Integration in CTC (Special Supplement 2)

by Jamie Lee

Many of the articles in this supplement explore the concepts and practice of 'integration' within CTC programmes. A variety of meanings and values are attached to the word 'integration' in this context. Among these are:

• The sense that integration is what moves emergency programmes towards a more sustainable development stance.
• The connotation of a comprehensive (as opposed to vertical) approach, which may be ultimately more effective.
• Working with existing delivery structures, including western bio-medical health care systems and 'traditional' systems such as TBAs, traditional healers etc.

We could therefore say that integration takes place along several planes:

1. culturally, into 'traditional' institutions
2. sectorally, across programmes (e.g. HIV/AIDS into Nutrition)
3. institutionally, into host country delivery systems
4. temporally, between relief and development.

The virtues of integration do not necessarily stand up to scrutiny in every case and there may be good reasons in some settings for agencies to resist the call to integrate on any one of these planes. The question is: what type of integration - if any - is appropriate in a given situation? The articles in this section seek to offer some insight into this question by illustrating the extent to which integration has been possible within CTC programmes and the consequent effects of this.

5.1 'Cultural Integration'

5.1.1'Cultural integration' in CTC: Practical suggestions for project implementers

By Jamie Lee

The SPHERE guidelines touch only superficially on culture and the cultural acceptability of humanitarian assistance. However, in recent decades, the wider field of international health has produced a variety of initiatives intended to account for culture in the design and delivery of programmes. These include international research efforts in control of diarrhoeal disease, vitamin A deficiency and acute respiratory infections, and the promotion of family planning. The challenge posed by HIV/AIDS prevention, much of it focused around behavioural change, has further heightened the attention to culture. Thus, at least in the context of well-funded multi-country international health interventions, some form of integration into local cultural settings is becoming standard practice. However, the language of 'cultural integration' can be controversial. "Who", it might be asked, "is to be integrated into what, and on whose terms?" There is also concern about the focus on culture as a problem or obstacle to be overcome en route to compliance. Caution is required, if culture is not to become a stick with which we beat the 'victim'.

Since late 2002, CTC projects in Malawi, Ethiopia, and South Sudan have each tried to improve nutrition outcomes by undertaking an element of social or cultural research, in parallel with service delivery. Investigators have included specialized anthropologists as well as community development generalists, and African academics and practitioners as well as expatriates. The level of effort has ranged from rapid reconnaissance of two weeks, to more thorough ongoing investigations of several months duration. In each case, the underlying assumption has been that an appreciation of the beneficiary perspective on the project (its procedures, institutional alliances, demands and trade-offs of participation, and the acceptability of treatments) can improve access and impact. This approach is hardly new, but it remains underexploited in emergency programmes, where the ability to devote staff time and energy to non-core functions is still considered something of a luxury by many implementing agencies. This article tries to summarise some of the lessons and suggestions arising from this work¹.

Take time to understand the context of the project - how do interventions relate to the wider range of options and pressures facing local people?

This requires little in the way of specialized skills, being primarily a matter of creating opportunities to consult with beneficiaries and other service providers. The general objective is to achieve a 360 degree picture of the interactions that individuals have with other services, with an eye toward minimizing mixed messages or contradictions. Doing this in Malawi quickly revealed that many children being screened for CTC were already subject to monthly growth monitoring from village health workers during vaccination days. Conflicting indicators used in the two programmes was causing frustration, as mothers whose children had, for some time, been judged malnourished on a weight-for-age basis, thought they were finally to be assisted when CTC arrived. But, on attending CTC screenings, they found that the same child was being judged healthy on a MUAC or weight-for-height basis and refused admission. Coming on top of long waits and sometimes lengthy treks to attend the screenings, this generated some bitterness and undermined interest in the CTC programme: "had they not been told to do something for the health of their child?" "Why, having acted on this advice and come all this way, were they being told to go home empty-handed?" Relatively little input quickly allowed project staff to make sense of the depth of community frustration at the rejection of children from the CTC screenings and take steps to reduce it. Similar findings from Ethiopia and South Sudan have pushed CTC towards a better harmonization of admission indicators with GM programmes, and in some cases, towards using MUAC alone as a screening and admission indicator.

Develop an understanding of the words and phrases used locally to describe wasting and swelling in children.

