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 International)
In December 2002, nutrition surveys carried out by Concern Worldwide, in collaboration with Amhara Region Disasters, Preparedness and Prevention Bureau (DPPB), reported acute malnutrition levels of 17.2% global malnutrition and 3.1% severe malnutrition (based on weight for height in z scores) in Kalu and Dessie Zuria districts, South Wollo. At the same time, the Federal Disasters, Prevention and Preparedness Committee (DPPC) led multi agency crop assessment reported the harvest to be below 25% of normal, and identified half (50%) of the population as in need of food aid.
The districts have a total population of around 450,000, the vast majority of which live in chronically food insecure rural villages, spread over a densely populated and poorly accessible mountainous terrain (260,000 hectares, population density 180 people/sq km). Concern have worked in South Wollo for the last 30 years, in nutrition, health, agriculture, water and livestock programmes. In response to the 1984 famine, they implemented SFP and TFC feeding programmes in the area and still retain some of the staff who remember those days. Partly due to this legacy, Concern were eager to explore a new approach which might offer some solutions to bringing services to the population of such an inaccessible area.
In December 2002, Concern began blanket supplementary feeding in response to the emergency and in January 2003, replaced this with a targeted supplementary feeding programme, providing a two weekly ration of a local blended food. The programme was spread over 18 decentralised sites. When Valid International supported the set-up of the CTC programme in February 2003, an Outpatient Therapeutic Programme (OTP), facility for inpatient care, and an outreach programme were integrated into this existing SFP intervention. The Concern/Valid team worked on an initial target of 2500 severely malnourished children, which was calculated using November 2002 nutrition survey results.
A mother and child wait to see the OTP nurse in Ethiopia.
Key features of the programme, reflecting the basic principles of CTC, were:
- Timely set up
Within just a few days, it was possible to add the OTP component to each existing SFP site, with all sites becoming activated within a six week period.
Treatment for severely malnourished children consisted of a weekly health check, provision of a RUTF ration according to weight, standard medical treatment, and basic nutrition education for carers.
- Formal training
Training of Concern and Ministry of Health (MoH) staff to implement the programme required only two days. This training covered the basics of malnutrition, identification of severe malnutrition, medical assessment, feeding and drug protocols, RUTF education, and record keeping.
- Sites at existing health facilities
Sites were then set up at existing SFP sites, using clinic or health centre facilities wherever possible, for weekly health checks.
- Ongoing support
Close supervision and ongoing training at the distribution sites was then carried out by Concern and MoH supervisors.
Concern outreach workers (who would live and work in the communities they were serving) were also trained on basic malnutrition, the structure of the programme, referral (using MUAC and oedema assessment) and follow-up through home visits for children not responding well to treatment.
Focus on achieving high coverage and good access to services
It was hoped that maximum access to services for the whole population would be achieved by setting up OTP sites quickly, and focusing the activities of outreach workers on mobilising communities through local contacts (traditional leaders, community workers), as well as active case-finding. The aim was to provide OTP services within three hours walk of all villages. In a minority of 'difficult access' areas, carers were given the option of attending sites on a two weekly, rather than weekly, basis thus avoiding subsequent default.
The aim of the strategy in the initial phase of implementation was to focus staff and resources on the OTP, and not to set up any new inpatient care for the severely malnourished until good coverage had been achieved. The provision of inpatient care, for the minority of complicated cases, was established through rapid but low level support for the MoH central hospital and is discussed in more detail in section 5.3
From the outset, the Concern and MoH team worked to maximise the profile and understanding of the programme in the community, by encouraging carers of registered children to take on an informal mobilisation role in their villages, encouraging others, with children in a similar condition, to attend. During the rainy season, when access roads to some sites became impassable, Concern went to great lengths to maintain SFP/OTP distributions, by employing donkeys and prepositioning food. These actions were vital to avoid interruptions in treatment and maintain carers' confidence in the programme.
