Technical and Management issues within CTC (Special Supplement 2)

4.1 CTC from Scratch - Tear Fund in South Sudan

By Ed Walker (Tearfund)

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

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.

Table 13: Outcomes of Tearfund South Sudan CTC Programme
Exit	SC		OTP		Combined
	n	%	n	%	n	%
Discharge	216	93.5%	522	78.1%	522	81.8%
Default	-	-	98	14.7%	98	15.4%
Death	6	2.6%	3	0.4%	9	1.4%
Transfer	9	3.9%	45	6.7%	9	1.4%
Total	231	-	668		638
Registered on closure*		-	58		58

 

The Future

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.

4.2 Adopting CTC from Scratch in Ethiopia

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 response to the 2003 food crisis. Historically Sidama was one of the most food secure zones of Ethiopia, classically a rich coffee growing area, situated in the enset¹-belt of Ethiopia. Over the last few years, however, erratic rainfall associated with an exhausted economy has led to failing agriculture, decline of coffee and livestock markets, reduction in land holdings and subsequently, threatened lives and livelihoods. Other contextual factors in the region include inadequate health access, inappropriate child feeding and caring practices, poor water and sanitation and high population pressure. During 2003, these factors combined to produce a rapid deterioration in the nutritional status of the population. A nutrition survey carried out in Awassa Zuria district in April 2003, gave alarming results² and triggered our emergency response.

SC-US started health and nutrition response activities on April 20, 2003 and over the next seven months, opened 12 centrebased Therapeutic Feeding Centres (TFCs). These were followed by three outpatient therapeutic programme (OTP) sites, and eight supplementary feeding programme (SFP) sites in 11 woredas.

CTC Implementation

On the first of August 2003, SC-US opened the first therapeutic feeding centre (TFC) at the Malgano health post compound in Hulla Woreda. This centre admitted 357 severely malnourished children during the first six weeks of opening, pushing its capacity limits to a critical level. In response, in mid- September, with the assistance of Valid International, SC-US transformed the existing nutrition programme to a Communitybased Therapeutic Care (CTC) programme. The team chose Hulla Woreda as the pilot site because the TFC was overcrowded and there was a shortage of water (2.6 litres per beneficiary, well below Sphere standards of 20 litres water/per day/per person) and collapsed latrines. The SFP was also about to be opened in Hulla and it was felt that the conversion of the therapeutic feeding centre (TFC) to a stabilisation centre (SC), and integrating an outpatient therapeutic feeding (OTP) and outreach programmes with the SFP, was a logical step.

The neighbouring districts of Arbegona and Bensa started CTC later, in October and November 2003, respectively. Figure 3 shows the map of the three districts with OTP/SFP distribution sites. All of the CTC programmes used the single, Hulla-based stabilization centre for referral of medically complicated cases. In each site, the CTC programmes included an extensive health education element, addressing child nutrition, hygiene, malaria prevention and control, intergrated management of HIV/AIDS and childhood diseases for beneficiaries and communities. The education element included traditional leaders, health workers, traditional healers and birth attendants. In addition, food security strategies were discussed and promoted involving Ministry of Agriculture extension workers.

Programme Results

By February 2004 1,470 severely malnourished beneficiaries had been treated in the OTP, of which only 264 (18%) had to be admitted to the SC because of complications. In addition, 5,558 moderately malnourished beneficiaries had been treated in the three SFPs. Important increases in beneficiary numbers came as a result of intensive community sensitisation, extension of active case-finding and outreach activities, and the opening of new decentralised distribution sites. Figures 4 and 5 show the monthly OTP and TFC/SC admissions and discharges, while table 14 summarises some of the performance indicators for all components of the CTC programme.

In December 2003, Valid International conducted an anthropological survey in Hulla district, to determine the acceptability of the CTC programme to the beneficiaries and strategies for improving coverage. The survey revealed that no systematic barriers to the programme existed. In addition, the community showed a remarkable consistency in understanding the types of malnutrition and the need for referral.