In emphasizing community-wide coverage, CTC faces a dilemma: how to encourage wide participation of malnourished children at OTP and SFP screenings, without also attracting large numbers of the non-malnourished? Efforts at the outset to establish a clear and consistent message concerning eligibility help limit confusion, prevent project staff from being overwhelmed, and minimize the community disappointment and frustration resulting from non-admissions. But the particulars of such a message are not as obvious as they might seem. It has been found that it helps to devote specific attention to the local language concerning malnutrition. The term 'malnutrition' may undergo subtle shifts in meaning, as it is translated by the project into the language of beneficiaries (for instance, available local terms might stress the idea of food shortage over dietary quality). Even when terminology seems roughly equivalent, local beliefs sometimes ascribe causes other than poor nutrition to swelling or wasting in children. For example, in Chichewa-speaking areas of Malawi, swelling is believed to relate to the moral conduct of the parents. Consequently, when describing the target population it is best to refer directly to physical symptoms, rather than to issue a general call for "malnourished children". Even then, wasting and swelling may also be translated in a variety of ways, and where this is the case, discussions which centre around pictures of malnourished children can help to elicit the full range of local terms. Staff can then employ these terms in information meetings designed to explain the project to the community. This lesson, learned in Malawi, has enabled more recent CTC projects in Ethiopia to improve the rate of programme uptake and raise the ultimate coverage rates (see section 3.1).

List common beliefs concerning the causes and appropriate treatment of wasting and swelling.

An iterative process of discussion with local families can be used to list the names of conditions, perceived causes and common treatments, resulting in a composite picture of malnutrition from the perspective of local parents. This is usually sketchy and cannot hope to reproduce the cultural meaning of illness or healing that might result from true ethnographic study. However, experience has shown that it is often sufficient to reveal the points of divergence from biomedical practice.

The nature of the revealed differences can have implications for conducting CTC. Where there is association made between malnourished children and the moral conduct of their parents, for instance, case-finding and outreach need to be conducted with due regard for family and community sensitivities. Where there appears to be a long interval between local treatment of kwashiorkor or marasmus cases and their presentation, there may be opportunities to engage local folk practitioners in early case referral to the project. Where several types of healer appear to be involved in treating malnutrition, approaches to the 'traditional' health sector may need to be broadened beyond the minimal contacts (often with TBAs) established by clinical health services. This type of collaboration with folk practitioners is for the moment, more of a potential than an actual feature of CTC but, in both Malawi and Ethiopia, healers have proved to be surprisingly approachable. And as CTC looks beyond emergency interventions towards integration with longer-term programmes, there may be opportunities to explore with host communities the possibility of more effective linkages between folk and modern practitioners in the treatment of malnutrition.

Use information on local beliefs and practices to map out critical linkages with other services, where these exist.

An investigation of the treatment of kwashiorkor in Sidama, Ethiopia, revealed that food proscriptions may exacerbate malnutrition. This suggested an important focus for eventual nutrition education work. In other examples, from both Malawi and Ethiopia, discussions with mothers about marasmus pointed to early complementary feeding as a possible health concern. Further investigation revealed that complementary feeding, in turn, was conditioned by a variety of concerns - including the possible 'spoiling' of breast-milk through conception of a second child. Consequences for the child who consumed the spoiled milk were thought to include severe diarrhoea. This finding highlighted the need to complement standard CTC interventions with instruction for care-givers in the control of diarrhoeal disease and the production and timely introduction of complementary foods.

Once project messages have been clarified, consider whether there may be local formal and non-formal channels of communication that can be utilized to explain CTC objectives and procedures.

As a matter of first principle, the CTC approach attempts to align projects with existing clinical services (see section 5.3). These often have their own means of outreach to the community (Village Health Committees, Community Health Workers, and other extension agents). In addition, experience to date has shown that there are less obvious cultural channels of information, authority, and decision-making. In African settings, these are usually systems of authority, built around clan or lineage. The relationship of these systems to the official government apparatus has ranged from active collaboration in some countries, to uneasy accommodation in others. In Malawi, 'Traditional Authorities' (TAs) are on the payroll of the state, and in the early stages of CTC, found themselves in an awkward position, mediating between government workers and project staff on one hand, and frustrated communities on the other. Based upon the rapid investigation described above, effort were made to understand the causes of frustration, which resulted in the design of a handbill to guide project staff in a series of meetings with the TAs. By respecting the TAs, and by responding systematically to the concerns of their constituents it was possible to secure their cooperation in initiating a series of cascading meetings with allied village headmen. A rapid increase in coverage followed these meetings.

However, the mere existence of 'traditional' systems of communication and authority may not be sufficient reason to invoke them in every case. Agencies implementing CTC must weigh potential benefits against other considerations, including consequences to the existing order. Whereas relief agencies may think of their actions as neutral humanitarianism, deepening community involvement may be read by host governments as a political act beyond the purview of the agencies. In Ethiopia, where government exercises strong oversight of emergency nutrition activities, CTC implementers in one region opted not to approach tribal authorities due to the political climate, which was characterized by a pervasive fear of local ethnic nationalism on the part of local government. In this case, a network of project outreach workers was already doing an effective job of expanding coverage, so forgoing contact with traditional leaders was not a significant handicap.