Some months into the programme, the team started to conduct Focus Group Discussions (FGDs) at sites to investigate barriers to uptake of the programme. These proved extremely useful, as feedback during the sessions revealed access issues in particular areas and led to the opening of extra sites. FGDs also highlighted dissatisfaction amongst some carers, generated by confusion over the use of MUAC (village level referral) and WFH (admission) selection criteria. This 'bad feeling' was discouraging some carers, after initial rejection, from bringing their children back to the site if their condition deteriorated. It was also deterring others in the community from attending. Based upon these findings, we adopted a system of compensation (soap) for those referred to the programme through outreach workers using MUAC, but who, due to the difference between the MUAC referral criteria and standard weight for height admission criteria, were not subsequently admitted. We received very good feedback on this strategy.
This commitment to maximising coverage bore fruit and a survey, carried out in June 2003, estimated OTP coverage at 77.5% (C.I 65.7% to 86.2%). The survey employed a new method for estimation of coverage using a stratified design, with strata defined using the centric systematic area sampling approach and active case-finding (see section 4.4). A calculation, based on revised targets from a March 2003 nutrition survey (severe malnutrition rates had fallen by this time to 1% based on z scores), shows a similarly high estimate of coverage at 67.7% by May 2003, only three months into the programme.
Integration with, and support of, the existing health structures
Despite running feeding programmes in response to emergencies in the area for the last 30 years, Concern had not previously established close links with the District or Zonal Ministry of Health or involved them actively in programmes. As part of the CTC programme, Concern sought advice from both District and Zonal health departments and began to forge links during planning and implementation of the OTP. The Valid/Concern team jointly decided that Concern would train existing MoH clinic workers to carry out the OTP, linking with Concern SFP distribution teams. Medical supervision for the OTP would be split between Concern Medical Workers and MoH Supervisors, seconded from the district health offices. Though existing commitments and turnover of MoH staff necessitated periodic retraining and increased Concern supervision, both parties continue to be extremely positive about the partnership. The benefits have continued as the process of handing responsibility for the treatment of severe malnutrition over to health facilities now begins.
Concern outreach workers measuring MUAC of potential beneficiaries in their villages, Ethiopia.
Concern outreach workers measuring MUAC of potential beneficiaries in their villages, Ethiopia.
All equipment needed for the OTP distributions (apart from the SFP food) fits on top of a landcruiser in Ethiopia.
The team decided against setting up separate inpatient facilities at the beginning of the programme. Based upon prior experience in other CTC programmes, it was felt that this prioritisation was vital in order not to divert the attention of the field teams away from outreach, mobilisation and the OTP. However, due to the need for inpatient care for a minority of cases, the issue was discussed with the director of the Zonal hospital1 who agreed for the paediatric ward to act as a referral unit for the phase 1 treatment of severely malnourished requiring inpatient care (those with severe medical complications, poor appetite or severe oedema).
Though initial progress in gaining acceptance of updated therapeutic feeding and drug protocols was slow, close dialogue with the medical director and respect for the constraints being experienced by staff led to great improvements in the care of the severest cases. This is demonstrated in the outcome indicators achieved (see table 6) with hospital mortality rates falling within Sphere standards despite the cohort of children representing the most severe cases. Before the start of the programme, the medical director of the hospital had reported that 50% of severely malnourished children treated in hospital died.
To date (Jan 2004), outcome indicators for the CTC programme in South Wollo have compared favourably with the Sphere Project's international standards for therapeutic care (table 6).
Weight gains and Length of Stay
Initial calculation of average weight gain of children discharged and recovered was 4.4g/kg/d and total length of stay was 81 days. The long length of stay and low weight gains in the programme reflect some of the challenges faced by a home-based programme, as factors inherent to the home environment (e.g. poor water sources, endemic malaria, poor quality family foods and sub-optimal caring practices) will affect the recovery time of some children. It also reflects using 85% WFH as discharge criteria, despite the presence of the SFP2 to minimise readmissions. However, subsequent CTC programmes have successfully used 80% WFH as discharge criteria where an SFP is in place. Though testing for TB in the hospital identified some cases, the predictive quality of the testing was poor and therefore the impact of chronic diseases, such as TB and HIV/AIDS, on length of stay is likely to be more significant than data suggested.