In January 2004, Valid International conducted a coverage survey, using the centric systematic area sampling (CSAS) approach to assess CTC programme coverage in Hulla and Arbegona districts. The coverage results were excellent, OTP coverage was 78.3% and SFP coverage 86.8%. The success of the CTC programme in accessing the population can be attributed mainly to the intensive outreach programme, where outreach workers closely monitored children of affected communities and provided health education at grass root level.

Lessons Learned

Transition to community-based intervention

During the peak of the food crisis, the response activities were concentrated on saving lives. Prior to CTC, severe malnutrition was treated as a deadly individual clinical condition, disregarding the needs of the wider family or community. The opening of many centres initiated a growing concern within the SC-US team about creating parallel structures, without involving and empowering communities or building upon existing community structures, such as health posts, EPI teams, community health workers. The momentum was created within the team to look for a more communitybased response and therefore, a more sustainable approach.

Perception at the community level

No community resistance was encountered when transitioning from TFC to OTP, apart from among the TFC staff, who feared losing their jobs. Carers and community leaders could see the valuable reduction in opportunity costs and therefore, the potential positive impact of the home-based approach on the families and the community in general, particularly as the planting season was starting. During the first days of CTC start-up, caregivers were given the choice of joining the outpatient care programme or staying in the centre. All caregivers opted for going home. An informal poll was taken a few weeks later, among outpatient caregivers who previously had been in centre-based care. This revealed that the great majority of caregivers were satisfied with the new type of home treatment. A major recognised advantage was the ability for caregivers to participate in resolving the malnutrition themselves, "I start to live without worry", "My heart rested".

Table 14: Performance indicators for Hulla, Arbegona and Bensa CTC programmes (October 03 to February 04)
Exit	SC	%	OTP	%	Combined	%
Discharge	201	87.7%	728	86.6%	331	77%
Default	1	0.4%	37	4.4%	60	14%
Death	6	2.6%	5	0.6%	0	-
Transfer*	17	7.4%	71	8.4%	39	9%
Non-recovered	4	1.7%	0	-	0	-
Total	229	100%	841	100%	430	100%
Still in project	4		391		3141

* This includes children transferred to the TFC or to the Hospital due to deterioration

Donor and government interest

At an early stage of the 2003 emergency response, UNICEF implemented a nation-wide training programme on the inpatient management of the severely malnourished. In June 2003, a consensus building meeting, including government officials, UN/NGOs, academics and donors, agreed the adoption of the centre-based therapeutic feeding centre model as the national protocol. Given the adoption of an exclusive inpatient strategy for the treatment of severe malnutrition in Ethiopia, and despite some interest, there was a generally circumspect attitude towards the community-based approach. Clinicians within the TFC programmes were initially reluctant to move towards the new CTC approach. However, once CTC was started, all the clinicians soon saw for themselves the positive outcome of the outpatient care and the vast community advantages possible, with little compromise on clinical treatment protocols. Government officials in SNNPR were flexible and showed increasing interest in the CTC implementation, expressing the wish to learn more and have access to research information or publications. Donors, who were consulted and informed prior to the change in strategy, were open-minded and encouraging and followed the CTC implementation with interest.

Sensitisation and empowerment of national services and the community

The CTC approach promotes intensive collaboration and sensitisation of local government, communities and families from the beginning. Our experience in the three districts has shown that increased involvement of local officials resulted in increased commitment and interest. Moreover, the innovative approach excited and empowered officials and broadened their interest to be involved in the nutrition response. At the community level, the programme involved local leaders, elders, traditional healers and birth attendants as active partners, hence increasing the flow of eligible beneficiaries into the programme. Conflict and distrust sometimes emerge during emergency nutrition programmes when the community is not aware of, or does not understand, the programme protocols. The Valid anthropological study in Hulla has shown that informing people about targeting, admission and discharge criteria, and malnutrition management provides a firm understanding and creates a momentum for achieving integration.