Understand the limitations of qualitative research.

Qualitative methods offer insights into beliefs and practices but cannot by themselves assign priority to project responses. Research has helped to illuminate a variety of ways in which local people may respond to symptoms, or to CTC interventions. However, these insights are not usually sufficient to suggest the most efficient use of project resources. For example, it is relatively easy, with minimal qualitative research outlays, to catalogue local names for symptoms of severe malnutrition and use these to foster communication and understanding. However, acting on other observations might not prove to be cost efficient. Developing a culturally appropriate nutrition education campaign which addresses complementary infant feeding issues would, for instance, be a multi-stage process requiring considerable resources. Before doing this, qualitative insights would need to be paired with rudimentary quantitative methods, in order to assess the true magnitude of the problem. The resource implications of such alternative programming choices are likely to loom larger, as CTC moves beyond an initial emphasis on coverage towards the integration of nutrition into longer-term care.

5.1.2 Community Participation and Mobilisation in CTC

By Saul Guerrero & Tanya Khara (Valid International)

Over the last few years of CTC development, the process of community participation and mobilisation has become central to the search for more efficient and more sustainable strategies to manage malnutrition. There have been major positive benefits associated with prioritising community participation including improved coverage, increased speed of uptake and therefore, impact, and increased community ownership over CTC programmes, making them easier to hand over. Importantly, enabling the implementation of more culturally-appropriate interventions through CTC, maximises the positive impacts for local people and minimises the opportunity costs to them.

In the short term, community participation can lead to the joint identification of logistical constraints, sites and target areas, as well as the mutual identification of programme opportunities and threats. In the longer term, community participation in programme activities promotes more sustainable programme design and provides a platform from which the communities can demand similar services from the existing national structures. Experiences to date have demonstrated that pressure from communities and their representatives is a necessary factor in promoting institutional integration and longer term, more sustainable programmes.

Experience acquired over the last few years of CTC implementation has led to a gradual improvement in understanding the role of community participation in:

1. Programme design and planning
2. Programme implementation
3. Hand over to more sustainable, local structures

This improved understanding has helped develop the CTC's public health approach. In particular, it has become clear that a high prioritisation of community integration and exploration of the relationship between implementers and beneficiary communities, is vital to programme success. Improvements in programme design, based on these findings, has allowed CTC to reach potential beneficiaries in a more effective, timely and appropriate manner. While the lessons learned are often contextspecific, they highlight the shift in focus from the passive recognition of community mobilisation as important, to actively seeking community integration into programme activities.

1. Programme design and planning

The involvement of existing social, religious, political and economic structures and key figures in the planning stages of the CTC programme can serve as the springboard for community integration into programme activities. By building upon the implementer's knowledge and experience in the area of operation, traditional channels of communication can be utilised to clearly lay out programme objectives and criteria at an early stage and, thus, prevent confusion among potential beneficiaries. Engagement with communities during programme planning can also facilitate the early identification of existing social networks (to be utilised in the mobilisation efforts) as well as the joint identification of sites, target areas, and possible constraints (e.g. logistical, attitudinal, etc.) to the subsequent delivery of services. On the other hand, overlooking community participation during the planning stages is likely to lead to confusion - among implementers and beneficiaries alike - during the subsequent implementation of the programmes. As the examples below describe, the exclusion of communities from the planning stages can significantly hamper the success of programmes, and increase the effort necessary to bring communities on board at later stages of programme implementation.

The Malawi experience

Malawi, where the CTC was originally established as a response to the 2002 nutritional emergency, provides a revealing example of how limited engagement can have important negative ramifications during the implementation of CTC programmes. During the planning stages of the CTC in Malawi, insufficient communication with existing formal structures and the initial omission of more informal or 'traditional' structures and community figures had a substantial impact on initial programme coverage and uptake. The project's limited understanding of local perceptions of the programme delayed recognition of the communities' distrust of unfamiliar Weight for Height (W/H) measurements. This, coupled with an initial failure to inform and involve 'traditional' structures, such as Traditional Authorities (TAs) and Village Headmen, appears to have greatly reduced initial attendance and programme coverage during the first three months of the programme.
If Malawi provided the first lesson on the impact of inadequate participation and delayed engagement with the community, it also offered the opportunity for socio-cultural input to contribute positively to CTC programme activities. In response to the slow uptake of CTC services, the work carried out by sociologists and anthropologists in Malawi offered valuable insight into the perceptions of the beneficiary communities regarding CTC, while simultaneously highlighting some of the shortcomings mentioned above. Changes in programme design and prioritisation based on these findings, in particular the more active and positive involvement of 'traditional' community structures, resulted in a rapid increase in the number of new cases of severe malnutrition admitted into the programme (see figure 7).

