness of the clinical care and the lack of 24 hour professional medical supervision for all severely malnourished children.

Implementation and Results The programme had two bases, one in Aweil East and one in Aweil South, both with experienced staff who were able to establish quickly the network of decentralised SFPs and train the local staff. The start of the Outpatient Therapeutic Programme (OTP), through these same decentralised sites, coincided with the arrival of Plumpynut® and the Valid Consultants who landed on the Wednesday morning, trained the staff that afternoon and on the next day began the first OTP centre in Aweil South. This very low requirement for additional training is an important strength of the approach, making it relatively easy for an agency such as Tearfund, who were new to the approach, to implement CTC.

Admission Figures

The numbers of severely malnourished treated in the programme increased far faster than they had done during our 2002 TFC programme. After two weeks of CTC, 138 severely malnourished children had been admitted and within four weeks, the number had risen to 257. In the same period, an additional 122 children had been admitted into the Stabilisation Centre. By contrast in 2002, in the same area and over a seven month period, less than 100 children had been admitted into Tearfund's TFC. By the closure of the programme in December 2003, Tearfund had admitted 726 severely malnourished children into the OTP.

Whilst this dramatic increase in numbers in part reflects the severity of the food insecurity in 2003, we believe that it also illustrates the enormous benefits in coverage of the decentralised out-patient approach. The start-up of this programme coincided with the beginning of the rains and cultivation season. During this time, the workload of mothers is very high and they cannot afford to miss four weeks away from the fields and their other children, to stay with a severely malnourished child in a TFC. During our focus group discussions, mothers all stated how much they appreciated being able to go home and 'take care of other family members' and consequently, how they greatly valued the weekly out-patient approach. Mothers also appreciated the shorter in-patient treatment for those children with medical complications, finding this much less disruptive to their lives.

Of the 726 children admitted to the OTP, three are known to have died. Combined with six children who died in the stabilisation centre (from 231 admitted), the overall mortality rate was about 1.3%. In addition, there was a 15% default rate. As few of these children were followed up, it is probable that this default statistic contains other children who also died. However, taken overall, these results compare very well with the SPHERE standards, achieved in a place where it is notoriously difficult to implement feeding programmes. The overall outcomes for the OTP and SC programmes are presented in table 13 and illustrate the low mortality and excellent recovery rates obtained by the end of the programme.

Local perceptions of the programme

The staff adapted to the approach immediately. Nurses who had spent over five years in feeding programmes and TFCs were, surprisingly, CTC's strongest advocates. Whilst it felt very strange to see a child of less than 65% weight for height (but with a good appetite and free from medical complications) being discharged from the Stabilisation Centre, the staff were prepared to trust the system, experience and expertise that Valid introduced. We found that the 'Plumpynut® test', given on admission into the OTP in order to determine whether the child will eat it, an important tool. This test ensures that the child would thrive on the OTP and also served to reassure staff.

The overriding impression gained from focus group discussions with mothers, village meetings, discussions with community leaders and chiefs, was that the CTC approach was popular with the people. In the stabilisation centres, it was the mothers who were asking for a discharge after a matter of days - arguing that "with Plumpynut® we will be able to care for the child."

Plumpynut® proved to be very popular among the children and, in the first few weeks especially, the weight gain amongst children was very encouraging. Focus group discussions with the mothers revealed that the children loved the Plumpynut® and were constantly asking for more.

Difficulties encountered

Inevitably there were difficulties with the approach and it had to be adapted to the southern Sudan context. Southern Sudan contains 'the Sudd,' the largest swamp in the world. Water from Chad and the Central African Republic flows through Northern Bhar el Ghazel en route for the Nile, causing flooding annually. In 2003, this combined with strong rains to render much of the lowlands of Northern Bhar el Ghazal inaccessible. Crucially, as predicted at the project planning stage, a number of Tearfund's 'decentralised' feeding centres became cut-off. Tearfund managed to fly to one location on a fortnightly basis, but for the other four centres, mothers were encouraged to bring their children to another site. However this entailed walking four hours through swamp carrying a child and food, which is a difficult journey and inevitably, the defaulter rate increased as a result.