Sustainability in the longer term

The CTC programme strategy is based on the idea that emergency programmes should 'leave something behind', i.e. lead into development programming and sustainability.

The emergency programme of SC-US in Sidama may not develop into a longer-term development programme. Nevertheless, district officials of Arbegona and Bensa have expressed their commitment for health facilities to take over the outpatient programme and the transfer process has started. Unfortunately, Hulla district has very few staffed health posts so that integration into the local structures will be more difficult. However, at least the stabilisation centre is now fully integrated in the health centre of the district capital. An important factor adding considerably to CTC sustainability is that from the start, zonal and district health staff were seconded to the CTC programmes. We believe they are potential trained collaborators for the continuation of CTC, both in response to future emergencies (where NGO support may again be available) or for a longer term ministry operated programme in the future.

 

4.3 RUFT

4.3.1 Local Production of RUTF

By Dr Peter Fellows

Introduction

The development of RUTF has been an important factor facilitating the development of CTC. However at the moment, most RUTF is made in France, is marketed at a high cost and incurs considerable transport overheads to move it to the point of use. This is a major factor in increasing the cost and decreasing the applicability of CTC. To address this, the CTC programme has included substantial research into the development of locally produced RUTF.

Technologically, RUTF possesses a number of advantages over other foods, making it an excellent product for local production and central to the implementation of CTC. It has a low water activity (Aw), which not only makes it microbiologically safe but also means that simple packaging can be used because it does not require protection against microbial contamination. Unlike some other products, such as highenergy biscuits, the paste does not require protection against crushing or other damage during transport to distribution sites or at the homes of beneficiaries. Even if it is contaminated (e.g. by children's dirty fingers), pathogens cannot grow in it. These are major benefits in the context of local production, where modern processing facilities and the availability of more sophisticated packaging materials may be limited. The product can be stored at ambient temperatures without the need for refrigeration, and the 3-4 month shelf life at tropical temperatures is sufficient to distribute RUTF, hold stocks at distribution points and allow for a few weeks' supply to be given to mothers for home consumption.

RUTF is eaten directly without cooking or the need to be diluted with potentially contaminated water, and each pot has a standard food value, therefore making administration of doses easier for programme staff. Also most children can feed themselves and do not require their mother's help. Provided peanut butter is available, the process is a simple mixing operation that can be easily learned by unskilled operators, and requires a relatively low investment in equipment and facilities. The inherent microbiological safety also means that the level of control needed during processing and distribution is less rigorous than for many other protein-rich foods. Local RUTF production also offers the opportunity to stimulate agricultural production and widen the benefits to farmers in surrounding communities.

Over the last 2 years I have been working with the CTC research programme on the development of local production of RUTF. This article describes our first attempts at developing relatively large-scale local production in Malawi.

Local production in Malawi

The use and production of RUTF is not new in Malawi. The Moyo House unit at the Queen Elizabeth Hospital in Blantyre, working with the St Louis University of the USA has been using RUTF for the home treatment of severely malnourished children in the recovery phase of treatment since 2001. In 2002, the unit developed some small scale local production and conducted a trial demonstrating that the locally produced RUTF was equally effective in treating severe acute malnutrition as the imported Plumpy nut product (27).

First steps - sourcing ingredients and equipment

The ingredients used to make RUTF are peanut butter, sugar, oil, dried milk and a mineral-vitamin complex (CMV) (Figure 6). In all but a few countries, it is necessary to import dried milk and CMV, but local manufacturers of sugar and oil are likely to be found. To make RUTF without a major investment in equipment, it is necessary to identify a local supply of peanut butter. Ideally, this would be an established food manufacturer that has experience of its production, quality assurance and also knowledge of the peanut market to ensure that high quality nuts are used. After investigating various options in Malawi it was concluded that Tambala Food Products Ltd. in Blantyre met these requirements. In Ethiopia, Valid and Concern staff have identified a potential producer that has experience of making medicines and has diversified into food manufacture with experience of the peanut market sector.