2. Programme implementation

The involvement of communities at an early stage - through key figures or otherwise - can often serve as the foundation for continuous active dialogue between the implementers and the beneficiary community. The joint identification of opportunities and threats, as well as the allocation of tasks and responsibilities among all stakeholders, are among some of the areas in which community involvement and consultation have proved invaluable during programme implementation. In South Sudan, for example, joint identification of sites helped to focus on existing logistical barriers to programme uptake. Having noted the difficulties for carers to cross the rivers and swamps during the rainy season, implementers and the local community developed a partnership with local boat-owners, who were recruited and provided with material incentives in return for free ferrying of programme beneficiaries.

This approach to community involvement succeeded insofar as it provided an initial solution to a permanent obstacle. Over time, however, ferry services were disrupted by disheartened boat-owners. The fact that project implementers remained unaware of this highlighted an important lesson: opportunities and constraints at community level are not constant and such arrangements demand systematic follow-up and a forum for discussion and feedback, to remain effective over time. In south Sudan, failure to appreciate this lesson and not institute appropriate mechanisms for discussion and feed-back, led to the weakening and eventual collapse of communication channels post set-up, a discontinuation of the ferry service and as a consequence, decreased attendance, greater opportunity costs to those in the programme and decreased impact.

One of the single most important by-products of developing community participation is the creation of systems for constant dialogue and joint problem solving. There are many challenges to putting such systems in place, but effective systems for communication between implementer and beneficiary provide many benefits. These are essential. On the one hand, regular engagement with the community can lead to the identification of post-implementation obstacles and joint problem solving. On the other, community feedback can shed light on developments at the community level which affect the performance of CTC interventions.

Maintaining such links has required commitment on the part of CTC implementers to understand, but also to bring onboard, beneficiaries' views and needs. In South Sudan, socio-cultural enquiry highlighted the need for an effective solution to the issue of boat-owners and their payment. As a way of facilitating the formulation of a joint strategy, the boat-owners were approached and their input regarding acceptable incentives put forward to the implementing agency. The eventual provision of such material incentives served to re-establish the complementary services for the duration of the programme.

In Ethiopia, consultation with beneficiaries also helped readapt existing programme strategies to better meet the communities' needs. For example, feedback from communities highlighted the difficulties faced by carers crossing rivers during the rainy season. Through further socio-cultural enquiry it was determined that a number of beneficiaries preferred travelling longer distances to crossing rivers, as crossing rivers often required both carers to travel to the sites, thereby greatly increasing the opportunity costs to families. As a result, the programme design was changed, and started to provide assistance in the process of transfer of beneficiaries to the preferred sites, to facilitate programme attendance and uptake. In Ethiopia, beneficiary concerns about contracting diseases at the distribution site, or confusion over the preparation of FAMIX, led to inclusion of these topics in health education and cooking demonstrations at the sites.

 

3. Hand-over to more sustainable, local structures

Socio-cultural enquiry and the community participation involved has brought together many of the different spectrums of society (i.e. religious, political, social, and spiritual) to discuss and develop more sustainable and appropriate courses of action. This cooperative process has produced recommendations on the preparation of a long-term, volunteer-based strategy for the outreach element of the CTC programme, that are now central to some local CTC strategies. The process has yielded many insights on the acceptability, potential risks and opportunities associated with selecting a community-based volunteer workforce and the need to involve more key figures, in addition to volunteers, to assist in case-finding and referral activities at a community level. The resultant combination of communityelected volunteers with key social figures forms a far more comprehensive and representative outreach network.

For example, in South Wollo, Ethiopia, the initial volunteer strategy struggled. Some village leaders felt they had not been sufficiently involved and therefore didn't support the outreach activities and local level elections resulted in the selection of male volunteers only. Concern addressed these problems by further discussions with village leaders and by going back to talk with communities, advocating for the inclusion of women, stressing their value for the programme in terms of more appropriate/sensitive home visits, and increased understanding of issues of child care. The result was a network of paired volunteers (male and female) working in connection with local leaders who have now been included in all trainings. This has helped to improve the acceptability of the strategy and already, (after volunteers have been working for 3 months), the Concern team and MoH workers are pleased with the referrals being made. As volunteers work within their villages only, their activities, so far, have remained manageable on a voluntary basis.

