Menu ENN Search

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:

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:

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:

Conclusions

The involvement of the MoH from the start, maximised the extent to which they accepted the Wollo CTC programme to be partly 'their' programme. A year down the line and they have a considerable sense of ownership. They have invested much of their time and energy in it for little personal gain, and as such will hopefully care that it continues to work well under their guardianship.

The experience in South Wollo has demonstrated that where programme implementers can accept some compromises in the early stages, employ masses of patience and respect and, most importantly, relinquish some of the desire to 'control', integration can be both a successful and rewarding experience.

More like this

FEX: CTC in Ethiopia- Working from CTC Principles (Special Supplement 2)

Isolated village in the highlands of South Wollo, Ethiopia. By Kate Golden (Concern Ethiopia) and Tanya Khara (Valid International) In December 2002, nutrition surveys...

FEX: Case Studies (Special Supplement 2)

3.1 CTC in Ethiopia- Working from CTC Principles Isolated village in the highlands of South Wollo, Ethiopia. By Kate Golden (Concern Ethiopia) and Tanya Khara (Valid...

FEX: CTC Approach (Special Supplement 2)

by Steve Collins (Valid International) 2.1 Main principles of CTC Community Therapeutic Care (CTC) is a community-based model for delivering care to malnourished people. CTC...

FEX: Integration in CTC (Special Supplement 2)

by Jamie Lee Many of the articles in this supplement explore the concepts and practice of 'integration' within CTC programmes. A variety of meanings and values are attached to...

FEX: CTC in South Sudan - A Comparison of Agency Approaches and the Dilemmas Involved (Special Supplement 2)

Tanya Khara (Valid International), Jennifer Martin (Concern Worldwide), Ed Walker (Tearfund) Introduction In 2003 both Concern Worldwide and Tearfund asked Valid...

FEX: 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...

FEX: CTC in North Darfur, North Sudan: challenges of implementation (Special Supplement 2)

By Kate Sadler (Valid International) and Anna Taylor (SC-UK) People waiting at a clinic in Darfur, North Sudan. Child eating plumpynut® in Darfur, North Sudan. North Darfur...

FEX: The Cost of Selective Feeding (Special Supplement 2)

by Rose Caldwell & Alistair Hallam (Valid International) The aim of this paper is to present the cost per beneficiary of CTC and discuss aspects of these costs, underlying...

FEX: Integration of CTC with strategies to address HIV/AIDS (Special Supplement 2)

By Paluku Bahwere, Saul Guerrero, Kate Sadler & Steve Collins (Valid International) The district health officer of Dowa, Malawi, briefs clinic and community workers about the...

FEX: Introduction (Special Supplement 2)

Glossary ACF Action Contre la Faim CHA Community Health Assistant CHAM Christian Health Association of Malawi CNW Community Nutrition Worker CTC Community Therapeutic...

FEX: Integrating OTP into routine health services CONCERN’s experiences

By Emily Mates Emily Mates is a public health professional with a focus in nutrition. She recently left Concern Worldwide, Ethiopia where she worked for many years in...

FEX: Effectiveness of Integrated Outpatient Care of Severe Acute Malnutrition in Ethiopia

By Martin Eklund and Tsinuel Girma Martin Eklund holds an MSc in Clinical Nutrition from the University of Copenhagen. His specialisation is community-based management of...

FEX: Adopting CTC from Scratch in Ethiopia (Special Supplement 2)

By Hedwig Deconinck (SC-US Ethiopia) Save the Children USA (SC-US) implemented an emergency health and nutrition programme in Sidama zone of SNNP region of Ethiopia, in...

en-net: Concern seeking consultant to evaluate South Sudan nutrition programme

Draft Terms of Reference for post project Evaluation of ECHO supported ‘Provision of Effective and Integrated Nutrition Care for Children Under Five Years’ project in Aweil...

FEX: Community Participation and Mobilisation in CTC (Special Supplement 2)

By Saul Guerrero & Tanya Khara (Valid International) Over the last few years of CTC development, the process of community participation and mobilisation has become central to...

FEX: Technical and Management issues within CTC (Special Supplement 2)

4.1 CTC from Scratch - Tear Fund in South Sudan By Ed Walker (Tearfund) Beneficiaries collecting their general ration in South Sudan. Tearfund has been working in Northern...

FEX: Temporal Integration - Demand driven CTC (Special Supplement 2)

By Steve Collins A small scale market in South Sudan Early CTC programmes prioritised the timely provision of an appropriate level of care to a large proportion of the target...

FEX: The roll out of IMAM in Kenya’s urban slums

By Koki Kyalo, Claire Orengo, Regine Kopplow Koki Kyalo is the Urban Nutrition Programme Manager at Concern Worldwide, Kenya. She has worked with Concern Worldwide for five...

FEX: The CTC Advisory Service: Supporting the Countrywide Scale-up of CTC in Malawi

By Gwyneth Hogley Cotes Gwyneth Hogley Cotes holds an MPH from Tulane University, with a focus on child health and nutrition. She has worked with the CTC Advisory Service in...

en-net: CMAM

Dear All,

What is the definition of CMAM ? is there any update on the components of the CMAM ? recently there were discussions to include/or not the SC in the south...

Close

Reference this page

Emily Mates (2004). Institutional Integration of CTC with existing clinical health systems (Special Supplement 2). Supplement 2: Community-based Therapeutic Care (CTC), November 2004. p51. www.ennonline.net/fex/102/5-3

(ENN_3161)

Close

Download to a citation manager

The below files can be imported into your preferred reference management tool, most tools will allow you to manually import the RIS file. Endnote may required a specific filter file to be used.