In Malawi we put systems in place to import dried milk and CMV, to purchase icing sugar and cooking oil from local suppliers, and to contract Tambala Foods to both produce peanut butter without added salt and produce the RUTF.

Using Tambala as the local supply of peanut butter removed the requirement for a peanut toaster and stone mill, meaning that to start local production the only significant equipment that we had to purchase were four 40-litre capacity planetary mixers. Once they had cleared the Customs and Excise procedures, the mixers were installed at Tambala's factory.

Factory audit, analyses and staff training

Because this was the first time that local production had been attempted, we needed to ensure that all potential problems were anticipated in relation to RUTF safety and composition. Three aspects were considered: an audit of the production facilities, processing methods and skills at Tambala; identification of independent analytical facilities; and training of production staff.

The audit of Tambala's operation included:

• Physical facilities (including the quality of the building used for production).
• Supplies of raw materials.
• Equipment and production facilities.
• Hygiene and sanitation procedures, cleaning routines, washing and toilet facilities etc.
• Production records and product labelling.
• Stock control procedures.
• Management of quality assurance.

I found that the company facilities, procedures and management were mostly suitable for RUTF production and suggested minor improvements to improve the factory buildings. However, a potentially serious problem was discovered in the peanut supply. Although the company's peanut storage facilities were satisfactory, there was no system of traceability to the peanut farmers or distributors. This meant that managers could not ensure correct post-harvest handling and storage of nuts before they were purchased. The risk was that incorrect procedures could result in aflatoxin contamination if moulds had been allowed to grow on incorrectly stored nuts. We therefore decided to implement three actions:

• As the nuts for a year's production had already been harvested and were stored in Tambala's warehouse, we took a representative sample for aflatoxin analysis.
• An additional inspection stage was introduced to the production process to remove discoloured or mouldy nuts
• We requested Tambala to introduce traceability procedures for future nut purchases. The company will introduce improvements in the next buying season and train their buyers to offer guidance to farmers on post-harvest storage.

The company had only basic analytical facilities and it was therefore necessary to identify an independent laboratory that could verify the quality of ingredients and RUTF, and confirm that routine quality assurance procedures were followed. Analytical facilities were identified in universities, research institutes and the Malawi Bureau of Standards. In order to assess the accuracy and reliability of results produced by these institutions, we conducted a study in which the same materials were given to four laboratories; three in Malawi and one in UK, and the results were compared. We also assessed the comparative costs of analysis, and the efficiency of the laboratories in producing timely results. Samples of oil were analysed for free fatty acids, Iodine and Peroxide values, proximate analyses were made on groundnuts, peanut butter and RUTF, and a microbiological analysis of RUTF was made. Groundnuts and RUTF were also tested for aflatoxins and Oxford Brookes University checked the Aw of the RUTF. Chancellor College in Zomba and Malawi Bureau of Standards in Blantyre each produced results in a timely way that were in agreement with the UK laboratory at Oxford Brookes University, and each had similar costs. The results indicated that the ingredients and RUTF had a satisfactory chemical composition and microbiological quality when compared to standards developed for PlumpyNutË by Nutriset .

The production process for RUTF is a straightforward mixing operation, but operators must ensure that exactly the same amounts of ingredients are added to each batch to ensure a standard nutritional value. Production supervisors also need to understand proper process control, cleaning schedules for the production unit, stock rotation and record keeping. To assist in training production staff and managers who were not familiar with the product a manual was produced. None of this is particularly arduous for a food technologist or for managers at Tambala who were familiar with these aspects of food production, but we also wanted to produce RUTF in a village unit where food technology skills and knowledge would be far more basic. If rural staff are unaccustomed to these procedures the lack of knowledge could cause quality problems, and I therefore included basic management aspects in the production manual. Before starting production, four Tambala staff were trained with assistance from staff at the Community Health Dept., College of Medicine, Queen Elizabeth Central Hospital, Blantyre and the St Louis Project, where RUTF had been produced on a small scale for a number of months. As part of the training, staff constructed calibrated containers to measure ingredients. This is not only faster than weighing, but enables production without the need for accurate and expensive scales.