Lessons Learned

The experience of implementing CTC programmes over the last three years has led to notable improvements in the formulation of a comprehensive but flexible approach to community participation and mobilisation. In particular:

There is no prescribed formula

The level and stages of community participation in CTC programmes must take into account the risks, opportunities and characteristics of each environment. Community engagement must also acknowledge the social potential or 'social capital' of the beneficiary communities, so as to assess the most appropriate areas of community participation in programme activities.

Early engagement with the community is central to the success of CTC

It is important to engage with beneficiary communities during the planning (or even pre-planning) stages of the programme. Early involvement of the community can minimise confusion and increase programme awareness at a community level and facilitate the selection of adequate and sustainable strategies. It can also provide a platform for further, post implementation engagement between implementers and beneficiaries.

There is a vital need for ongoing engagement and feedback

Community mobilisation should be an ongoing process, spanning from the planning stages to (wherever possible) the hand-over to national structures. Communities and their representatives must be provided with a forum for discussion and feedback on issues relating to programme implementation and acceptability. Joint decisions must be followed up to guarantee their effectiveness over time, along with information feedback to communities and their representatives.

Socio-cultural enquiry plays a valuable role in community mobilisation

Socio-cultural input provided during the implementation of CTC programmes has served a dual role. First, it has allowed implementers to gain a more insightful understanding of the beneficiary communities. Secondly it has allowed beneficiaries themselves not only to voice their views on issues relating to programme acceptability, but also to bring about tangible changes in programme strategy.

Large scale community mobilisation is feasible and essential even during nutritional crises

Community mobilisation during nutritional emergencies is feasible. While challenges do exist, experience has shown that the success of community mobilisation depends largely on the level of commitment by the implementer to prioritise community mobilisation prior to, during and after the cessation of programme activities.

New developments and future directions

The process of engaging with different aspects of community integration remains ongoing. For example, the role of volunteers within the CTC approach is being simultaneously explored in Ethiopia and Malawi. In Ethiopia, the volunteer system is being introduced as a more sustainable follow-up for outreach activities (e.g. case-finding, referrals and follow-up). Through socio-cultural enquiry, the views and opinions expressed by the beneficiary community have to a large extent guided the selection of volunteers.

Like all aspects of community mobilisation, this level of community integration requires further assessment to guarantee its effectiveness and acceptability over time. In Malawi, this process has been taken a step further. Teams are developing mechanisms to integrate the MoH extension services (Health Surveillance Assistants (HSAs)) with pre-existing, but previously moribund, networks of community growth monitors, with new community volunteers recruited from those familiar with the CTC programme, and with village health committees. Following this approach, outreach activities are supervised by MoH staff but supported by a network of clearly identified community-based volunteers. Future developments in this area include the identification of appropriate incentives for the volunteer workforce, the formulation of sustainable lines of communication between programme implementers and volunteers, and ongoing investigation of the overall acceptability of the approach among the beneficiary population. There is also currently an enquiry into the perceived needs of PLWHA and the current Home-based Care service provision in Malawi, with a view to better identifying the role of CTC in the area.

There are plans to conduct further research in areas where community structures have been disrupted. Based on past experiences, it is felt that the variety and flexibility of the social and cultural links that exist at all social levels mean that even in highly disrupted communities, engagement, mobilisation and participation should be possible. Ultimately, such scenarios are likely to present unique challenges. To engage with whatever aspects of community are present will require context specific responses, albeit drawing upon accumulated knowledge. The task is now to investigate how this can be best done.

5.2 'Sectoral Integration'

5.2.1 Challenges and Opportunities in Integrating CTC and Food Security Programmes in Malawi

By Jim Goodman (Concern Malawi)

As with the majority of famines and food crises, the 2002-3 Malawi crisis was caused by the interaction of many pre-existing factors of vulnerability that combined to over-stretch fragile coping capacities. The resulting situation demanded both an emergency nutrition intervention and a means of re-establishing food security to, at least, a pre-crisis level.

This article describes experiences from the CTC and food security programmes that Concern Worldwide has been implementing in Dowa district since June 2002. It describes the opportunities that were capitalised upon during the CTC programme, for delivering food security activities through the health service, improved targeting of households to receive direct assistance with agricultural inputs and providing an entry point for longer-term interventions. The main challenges were aligning development and relief approaches, matching the scale of interventions with available resources, and working effectively with Government structures.