A system of outreach home visits, using a checklist for discussion and observation, was put in place at the beginning of the programme. The aim of these visits was to investigate possible reasons for non-response and offer support in terms of health and nutrition education. Efforts were also made to make sure, through advocacy with government and community targeting committees, that all OTP beneficiaries were registered for EGS3. This process was complicated by the community targeting process, which is based mainly on economic vulnerability (i.e. doesn't necessarily identify households with a malnourished child as vulnerable), and the fact that targeting normally takes place periodically (every 3-6 months), whereas families were entering the OTP every day. Though the general consensus of follow-up visits and of an anthropological study carried out by Valid International was that sharing of RUTF was not a major issue, it is likely that a degree of hidden sharing was happening, and that the root of this lay in resource scarcity rather than lack of knowledge.
Mountainous terrain proved a challenge to gaining access to the population of South Wollo, Ethiopia.
Outreach workers followed up all defaulters within the programme in order to better understand the causes, encourage return and to uncover any 'hidden' deaths (table 7). The main reasons found for default were that the mother or child was sick or that the carer had moved out of the programme area. Particularly during the rains, lack of access to sites also became a main cause of default, but one that all efforts were made to reduce.
|Table 6: CTC Interim Outcome Monitoring data, Ethiopia (Jan 03 - Jan 04)|
|Still in project||0||204||204|
* All OTP deaths were followed up. All were in the under 2 age group and did not occur in the early stages of treatment (average length of stay was 50 days). Ten were children admitted with oedemas, 10 occurred in children who had already spent some time in the hospital and 3 occurred when the carer refused to be transferred to the hospital. The main causes of death reported by the families were diarrhoea and suspected malaria and cough.
**The percentage of transfers from the OTP to the Hospital is high, partly due to a proportion of children with poor weight gain being sent for investigation of underlying chronic disease (e.g. TB). Of 93 transfers, 19 returned with positive TB results (based on x-ray) and subsequently continued in the OTP whilst receiving standard Directly Observed Treatment Short Courses (D.O.T.S). The outcomes of all transfers are represented in the combined results.
***After 4 months in the programme, cases who had not yet attained the discharge criteria of ?85% WHM were reviewed by the supervisory team. Those over 80% WHM were discharged non-recovered if their weight was remaining stable and if all alternatives (counselling, home-visit, or hospital referral for investigation of chronic disease), had been pursued. Many of these cases were found to be children with some physical disability.
Future Challenges: moving into a period of handover
The South Wollo highlands, Ethiopia. Ethiopia
Following a relatively good harvest for most of the population at the end of 2003, the need for an acute emergency response in this project area is diminishing. The CTC programme has begun a six-month transition period to gradually hand a more streamlined programme over to the community and the government health structure. Planning this handover has required the active participation of all stakeholders, with the Concern team and partners in the MoH and the community coming together to plan roles and responsibilities, and jointly predict and solve problems.
Priorities over this transition period are:
- To work closely with the MoH to strengthen their capacity to manage and supervise the programme and to maintain a simplified monitoring and reporting system.
- In order to maintain a manageable system for clinics, all children will now be seen on a 2 weekly basis.
- Concern will likely continue to provide RUTF over the next year but is currently in the process of setting up local RUTF production. This will dramatically reduce costs and therefore, open up possibilities for government purchase.
- The provision of medicines for OTP will also be an issue. At present it is not known whether the MoH will be able to maintain the free OTP service and if they cannot, what impact this will have on service uptake and compliance. A government 'free paper' welfare system does exist to cover hospital expenses for the poor and part of the strategy will be to improve this system (currently takes 3 days to receive the paper) for critical cases referred from the clinics.
- Logistical support for the delivery of supplies to the dispersed network of clinics will likely need to continue initially for the short term, although alternatives are being investigated, particularly those involving more community participation. The system for referral to the zonal hospital of cases of complicated malnutrition, previously transported by Concern, is also being discussed.
- To hand over sustainable screening, referral and follow-up activities to community volunteers at the village level.