When the equipment, ingredients, analytical checks and staff training were in place, a contract was drawn up between Concern Worldwide and Tambala for 6 months' production. The contract covered amounts to be produced, delivery times, payments, raw material supplies and quality assurance. Tambala started production in February 2003. Our intention was to increase production each month from 6 tonnes to 20 tonnes, but a reduction in demand meant that the contract was revised downwards. There were some initial teething problems, but Tambala largely met the terms of the contract and supplied Concern Worldwide with RUTF of the correct quality and volumes. In April a routine analysis picked up high levels of aflatoxin in a sample. This is likely to have arisen from a small number of heavily contaminated peanuts that escaped the routine inspection stage. In response Tambala reinforced their inspection procedures to visually examine all nuts, which has cured the problem to date. Other contracts were made with the St. Louis Project and later with other agencies including MSF.

Village scale production

Producing RUTF at the village level has many potential advantages. It is likely to reduce costs and improve cost efficiency as the funds from donors can be used directly in the target district without incurring European or capital city production and transportation overheads. Local production should also help to link CTC more effectively to agriculture and food security interventions. This is particularly true for new recipe RUTFs which aim to make RUTF from local crops without the need for imported milk powder. Local production is likely to be more responsive to local needs and will hopefully engender a greater feeling of local ownership over CTC programmes. Given the wide range of applications for RUTF, local production also has the potential to generate income for small local manufacturers such as district hospitals.

Given all these potential advantages we decided to see whether the process followed at Tambala could be replicated in a village production unit, and selected the Nambuma Mission Hospital as the first site. Mission staff prepared a small production room and three staff were trained by Tambala production staff in Blantyre. In January 2003 an audit was conducted of the production site that identified some minor improvements required to upgrade the facility. In February 2003 we moved one of the mixers to the mission from Tambala and production started within one hour of its arrival. As part of this exercise, three studies were undertaken:

• To determine whether absence of pre-mixing dry ingredients by hand had any effect on the uniformity of RUTF. We wanted to check this as the pre-mixing could be a problem in village production, because the operator leans over a mixing bin and hair or other contaminants could be introduced. It would also simplify the process if this stage were omitted.
• To determine whether the mixing time and speeds were adequate to produce a uniform product using the mixers chosen for local production.
• To determine whether contamination of RUTF by children's dirty fingers affected the microbial composition.

We found that pre-mixing is required to achieve uniform mixture, and that the chosen mixers adequately mixed the ingredients using the selected speeds and mixing times. Microbiological analyses revealed no pathogens in the samples exposed to contamination.

The unit is producing 100-160 kg per day, which meets the mission needs and supplies all the nearby CTC distribution centres in Dowa. All ingredients and packaging are transported to the mission because the quality of oil available in the village is inadequate and other ingredients are not locally available.

Future directions

The developments to date have shown that a village-scale production unit can produce high quality RUTF in the required amounts for one or more NRUs and a moderately sized OTP programme. Already some of the benefits of local production have been realised including lower costs compared to the imported product, greater control over supplies, the creation of local employment and a new income stream for the Nambuma mission. Concern is now working to develop the extent and quality of local peanut farming to support this production and this should provide substantial benefits to local farmers.

We now plan to study the economics, logistics and relative cost/benefits of supplying all materials to village-based production units compared to supplying packaged RUTF from Tambala. If village-scale production is selected as a preferred option, there are a number of ways in which future developments could take place, including:

• Units that are operated by an NGO, which provides staff and supplies ingredients and other process inputs.
• Units that are semi-commercial, supplying RUTF on contract to NGOs, the Ministry of Health or other agencies, but with support from an NGO.
• Units that are fully commercial, with all inputs paid for by sales of RUTF on the open market.