Integration in practice - health centres and communities

Achieving sustainable improvements in household nutrition, from a food security angle, demands interventions to improve skills, knowledge and community organisation in the areas of food production, post-harvest food management and food utilisation. The specific challenge for the food security team was to identify interventions that could be implemented effectively in tandem with the OTP programme, taking into account the scale of CTC coverage, its timetable and the resources available.

Food security programme extension staff took advantage of the regular presence of mothers at health centres to distribute agricultural inputs and deliver simple messages on planting and fertilising. Concern also attempted to use the time people spent waiting for distributions constructively, by entertaining mothers through motivational songs about food security issues - these encouraged identification of a group problem as opposed to an individual problem, and helped to create a positive atmosphere. Demonstration gardens, supported by posters, were staged at each OTP distribution point, displaying technologies mothers could adopt at home to diversify diets. Health Surveillance Assistants (HSAs) were trained with simple agricultural skills at the same points on non-distribution days.

The results of these efforts were mixed. The availability of agricultural inputs and training provided an additional incentive for attendance at distributions and probably helped increase admissions. However, the potential for learning at distribution days was constrained by the time available, the frame of mind of attending mothers and the general atmosphere. Mothers were usually tired and focused on their main reason for attendance - access to supplementary food and RUTF. Because of this, messages had to be kept short, and focused on the agricultural inputs provided, simple food processing and hygiene techniques. This left important areas of subject matter uncovered, which had to be addressed with extension work back in communities.

An important question was how practically to deliver extension to OTP mothers who, because of the relatively low prevalence of severe acute malnutrition (1.5%), were thinly dispersed among villages across the District. The chosen solution was to promote OTP households as an important subgroup within existing community groups, in particular Village Health Committees, as opposed to creating separate OTP agricultural support groups. Using existing structures allowed extension staff to reach OTP mothers through their normal extension schedules, increasing the possibility that these groups could continue receiving extra support after the end of the

Concern supported emergency intervention. All that was required was for them to adapt the subject matter, where necessary, to include community nutrition issues of particular relevance to OTP households. The Concern team are now in the process of piloting small programmes aimed at identifying and promoting positive deviant behaviours as an extension methodology which if successful, might improve the focus of this approach and its longer term effectiveness and sustainability.

Issues in targeting the most vulnerable

Food security and nutrition interventions target in very different ways. Food security programmes seek to improve food security at community level, whereas the OTP programme focuses on the individual child and their carer. There are several tensions inherent in this. One is the assumption that households with a malnourished child (OTP/SFP households), are likely to be among the most food insecure. However, in Malawi, nonfood factors, particularly disease and the social care environment, are extremely important determinants of malnutrition. This raises questions about the utility of a food security strategy targeted at only OTP/SFP households. For this reason in Dowa, Concern adopted a community-wide approach that included, but was not restricted to, OTP households. The team also tried to consider food security and nutrition problems holistically and with participatory problem analysis, to address a wider range of causative factors. OTP households were provided with agricultural inputs in an attempt to strengthen their resource base and enable meaningful participation in longer-term food security interventions (e.g. cassava cuttings to enable them to process and store cassava as an alternative to maize).

The Dowa food security intervention also had to address issues surrounding local perceptions of vulnerability. Identification of the OTP/SFP household is relatively fast and easy and ensures that extension staff recognise them, but it does not necessarily ensure acceptance by the community, or action by the extension worker. The notion of 'deservedness' influences both community group dynamics and the attitudes of extension staff. In practice in Dowa, community self-targeting is often biased towards the ability to participate as opposed to objective nutritional status. Mothers with malnourished children may be the least able to participate in community activities, while for both social and economic reasons men tend to capture project benefits. Project staff skilled in these issues needed to devote much time and effort to facilitation between the community and extension staff to increase inclusion of OTP/SFP households. Such facilitation skills are not always well developed and their absence would be an important barrier to success. Participatory discussions and problem analysis did overcome some negative attitudes towards households with malnourished individuals, however more experience and research was needed to determine ways of aligning community priorities and the objective of improving nutrition. This is likely to reinforce the importance of skills in facilitating participatory discussions and problem analysis. This raises another question about whether a Districtwide emergency intervention can devote sufficient resources to exploring and resolving such issues.

Entry and exit points

In Dowa, the team found that an important strength of CTC was that it offered not only immediate action on malnutrition, but also gave the opportunity for better continuity between relief and recovery assistance. CTC's potential to achieve this lay in its focus on working with mothers in their communities. This focus of resources and attention at the community level helped provide an entry point into communities for recovery work, by establishing groups to work with and beginning the process of discussing problems and objectives directly related to improved nutrition with them. CTC also offered an alternative starting point for targeting and promoting other sectoral interventions such as gender awareness, economic empowerment and HIV/AIDS, as components in longer-term food security programming for vulnerable households. This horizontal multisectoral programming is essential in Malawi, where the many problems associated with these issues combine to keep the rate of under five chronic malnutrition above 50%.