- At the time of writing, more than 2,000 volunteers have been elected by their communities and trained in the use of MUAC and confirmation of oedema, so they may continually screen and refer severely malnourished children to the nearest clinic for treatment. At present, paid Concern outreach workers are still in place to support these volunteers, but it is hoped that local and district level administrators will be able to assume responsibility for overseeing and motivating these volunteers so that referrals are sustained in the future.
- The strategy of using MUAC as entry criteria, rather than WFH, came from consideration of the problems of having different referral and admission criteria and the need for a practical measure that community volunteers could use at a village level. The rejection issue, discussed above, is heightened due to the absence of the SFP and the compensation strategy would be impossible for the MoH to sustain. We are currently investigating the implications of this strategy and of lowering height cut-offs for the use of MUAC in a stunted population.
- We also hope that working links can be forged between community volunteers and the clinics for effective followup of absent or sick children and other activities, e.g. vaccination campaigns.
- To make modifications to the programme to compensate for the lack of an SFP.
- The high logistic demands of a decentralised SFP programme preclude this being implemented by the government as a normal activity.
- As all aspects of the programme will now be handled through the clinics, a system for nutrition education, both at the point of entry into the programme and subsequently linking through community volunteers/carer groups, will be needed.
- One concern, in the absence of the SFP, is that without assistance for the continued recovery of the OTP beneficiaries after discharge, readmissions will increase. As the harvest was fairly good for most areas, improved food security within the household should mean that children are able to continue their recovery through the use of local foods at home. An education programme promoting the preparation of quality complementary foods and continued breastfeeding, through clinic workers and community volunteers, is being developed to try to aid this process. However general food security and the nutrition situation, including the level of readmissions, will need to be closely monitored in order to identify and act if the situation deteriorates.
|Table 7: Information on Defaulters, Ethiopia (Jan 03 - Jan 04)|
|Total defaulters||Traced||Average time to default||Deaths*|
*Including these deaths in the overall statistics would give a mortality rate of 5.1% for OTP.
There have been a number of major lessons learnt from the Wollo CTC experience. First, the partnership with the central hospital for the provision of phase 1 care successfully allowed the field team to concentrate on treating the majority of severely malnourished children in OTP, without compromising care for complicated cases. The other advantage of this strategy of low level, but consistent, support for the hospital is that a sustainable service for the provision of standard phase 1 is now available for all children in the hospital's catchment area.
Focus on outreach has also been key to the success of the programme, leading to excellent coverage of both severe and moderate malnutrition through flexibility in addressing issues such as mobilisation and access. Though the strategy has been reliant on externally recruited outreach workers, they have become firmly rooted in the communities they serve, particularly in the more remote areas. As a result, natural links have been forged with other community workers, including agricultural extension and family planning agents, teachers, and community leaders, building a basis for a more sustainable strategy in the future.
In the challenging terrain of South Wollo, logistics proved one of the most demanding aspects of the programme. Getting teams to and from distribution sites was a challenge, particularly during the rains when various access roads became impassable. For future programmes, having more field-based teams that are able to move from site to site by foot and mule, coupled with pre-positioning of food, would be recommended. Dialogue with the community on appropriate solutions to access, from the outset, may also yield less costly alternatives.
One of the failings of the Wollo CTC programme was the limited sectoral integration between the CTC programme and longer term food security, and water and sanitation programmes that were running at the same time. Though the team did make great efforts to ensure that programme beneficiaries were tied into the EGS general ration, in retrospect, by integrating sectors (targeting of agricultural inputs or water supply improvement in particularly affected areas), we could have done more to address the underlying causes of malnutrition for beneficiary families.
Finally, the full potential for sustaining both community and MoH participation and ownership of the programme, over the long-term, remains to be seen. This process inevitably requires careful evaluation and flexibility. At all levels, it will involve balancing the needs for effective targeting, and treatment of severely malnourished children with the objective of community and MoH management of the programme.
3.2 Integrating CTC in health care delivery systems in Malawi
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:
- Decentralised supplementary feeding programmes (SFP) delivered through 17 MoH/CHAM (Christian Health Association of Malawi) health units on a fortnightly basis.