At present the second approach appears to be the most feasible as it retains NGO control over RUTF supplies and quality. However, future developments that may result in RUTF becoming available nationally in Malawi via the Ministry of Health may have a significant bearing on the development of village-scale production.

4.3.2 Alternative RUTF formulations

By Steve Collins & Jeya Henry

Developing CTC programmes that use Ready to Use Therapeutic Food (RUTF) made locally, from locally available produce, and used to treat malnutrition and HIV amongst the local population, is an important vision for the future of CTC. This article describes research work into developing new RUTFs.

Basis of RUTF

To date, the commercial forms of RUTF are either BP100, a compressed biscuit made by Compact, or Plumpy nut, an oil based paste developed by IRD and Nutriset in France (22). Technology to make compressed biscuits is complicated and expensive and not transferable to small scale manufacturers in developing countries. By contrast, oil based pastes such as Plumpy'Nut can be made using simple technology that is easily transferable to small scale local producers in developing countries. Plumpy'Nut is made from peanuts, sugar, milk powder, vegetable oil and a vitamin mineral mixture. Although this combination of ingredients produces a product that is very well suited to the treatment of acute malnutrition, the recipe has several features that decrease its suitability as a candidate for widespread local production. Milk powder is expensive and often must be imported - in Malawi the cost of milk powder represents over half the cost of the final RUTF. Peanuts are also notorious for being contaminated with aflatoxin and this greatly complicates the quality control of small scale production. There is also growing concern about allergic reaction to peanut and their high phytate:zinc ratio (which increases the risks of binding all micronutrients) thereby reducing their suitability.

The idea of developing local, low cost RUTF, rich in protein, energy dense and suitable for feeding to young children and other vulnerable groups, arose in the early 1950s largely due to the work of Jelliffe (1955) and Brock (1961). The simplest recipe for RUTF is one which has only two ingredients, for example a cereal or root mixed with a legume. However, other foods must be added to this basic mix in order to make a multimix that is nutritionally suitable for the treatment of acute malnutrition. A nutritionally suitable multimix for RUTF has four basic ingredients:

1. A staple as the main ingredient - preferably a cereal.
2. A protein supplement from a plant or animal food - beans, groundnuts, milks, meats, chicken, fish, eggs, etc. To be practical such foods must be low-cost, and this requirement has pushed development towards legumes and oilseed as these are cheaper than products containing milk or other animal products.
3. A vitamin and mineral supplement - a vegetable and/or fruit.
4. An energy supplement - fat, oil or sugar to increase the energy concentration of the mix.

In addition, an ideal RUTF formulation must have the following attributes:

• Good nutritional quality (i.e. protein, energy and micronutrient content)
• Long shelf life
• Highly palatable with a good taste
• A consistency and texture suitable for feeding to children
• Require no additional processing prior to feeding
• Amino acid complementation for maximum protein quality
• Product stability
• Ingredients should be easily available in developing countries

Product development

Numerous cereal, legume and oilseed mixtures were evaluated on the basis of the above criteria. In particular, efforts were made to combine the various cereal, legume and oilseed mixtures to maximise the protein quality, attempting to offset any essential amino acid deficiencies in one ingredient by combining it with another ingredient that was high in that particular amino acid. This process led to a list of 13 products that had reasonable theoretical properties. Following numerous products development trials, the list was reduced to three potential alternatives. The foods were prepared from roasted or processed ingredients with total exclusion of water. They had low dietary bulk, low potential for bacterial contamination and were ready to eat without cooking. Similarly, the commodities chosen had the most appropriate energy density and high biological value of protein. Moreover, the proposed foods had an optimal physical characteristic of being soft in consistency, easy to swallow and suitable for infant feeding¹. The three most suitable recipes were:

Rice - Sesame' RUTF 1

Ingredients: Roasted rice flour, roasted sesame seeds paste, Soyamin 90, sunflower oil, icing sugar, vitamin and mineral premix (CMV therapeutique, Nutriset).