Scale and Resources

Defining the scope of the food security intervention in the context of the District-wide CTC programme in Dowa was, in part, a question of resources. A balance between achieving coverage of the needy population and addressing the various aspects of food security for that population in a comprehensive manner, needed to be struck. This balance had to be reached based on the capacity of District Government to take on extra work outside their normal scope of duties.

Concern's response to this was to concentrate selected programme activities in a number of focus villages associated with health centres and specific extension workers. These acted as centres for promoting nutrition as a special topic within the long-term work of government extension staff. Within each focus village, a community volunteer acted as the main contact point for staff and follows up activities between extension staff visits. Government staff were encouraged to replicate successes in other villages. The effectiveness of this pathway depends on staff capacity and attitude; these are factors which themselves are open to development through training, exchange visits to successful sites and participatory meetings. In Malawi, individual extension workers from both Ministries of Health and Agriculture, have been able to address day to day problems outside their normal scope of work. This has enhanced their profile within communities and been a source of motivation. Some individuals, however, are still heavily influenced by the expectation of additional financial gain for participation in new work. Training, meetings and exchange visits, although not necessarily expensive, require funding which, for the foreseeable future, must be provided from non-governmental resources.

Aligning relief and development approaches

An overarching challenge was that different actors involved in programme planning viewed the problem through different 'professional lenses'. Integrating the two required a development perspective to merge with an emergency perspective. This requires resolving differences in the time-scale over which funding is made available, differences in perception of the types of behaviour change which can be tackled over different time scales, and aligning long-term and short-term programme capacity requirements.

Short term impact and long term change

The OTP programme has delivered a set of replicable systems for treatment of malnutrition that will ultimately be managed by the Ministry of Health, and emphasised staff training and logistics management to achieve impact. During the first year of intervention, the participation of mothers in the nutritional rehabilitation of the child was predominantly passive. The short term impact on the patients did not require the carer to understand the reasons for the child's condition or how the treatment works. Selected topics were covered with less intensive staff:mother contact at distribution points (e.g. short demonstrations on a precise topic such as preparation of soya flour), but it is questionable whether these were sufficient to produce lasting behaviour change.

In the same way, a relief programme can successfully use OTP distribution points to distribute familiar agricultural inputs that the recipients know how to use and in so doing, achieve largescale rapid short term impact with minimum follow up. However, this minimalist approach cannot work using inputs that the people are unfamiliar with and cannot hope to influence behaviours and cultivation techniques.

The achievement of longer-term benefits in the Malawian context of chronic food insecurity requires both crop diversity and changes in agricultural, storage and processing practice. These can only be achieved if substantial staff time is spent discussing constraints to production and various preferences with communities, improving crop husbandry skills, exploring new crops and following up on crop development. In Malawi, this is being achieved by a small team of extension staff working in tandem with the larger scale intervention in 30 focus villages across the District, researching and developing activities in these areas. The use of positive deviance as an extension methodology is a key component of this and is one mechanism for improving skills in participatory techniques among programme and government staff. While staff are only able to do comprehensive community nutrition extension in a sample of villages, this provides experience and a model for rolling out the rehabilitation phase of CTC to government staff

Scale

In the direct treatment of clinical malnutrition, staff time is dedicated to ensuring geographically wide coverage; resources are unlikely to be available to provide staff for more developmental work on the same scale. An objective of the posttreatment phase is to increase whole community capacity for involvement in nutrition management. This requires a more developmental perspective, delivering technical training in the context of a broad understanding of the household food security problem and linking of problems.

This approach requires the adaptation of long- term development considerations (inter-alia, sustainability, participation, the adult learning process, group dynamics, community ownership, long-term behaviour change), to an immediate problem. Inevitably availability of resources determines the scale on which this is possible and it is most likely to be on a much smaller scale than treatment. This pathway for programming in overlapping phases (i.e. relief, recovery, development) overcomes some of the differences mentioned above. It requires positive discussion and collaboration between 'relief' and 'development' stakeholders from an early stage.

Working with government

Inter-sectoral programmes are typically slowed down due to confusion over responsibilities. This occurred in Malawi where the pressure for a speedy emergency programme detracted from the process of consultation and discussion with other implementing bodies. In the long run this pressure to achieve results has led to delays (for example in deciding which sector should be responsible for food hygiene or food preparation extension work) that could have been avoided. To minimize these problems future CTC programs should conduct a thorough institutional and capability analysis at the planning stage, even if this slows initial implementation down a little. They should also make more time for on-going discussion and consensus building among managers at District and programme management level during the programme.