- Decentralised outpatient therapeutic feeding programmes (OTP) delivered through 17 MoH/CHAM health units on a weekly basis.
- Stabilisation centres (SC) for phase 1 treatment delivered through four nutritional rehabilitation structures.
- Community-based case-finding, referral and beneficiary follow up using traditional authority structures, mother-to -mother networking and community based health staff.
- Integrated agricultural extension through Concern's food security programme.
- Local production of RUTF at one CHAM health unit.
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|
|Referred to hospital/SC||50||3||217||13||50||3|
|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|
|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:
- CTC now appears to be very popular with the target population. Though mistakes were initially made due to the programme's failure adequately to consider community structures in the rush to implementation (see section 5.12 on community mobilisation), figure 1 shows that uptake of services remains as high now as it was one year ago2. This is important, as since July 2003, presentation of cases to the CTC has been as a result of mother-to-mother notification and mobilisation by the traditional authority structures, in collaboration with MoH community health workers (Health Surveillance Assistants - HSAs), rather than active outreach performed by NGO workers. This method of mobilisation can be sustainable.
- Data from anthropology studies conducted in March 2003 indicate that there had been a shift in the perceptions of traditional practitioners. This group are now more likely to attribute malnutrition to nutritional causes and refer people to the CTC for treatment. Traditional practitioners represent the first line treatment of malnutrition in Malawi and are therefore, potentially a vital outreach and referral resource. This method of case finding could be sustainable.
- There are now a large number of trained community and government health workers who understand OTP protocols and are able to implement them, and a widespread network of clinics that are already delivering the OTP protocol every week with minimal input from Concern staff.
- There are three stabilisation centres run by local partners that provide high quality phase one care.
- Links are developing between CTC and general strategies being developed in Malawi for the support of HIV affected people.
- Now that RUTF local production is well established, there is good potential to make production self-sustaining by using cheaper local ingredients, such as soya beans and chickpeas.
- The reputation of Concern and of the CTC programme within Dowa and at the MoH in Lilongwe is now very good. The success of the programme has generated a sense of pride in all those who have been involved in its implementation. As a result, the MoH at national level is keen for CTC to expand to other districts and the Dowa District Health Office is enthusiastic to establish the programme in the longer term.
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:
- Integrating delivery into community-based systems. A Valid anthropologist will explore possible mechanisms for community-based transport systems in Dowa.
- 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.
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)
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:
- CTC provides a mechanism by which people can be cared for in their homes. The opportunity costs associated with home care are less, which could help households and communities affected by HIV/AIDS maintain economic productivity. Care and psycho-social support are also easier to provide in familiar surroundings.
- By treating common complications of HIV/AIDS, such as acute malnutrition, in the home rather than in hospitals or TFCs, CTC has the potential to decrease the frequency and shorten the duration of inpatient admissions, helping to relieve pressure on hospitals. In addition, maintaining people in their home environment reduces exposure to foreign pathogens and should reduce the frequency of nosocomial infections.
- The programme provides new, specially designed, therapeutic diets and medical protocols. There is emerging evidence that the provision of high quality therapeutic foods of a high energy density and an optimal balance of essential micro-nutrients prolong productive life and increases the time before HIV/AIDS leads to illness and death.
- A large proportion of the CTC caseload already comprises people living with HIV/AIDS (PLWHA). A previous study showed that approximately one third of severely malnourished children admitted to a central Malawi NRU were HIV positive3. The study took place at the height of the hungry season and the proportion of admissions with HIV would be expected to be higher in the non-hunger periods. HIV infected children are found within families already affected by HIV, therefore using CTC as an entry point could focus initial interventions towards HIV affected families.
- CTC can provide an entry point for health care workers to establish a presence at community level and give them space to plan interventions. This is important as the stigma attached to HIV/AIDS in Malawi society makes identifying affected families very difficult. At the same time, experience has shown that interventions that involve spending long periods researching and planning, without providing visible assistance rapidly, become unpopular in Malawian villages.