Quantities (%):

Roasted rice flour	20.0 %
Soyamin 90	8.0 %
Roasted sesame seeds paste	29.0 %
Sunflower oil	19.4 %
Icing sugar	22.0 %
Premix	1.6 %
Total	100.0 %

 

'Barley - Sesame' RUTF 2

Ingredients: Roasted pearl barley flour, roasted sesame seeds paste, Soyamin 90, sunflower oil, icing sugar, vitamin and mineral premix (CMV therapeutique, Nutriset).

Quantities (%):

Roasted pearl barley flour	15.0 %
Soyamin 90	9.0 %
Roasted sesame seeds paste	27.0 %
Sunflower oil	24.0 %
Icing sugar	23.4 %
Premix	1.6 %
Total	100.0 %

 

'Maize - Sesame' RUTF 3

Ingredients: Roasted sesame seeds paste, roasted maize flour, roasted chickpeas flour, sunflower oil, icing sugar, vitamin and mineral premix (CMV therapeutique, Nutriset).

Quantities (%):

Roasted maize flour	33.4 %
Roasted sesame seeds paste	27.0 %
Roasted chick peas flour	25.0 %
Sunflower oil	12.0 %
Icing sugar	15.0 %
Premix	1.6 %
Total	100.0 %

 

It is important to emphasise that the cereals, legumes and oilseeds were all roasted prior to the milling into flour, as the use of raw non-roasted commodities could lead to the presence of potentially high levels of anti-nutritional factors and phytates. In keeping with the recommendation of the UN nutritional standards (Codex) sunflower oil was used in all products in order to meet (n-3) and (n-6) fatty acids requirement. It is usually specified that at least 3 to 10% of total energy should be provided by (n-6) fatty acids and 0.3 to 2.5% by (n-3) fatty acids.

Table15: RUTF-1, RUTF-2, RUTF-3 and Nutriset Plumpy'nut® nutritional composition per 100g and percentage contribution to energy
Nutrients		RUTF-1	Energy	RUTF-2	Energy	RUTF-3	Energy	Plumpy'nut®*	Energy
		100g	%	100g	%	100g	%	100g	%
Energy**	kcal	551		567		512		530
Energy	kjoules	2307		2373		2142		2218
Protein	g	13.8	10	14.1	10	13.4	11	14.5	11
Carbohydrate***	g	43	31	39.9	28	50.2	39	43	32
Fat	g	36	59	39	62	28.6	50	33.5	57
Ash	g	4.3		3.9		4.9		4
Moisture	g	2.9		3.1		2.9		<5

*Protein and fat are reported to contribute 11% and 57% in energy input. Total energy is reported to be 530 kcal/100g and moisture < 5%.
**The energy has been calculated using Atwater factors.
***Carbohydrate is by difference assuming protein to be nitrogen (N) times 6.25.

Table 16: Mineral analysis for RUTF products
	RUTF-1	RUTF-1	RUTF-3	Plumpy'nut®
	mg/kg	mg/kg	mg/kg	mg/kg
Cu	2.1	2.1	1.8	1.7
Zn	10.9	10.9	10.2	13
Ca	338.1	338.1	209.8	310
Na	256.5	256.5	189.9	<290
Mg	118.4	118.4	119.1	86
Fe	5.6	5.6	4.4	12.45

 

Table 17: Water activity (aw) in 3 RUTF samples
RUTF samples	Water activity
Rice-Sesame (RUTF-1)	0.290
Barley-Sesame (RUTF-2)	0.279
Maize-Sesame (RUTF-3)	0.260
Plumpy'nut®	0.241

 

Analytical Studies

To ensure that the products were safe and appropriate for field testing, macro nutrient and micronutrient composition, water activity, levels of microbial contamination and indices of rancidity (free fatty acids and peroxide values) were tested. The results (presented in tables 15, 16, 17 and 18) demonstrated that the nutritional composition, with the exception of iron, of each of the new RUTFs is close to Nutriset's Plumpy'Nut®. The products are palatable, stable and microbiologically safe.