As with all nutrition programmes, strong logistics is a major component in achieving the project objectives. In southern Sudan, this is especially true, with all feeding materials having to be flown into Bahr el Ghazal (the Plumpynut® needed to be bought and transported from France and caused a number of delays in the start up of one programme site).

The months of July and August, before the first harvest in September, are the most severe months of the hunger gap. With a severe drought in 2002 producing a poor harvest, large numbers of displaced people sharing the food resource, and an intermittent WFP food-supply (no food was dropped for a 3 month period pre-harvest), the food available to the Bahr el Ghazal population in 2003 was very low. This, combined with a malaria epidemic, further undermined the nutritional status of the population.

Inevitably in such a situation, despite an extra 'supplementary ration' (an extra 2 Kgs of CSB given to the mothers of OTP children), the pressure on a mother to share food within the family was immense and during this period, the weight gain of the children in the OTP programme was slow. This, perhaps, is the greatest difficulty with CTC - unlike an inpatient feeding approach where meals are observed and controlled, with CTC the responsibility is given to the carer, with support through outreach. Outreach was provided by extension workers, following up on children with poor weight gain and on defaulters. Ultimately, decisions on distribution of food within the household lie with the carer and household head and, in the absence of other food in the household, the SFP or OTP ration may be shared. The significance of slow weight gain is a matter for debate, but in this Bahr El Ghazal context, it is inevitable that, compared to an in-patient approach, the rate of weight increase in an OTP will, on average, be slower. For this reason, Tearfund concluded that when running a CTC programme in Bahr El Ghazal, it is vital for WFP to provide the general ration to the community Without this, overall CTC effectiveness will be undermined.

With the arrival of the first harvest, there were notable gains in the health and weight of the children. By the end of the Tearfund programme, 522 severely malnourished children had been cured. Fifty-eight children remained in a malnourished condition and were discharged with a ration for six weeks intensive feeding using Plumpynut®¹.

Integration

Throughout the programme, Tearfund aimed to integrate the nutritional activities with its agriculture and health education programmes. For an INGO in a war affected area, culture, language and layers of beaurocracy make access to the poor difficult. However, the contact afforded by the CTC activities opened access for other elements of the programme. Thus, mothers in the SFP and OTP benefited from a seed-fair, fishing equipment, vegetable seeds and health education. In Aweil East and North, many mothers of the OTP agreed to return to the feeding centres on one extra day per week to receive health education. They have subsequently formed into a number of 'women's groups' that meet every week to receive further health education. These groups will be targeted in the 2004 agriculture programme and their families will be some of the beneficiaries in the rice and ox-plough projects.

The Future

Getting to distribution sites during the rains proves impossible in South Sudan.

To reflect on 2003 is to remember the many challenges and the hard work and commitment of all the Tearfund staff, to acknowledge the huge amount of learning that occurred through this approach, and to take pride in the success of the programme in such a difficult and complicated operating environment. For 2004, Tearfund Sudan intends to expand the CTC approach in existing locations, as well as engage its mobile nutrition team, who are able to deploy to nutritional problem areas anywhere in southern Sudan. This expansion will incorporate the lessons learnt from 2003. One of the major objectives for 2004 is to increase the emphasis on outreach services to improve follow-up, explore ways of minimising default, and to better understand the social implications and benefits of the programme.

Based upon the positive results from the programme, Tearfund has since put a lot of energy into information sharing and advocacy work at the coordination level. A number of other agencies are now adopting aspects of this approach in Southern Sudan, including MSF F, MSF B and Concern.

¹The programme was funded by DFID for a fixed time period, from 1 March to 31st of December 2003. The intervention was originally timed to finish at the end of October, but an extension was granted by DFID because of the high numbers of children still in the programme at the end of October.