- CTC identifies and develops existing social support networks. Malawi and Bantu culture is based around the interdependence of individual, family and village. Caring for people in their community, instead of removing them to hospital, is more culturally acceptable.
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.
3.3 CTC in North Darfur, North Sudan: challenges of implementation
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 state lies 1000 km to the west of Khartoum. It is an area the size of France but is inhabited by only 1.4 million people. The state has considerable variation in vegetation, ranging from desert in the north (average annual rainfall of less than 100 mm), to arable land in the south (average annual rainfall of 100 - 300 mm).
The state is divided into six food economy zones, each representing an area where a different livelihood strategy is dominant. The majority of the population practice traditional, subsistence-orientated rain fed agriculture, predominantly of millet. In addition to subsistence farming, there are pastoralist communities who depend on camels, cattle, sheep and goats, and cash crop farmers who cultivate chewing tobacco, sesame, groundnuts, vegetable and watermelon seeds.
The area has a long history of severe food shortages. Major famine, resulting in widespread loss of life, occurred in the late 18th century, 1913-14 and more recently in 1984 - 85. Since this time, there have been cyclical episodes of drought, which have gradually eroded traditional coping mechanisms. In October 2000, annual assessments of food needs concluded that crop production in two thirds of the North Darfur villages was poor or very poor. Subsequently, nutritional surveys implemented by Save the Children UK identified rates of acute malnutrition of > 20% in the under 5 population, and a severe food security situation.
In response to this situation, SC UK, with support from Valid International, began implementing a community based therapeutic and supplementary feeding programme, sited in ten of the worst affected districts. The programme was very decentralised, where 104 distribution sites allowed beneficiaries good access to treatment without requiring them to spend prolonged periods away from their fields. Six mobile teams assessed children and provided medical and nutritional treatment at weekly outpatient sites while a network of community nutrition workers screened and followed up children in the villages.
This programme was a short term emergency response to high levels of acute malnutrition. Although it allowed local structures and communities to experience the benefits of such a decentralised approach, it was not without consequences. The sudden programme closure was a de-motivational force for the many community workers and health staff trained to work on the programme. In addition, such a short timeframe does not make efficient use of the high inputs required to train and organise a large field team.
Revisiting CTC in North Dafur
In 2001, annual food needs assessments in North Darfur once again predicted large shortfalls in food availability for 2002. Following nutritional survey assessments in May 2002, SC UK and Valid International again began implementation of an emergency nutrition response. Evaluations of the previous year's community based therapeutic and supplementary feeding programme had highlighted a number of potential advantages for North Darfur over a more centre based treatment programme:
- Decentralisation of treatment sites improves access for a target population who are widely dispersed over a large target area.
- Minimal existing capacity in local health structures favours the set up of small, simple units rather than larger, more resource intensive centres.
- The home-based treatment regimen requires much shorter stays in centres. This reduces disruption to subsistence farming and other activities in the home.
The same approach was therefore adopted for intervention in 2002. Based on recommendations made in the 2001 programme's evaluations, some adaptations were made in 2002 to programme methods and protocols.
A team of four SC UK national staff (managers and nutritionists) and one expatriate advisor, trained 16 field staff and 20 staff from local health structures in the first three weeks of the programme. During the subsequent three week period, the programme scaled up to operate through a system of 57 decentralised distribution sites, positioned strategically to maximise beneficiary access across the target area. From these sites, the SC UK field staff conducted anthropometric screening to identify patients, and administer nutritional and medical treatment for all those registered on the programme. A network of community nutrition workers (one from each village in the target area) provides follow-up support at home. A high proportion of these workers had been trained during the previous year's programme and were keen to be involved in the intervention again. This made the re-activation of community screening and follow-up easier as both staff and beneficiaries were already familiar with the programme's objectives and methodologies. SC UK also supported four small stabilisation centres (SCs). Based in local health structures, they provided phase 1 care only to children with severe complicated malnutrition whose carers agreed to their being admitted as inpatients.