Using the basic formulation outlined above, it would be easy to alter the amount of macronutrient and/or micronutrient of the products by varying the oilseed-cereal-legume combinations and/or the mineral and vitamin mixture. The low level of iron could be easily rectified by increasing the level of iron added to the premix. Table 18 demonstrates that the three new products have low water activity, similar to that of dried coffee, and below the level required to support any form of bacterial or even fungal growth. This finding was supported by bacterial analysis that demonstrated that for all the pathogens tested, the results were within microbial specification for this type of food.

These studies demonstrate the potential of new RUTF, produced from locally available grains and legumes, without the addition of milk powder or peanuts. Eliminating milk powder and peanuts and using local grains should allow these products to be made very much more cheaply than the $3,500 USD / MT that Nutriset charge for Plumpy´nut®, and more cheaply than the $2,000 USD / MT cost of the locally made peanut-based equivalent in Malawi (see section 5.21). Clinical field trials are now being conducted in Malawi, to compare the effectiveness of these new RUTFs with locally made RUTFs that include peanuts and milk powder, in treating severely malnourished children.

Table 18: Interaction between aw and microbial proliferation in some foods
Water activity	Foods	Microorganisms
0.98	Fresh meats, Fish, vegetables, Milk	Most food spoilage and food-borne pathogenic organisms grow
0.85 - 0.60	Flour, cereals, Nuts	No pathogenic bacteria grow
0.60	Confectionery, noodles, dried Milk	Microorganisms do not multiply but can remain viable for long period
0.30 - 0.20	Biscuits, Instant coffee	No viable microbial growth

Source: Peter Fellows (2000)

Future developments

These new RUTFs are eaten uncooked and have a low water content. This makes them suitable vehicles to deliver not only vitamins/antioxidants, but also probiotics and prebiotics (see box).

Synbiotic enhanced RUTF, designed with high levels of certain micronutrients, have recently been shown to slow the progression of HIV/AIDS. These may have huge potential in the treatment of HIV/AIDS, as well as acute malnutrition and a whole range of other illnesses and post operative conditions associated with diarrhoea and wasting, in particular. The current trial in Malawi is therefore also examining the effect of adding a mixture of probiotic and prebiotics called Synbiotic 2000 forte (Medipharm AB, Kågeröd, Sweden) into the new RUTF. In this study it is planned to test the effectiveness of synbiotics in combination with RUTF, in the treatment of patients recovering from severe malnutrition. As severe acutely malnourished children have features of immuno-suppression similar to some of those found in HIV/AIDS, it is hoped that this study will also provide initial evidence into the feasibility of using RUTF-synbiotic combinations, to slow the progression of HIV.

 

4.4 New Method for Estimating Programme Coverage

By Mark Myatt

This article gives an overview of the coverage estimation method developed for the Community Therapeutic Care (CTC) Research Programme in Malawi¹.

Coverage is becoming an important indicator for monitoring and evaluating humanitarian interventions. Coverage indicators for selective feeding programmes were included in the SPHERE project's humanitarian guidelines for the first time in 2003². Current approaches to estimating therapeutic feeding programme coverage rely on the use of nutritional anthropometry surveys that commonly employ a two-stage cluster sampling strategy. Such surveys will be familiar to many humanitarian practitioners as 'thirty-by-thirty' surveys. Coverage is calculated either directly using survey data or indirectly using survey data, programme enrolment data, and population estimates. Both methods assume that coverage is similar throughout the entire survey area and both can provide only a single wide-area coverage estimate (see below).

The two-stage cluster-sampling approach uses population proportional sampling (PPS) in the first stage to select cluster locations and proximity sampling in the second stage to select households and children.

The PPS approach is unsatisfactory because:

• The bulk of data are collected from the most populous communities. This may leave areas of low populationdensity (i.e. those areas consisting of communities likely to be distant from