Institutional Integration of CTC with existing clinical health systems (Special Supplement 2)

By Emily Mates (Concern Ethiopia)

Therapeutic Feeding Centres (TFCs) are often highly effective in treating individual cases of severe malnutrition. Their exacting requirements for hygiene, and delivery of the medical and nutritional protocols means that they are often set up as 'parallel structures,' with little room for local Ministry of Health (MoH) involvement. Where some form of government health structure exists, experience shows that CTC offers good potential for integration. The amount and type of integration depends on various factors, for example:

• Existing capacity
  • Structures
  • presence, availability, condition
  • Staff
  • availability, level (and recentness) of training
  • Available resources
  • Communication systems
• Perception/motivation - usually governed by the history of NGO involvement in the area, e.g. high per-diem expectations
• Relationship with, where existing, government structures, such as Ministries of Health, Agriculture, or Education.

For successful integration with local systems, plans must be made right from the start, even in an emergency situation where the pressure is on to get the programme open quickly. It is relatively easy, and very tempting, to take the faster and more straightforward route of setting up your own system, with only a token nod towards integration. An alternative is to take the slower, and initially often more frustrating option, of really working with existing services. However, experience shows that this ultimately turns out to be far more rewarding and also engenders considerable capacity that did not exist before. The more capacity that exists, the more opportunities there will be for integration. Even where facilities are poor, in South Sudan for example, limited integration is still possible so that capacity can be developed for future emergencies (see section 3.3) This article presents experiences of trying to implement an integrated CTC approach in South Wollo, Ethiopia. South Wollo was fortunate in that there was some existing capacity (although limited), with excellent possibilities for collaboration (see section 3.1). Integration with clinical services took place at the district health facilities (Centre, Clinics and Posts ), the local referral hospital and at the woreda health officer level.

Health Services Integration in South Wollo

Health Facilities

South Wollo is a densely populated area, with rugged mountains that render many areas inaccessible. Health services for the population are provided by a total of 23 health facilities, most of which are in relatively good condition and have moderate resources (although many have no water access). Each serves an average of 19,500 people and is staffed, on average, by two health workers. The local MoH has a strong bureaucratic system and while staff have differing levels of expertise, most are reasonably competent and, crucially, motivated to participate in NGO activities. Concern has a long history in the area and a good rapport exists with the local authorities. The strength of this relationship and understanding was an important factor behind the MoH's willingness to try a new approach. From the start, Concern and the MoH made decisions, where possible, together, and this engendered a vital sense of MoH 'ownership' of the programme.

Training

After gaining permission to work in partnership with the MoH staff, including seconding workers to act as medical supervisors (working during their annual leave for a 'top-up' salary), Concern conducted an initial one-day workshop introducing CTC. To allow for a fast set-up, Outpatient Therapeutic Programme (OTP) sites were opened alongside the 18 existing SFP sites in a staggered fashion (those with the most identified severely malnourished children opened first). In this way, the whole of the district was covered with OTP within six weeks, admitting a total of 169 severely malnourished children. A Concern health worker, or seconded MoH supervisor, travelled out to the site on each day of an OTP distribution to give on-the-spot training and support. For sites that were based near to the clinics, one MoH clinic worker would attend the OTP children (for a minimal per-diem payment) while the other clinic worker would attend to the regular patient load. It was designed this way to ensure that CTC never caused the clinics to be closed due to staff shortages.

Training and supervision of the MoH workers and supervisors has been ongoing and has required considerable commitment from Concern. The results appear extremely promising, with most of the clinic workers now able to implement the OTP protocols with minimal (or no) support from Concern. In addition, the clinic workers have collectively and consistently made appropriate decisions about whether to refer a child to hospital or not. The process of working with the MoH as partners has not only greatly reduced the need for Concern to employ health workers from the capital Addis Ababa, but also substantially raised the capacity of the MoH to recognise and treat severe malnutrition in this area. The seconded workers have been a particular success. Working with Concern full-time has allowed them to become channels for the development of real communication and transparency between partners, and has made collaboration on issues such as synchronising vaccination schedules much easier. As two of the seconded workers were from the district health office, it is hoped that with the experience gained, they will emerge as focal personnel to co-ordinate the programme after handover.