|Table 10: Combined SC and OTP Outcomes (March 2003)|
*Transfer: The high transfer rate at this stage of the programme is predominantly the result of a protocol introduced to identify children demonstrating poor weight gain. These children were all transferred back to a stabilisation centre in order that any underlying infection could be treated and weight gain improved before programme end, when all children were to be discharged.
|Table 11: The proportion of children in the community screened|
|District||% coverage from CNW reports (Nov 2003)||% coverage from mid-term coverage survey (Nov 2003)|
Key programme activities
Phase 1 care in a rural hospital in Darfur, North Sudan. Figure 2. Pictorial card
Dry supplementary feeding is provided for all moderately malnourished children under five years old. Each child receives 4kg of a fortified blended food (UNIMIX) mixed with oil and sugar, according to national and international protocols.
Medical screening and treatment of all malnourished children is carried out, with subsequent referral for those with complicated malnutrition who are too sick to be managed at home and agree to a period of inpatient admission.
Each distribution team includes a medical assistant who screens patients for acute illness, verifies measles vaccination and vitamin A status and provides a single curative dose of an anti-worm drug. Children found to be ill or unvaccinated are referred to the nearest clinic or dispensary.
Box 1 Key aspects of treatment in the OTP
Nutritional and medical treatment
On admission to the CTC programme, all patients undergo a medical screening and receive medication according to a standard protocol based on that recommended by WHO. After their medical examination and registration, each child receives on average 4kg of Ready to Use Therapeutic Food (RUTF) providing 1500 kcal of energy and 36.5 g of protein /day, as well as 4kg of UNIMIX. Each child returns to the same distribution site every week to be assessed by the medical assistant and to receive a ration of RUTF and UNIMIX. If a child's medical or nutritional status deteriorates, he is referred back to a SC for treatment.
Education and follow-up
On admission, patients are introduced to the community nutrition worker (CNW) who lives in their village. He/she discusses an education message sheet with the mother that focuses on important practices regarding the feeding and caring of the sick child at home. The CNW reinforces this initial education during home visits as well as making a general assessment of the patient's progress. A key tool in this process is the mother-CNW, pictorial card (see figure 2). This is given to the mother at admission during discussion of important care practices for children suffering from malnutrition. She is asked to fill in the form each day by colouring the appropriate box if the child demonstrates the sign or symptom during that day. This form then forms the focus for discussion during home-visits when CNWs give advice and support in relevant areas. Although the impact of this card on recovery has not yet been examined systematically, the CTC programme team and CNWs feel that it is a useful tool to encourage involvement of the mother in the recovery progress of her child. Evaluation of the value of this card is planned during future programme assessments.
Patients are discharged from the OTP once the field staff have confirmed their Weight-for-Height is > 85% of the reference weight-for-height for two consecutive weeks, and that they are free from infective disease. After discharge, every child is admitted into the supplementary feeding.
An OTP is available for all children under five years with uncomplicated severe malnutrition. The programme team identify all patients who are severely malnourished. After identification, they will either register them into the OTP or refer them to one of the four SCs. Whether the child is referred to the OTP or SC depends on the physical condition of the child, appetite, existing capacity at referral centres and the agreement of the mother for the child to go to inpatient care. Key elements of the treatment of those admitted to the OTP are outlined in Box 1. Treatment in SCs is based on the standard WHO inpatient treatment protocols for initial re-feeding (phase 1) and transition phase. This includes the use of formula milks (F75 and F100) adapted for the treatment of severe malnutrition and systematic medical treatment.
However, instead of transferring children in to a phase two protocol within the SC (as recommended by WHO), children are discharged from the SC into the OTP when their appetite has returned and infection is under control. This speeds up patient turn around in the SC, making them less crowded and allowing a good staff to patient ratio. Depending on the preference of the carer, this also allows the carer and their child to return to the rest of the family as soon as possible.
The challenging landscape of Darfur North.
At March 2003, outcome indicators from the CTC programme in Darfur compared well with the Sphere Project's international standards for therapeutic care (see table 10).
Using the nutritional surveys conducted during the implementation of this programme, it was difficult to measure coverage with any precision. However it can be confidently stated that overall, coverage (measured in March 2003) at least met the new international Sphere standard of >50% for rural communities. In the context of the scale of North Darfur and the widely dispersed and pastoral population, this is quite an achievement for a selective feeding programme, especially given the number of children screened by the programme team in the first 3 months of implementation (table 11).
The mid-term coverage survey showed that in all Districts, apart from El Malha, a high percentage of under 5s had been screened at least once during the past 3 months. Figures taken from the CNW weekly reporting at the end of November also show high results.
Future challenges for CTC in North Darfur
Cost versus coverage
One of the OTP decentralised distribution sites in Darfur, North Sudan.
Transportation of UNIMIX for the OTP and SFP programmes in Darfur, North Sudan.
The North Darfur programme highlighted the issue of diminishing returns in the balance between coverage and cost. To improve accessibility for both beneficiaries to the OTP sites and for CNWs to their target population, the number of districts and the number of CNWs could be increased. However, in a context such as Darfur, where large distances exist between very small centres of population, the present programme systems could not expand to reach all those in need without huge logistic overheads. The experiences of the distribution centre in El Malha demonstrate this. Here, 45% of children registered from this small community came from the village in which the distribution site was operating. The seven other villages covered by this OTP site were between 2 and 6 hours away by donkey. House to house visits in two of these outlying villages found that only 10% of children under five in households had been visited by a CNW. Under present programme systems, it is likely that some trade-offs for coverage against cost have to be made here. This highlights a limitation in the present 'centre working outwards' model of CTC implementation. Work is currently ongoing to develop models of 'CTC in situ', wherein local communities are responsible for case selection and the delivery of OTP protocols (see section 2).
Integration of CTC into community based health and referral systems
Integration is an important principle in CTC (see section 2). If capacity can be adequately transferred to the affected population and the service providers, then there will be less need for externally driven responses in future. Save the Children in Darfur already relies entirely on Darfur based national staff to run the emergency feeding programmes. After a CTC programme in the same area in 2001, CNWs employed in 2001 were rehired in 2002. An attempt was made to second the same MoH staff again in 2002, but MoH insisted that other staff be given this opportunity. However, implementing the North Darfur CTC programme required very strong logistics in order to deliver the feeding programme inputs (i.e. drugs, Plumpynut, F75 etc) and the trained staff to the distribution points.
Health care systems in Darfur have a weak infrastructure and are very poorly resourced. It seems unlikely therefore, that these systems would be able to sustain emergency CTC services without considerable external facilitation. However, CTC has significantly increased capacity within MoH staff and community based workers for the identification, treatment and follow up of severe malnutrition. In addition, the positive attitude towards CTC created during the 2001 and 2002 experience has generated an enthusiasm and demand for CTC from local staff, health workers and the general population. This makes it a lot easier for external support agencies such as SC UK to re-activate emergency CTC interventions in the future.
In the longer term, case finding, referral and follow up might be integrated into community-based systems that require a less intensive, but longer term, support. This could include community-based surveillance and early warning systems that would use many of the local people with experience of CTC.
3.4 CTC in South Sudan - A Comparison of Agency Approaches and the Dilemmas Involved
Tanya Khara (Valid International), Jennifer Martin (Concern Worldwide), Ed Walker (Tearfund)
In 2003 both Concern Worldwide and Tearfund asked Valid International to support them in the setting-up of CTC programmes to address high rates of acute malnutrition in South Sudan1. Initially questions came both from within Valid and the NGOs themselves. How would teams receive the new approach? Would the decentralised nature of CTC work in such a logistically challenging setting? How would severely malnourished children recover at home given the famously egalitarian sharing culture of the Dinka? What were the implications of the lack of health services in South Sudan on the CTC principle of sectoral integration?
Both Tearfund and Concern programme areas are in
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Kate Golden, Tanya Khara, Kate Sadler, Alem Abay, Anna Taylor, Jennifer Martin and Ed Walker (). Case Studies (Special Supplement 2). Supplement 2: Community-based Therapeutic Care (CTC), November 2004. p14. www.ennonline.net/fex/102/chapter3