Hospital care

At initial programme set-up, plans were made to site the stabilisation centre (SC) for children requiring in-patient care for severe complications, poor appetite or advanced oedema) in the local health centre. On visiting Dessie Hospital (the local referral hospital, serving a 2.4 million catchment population), it was found that there was a 50-bed paediatric ward with one room already allocated as a nutrition unit. Practices were, however, very out of date, for example they were using the old fashioned 'kwash' milk recipe complete with eggs. Milk was made once per day in the morning and left in a container beside the bed for 24 hours. Perhaps not surprisingly, the reported average mortality rate was 50% of severely malnourished admissions.

With some existing capacity and, again, very motivated staff (particularly the paediatrician/medical director), Concern supported Dessie Hospital's nutrition unit through training and bettering of practices, as a sustainable option to treating severe malnutrition in South Wollo. The support provided included:

• Procurement and donation of therapeutic milk from UNICEF, accompanied by training in preparation and protocols
• The paediatrician was enrolled in UNICEF training on the Ethiopian National Protocol for in-patient treatment of severe malnutrition. Due to this training, he was able to update his skills and crucially, on his return, train all the hospital paediatric staff.
• Appointment of a 'hospital liaison assistant' (deliberately non-medical) to facilitate the admission and discharge of patients, purchase of medicines, etc.
• Construction of a small structure adjacent to the paediatric ward to increase the nutrition unit capacity by 8 beds.
• Provision of certain supplies not available in the hospital, e.g. salter scales, naso-gastric tubes, regulator for the oxygen cylinder.
• Concern facilitated the transfer of children to and from hospital and paid for all medical expenses incurred while in hospital.

A concern supervisor helps a ministry of health clinic worker to fill in monitoring reports in Ethiopia

Results from one year of support (Feb 2003-Feb 04) have been very encouraging. The hospital mortality rate for severely malnourished children dropped from 50% to 9.5%, 168 children have been treated with no per-diem payments paid to hospital staff (they consider the children as part of their regular caseload), and long-term capacity has markedly increased. Children from the 16 other districts in the catchment area have benefited from this increased capacity and an excellent relationship has developed between Concern and the hospital, which will benefit future programmes.

Compromises

Genuine integration with pre-existing clinical systems will inevitably be slow. To have real collaboration, one cannot simply walk into the local hospital and demand that certain protocols are adhered to, even if a one-off training in protocols is provided. Building up the relationship and changing practice takes a long time, during which compromise is required all round - in this case it was difficult to accept that the level of care was not always what was hoped for or expected. Working with local infrastructure requires an understanding of the constraints under which these institutions operate, the workloads of the staff and the factors affecting motivation. Merely imposing external protocols and systems, no matter how theoretically beneficial they may be, is not of itself a solution. Furthermore, integration is not a one-off event, but is an on-going process.

A Platform for Transition

A health centre used for OTP distributions in Darfur, North Sudan.

The programme in South Wollo is currently entering a 'transition stage,' wherein the MoH gradually takes on more responsibility for programme implementation. This process will be greatly facilitated by the experience of working together over the last year. The capacity gained by MoH staff and the fact that many issues have already been worked through jointly with MoH partners throughout the programme, instils optimism that handover will be a success. Undoubtedly, there are many challenges inherent in this process and some of the particular issues currently being worked on in Wollo are described in detail elsewhere ( see section 4.2). A similar transition process is also underway in Malawi where many of the same issues are being faced (see section 3.2).

Many of these issues relate back to the same factors that determined the possible extent of integration at the start of the programme, namely:

• Capacity - to what extent has local capacity been built (structures, staff, available resources, communication systems) and where are the potential gaps in relation to the organisation's withdrawal strategy?
• Perception/motivation - is there a true sense of ownership of the programme within the MoH and what can be done to enhance this? How confident are the community that real handover is possible?
• Relationships - how will the relationship between the MoH and the organisation need to evolve in order to gradually shift the balance of programmatic responsibilities?