In practice, in Malawi despite some initial confusion, the efforts made to develop horizontal links and understanding have borne fruits and an 'inter-sectoral understanding' is evolving as implementation proceeds. At field level, from the outset, staff from the Ministries of Health and Agriculture were encouraged to consider new subject matter, enabling them to recognise and address simple problems not traditionally addressed within their Ministries. This sets up a denser network of extension staff to implement the post-emergency phase. In Dowa, agricultural staff regularly refer mothers to health centres and NRU's and health staff are now able to trouble-shoot agricultural problems. This has been straightforward technically, with staff being eager to acquire new skills to face the problems they meet in everyday community work. At the time of writing, the food security team was training OTP mothers on diarrhoea prevention, while HSAs were distributing indigenous vegetable seeds. This cross sectional cooperation has provided a denser network of extension staff to implement the post-emergency phase improving the impact of both OTP and food security extension activities.

The biggest challenge has been finding space for quality training in the over-stretched and under-resourced schedules of government field staff and avoiding conflict between the programme and District Ministry Offices. Where possible the team tried to design training that was succinct and sometimes conducted outside normal working hours, and generally provided 'take-away' training notes. Some topics were dealt with as part of short planning sessions at health centre level with small groups of staff from both Ministries. Such sessions have also encouraged agriculture and health staff to work together with the same households.

Future Opportunities and Challenges

The work in Malawi has laid the foundations for further work in integrating nutrition, food security and health within the CTC framework. At this phase of the programme Concern are focusing on the development of positive deviance techniques as a community extension tool, organising farmer groups for the local production of RUTF ingredients and developing homebased care for HIV affected households identified through CTC.

 

5.2.2 Integration of CTC with strategies to address HIV/AIDS

By Paluku Bahwere, Saul Guerrero, Kate Sadler & Steve Collins (Valid International)

Home-Based Care (HBC) is now seen as the way forward for caring and supporting People Living With HIV/AIDS (PLWHA) and HIV affected households (30;31). Given the ever-increasing numbers of people infected and affected by HIV/AIDS, and the capacity limitations of the health structures in the countries where most of the cases are, home-based care is the only realistic response that can prevent the formal healthcare services from being swamped (30;32-37).

CTC offers several important opportunities to integrate the treatment of malnutrition with HBC and to support wider homebased strategies to address HIV/AIDS (37). The CTC approach to community-based support, mobilisation, case-finding and assistance provision, provides an appropriate entry point to support, strengthen and adapt existing social structures to better deliver HBC. New RUTFs specifically designed with appropriate levels of micro-nutrients, anti-oxidants, protein and energy can help improve the nutritional status of PLWHA (21;27;28;38-40). The addition of pro and pre-biotics to these RUTFs, to address HIV related diarrhoea and wasting, offers the potential for low cost effective therapeutic support either in combination with ARVs or alone (28).

Already in many countries, CTC programmes are working with and treating many PLWHA. For example, recent research in Malawi indicates that up to 30% of malnourished children are HIV positive. This research also indicates that when these severely malnourished children with HIV/AIDS are treated with RUTF in an outpatient programme, the majority can recover to normal nutritional status (38-40). For the past 8 months, research has been ongoing into how best CTC can be modified to maximise this potential for integration and synergy with existing HBC support mechanisms.

The move towards home based models

Health facilities in many affected countries do not have the capacity to deal with the high number of PLWHA(32-35). This is the case for Malawi which has 800,000 PLWHAs, including 65,000 children (41). In Malawi and many other African countries, community/family networks represent the primary sources of support for these people. The appropriate implementation of community and home based care models could help strengthen existing family and community capacities to assist affected people and households, while simultaneously building local capacities.

All HBC models have in common a holistic view of the problems of PLWHA and their families and attempt to provide physical, psychological, social, palliative and spiritual care and support for infected/affected individuals and families (31;42;43). The CTC approach as implemented in Malawi, Sudan and Ethiopia has many features in common with such models:

• CTC cares for people in their homes and can evolve to include a wide range of sectoral interventions. The opportunity costs associated with home care are less and this could help households and communities affected by HIV/AIDS maintain economic productivity.
• CTC provides new, specially designed, therapeutic diets and medical protocols. There is emerging evidence that the provision of high quality therapeutic food may prolong productive life and increases the time to AIDS defining illness and death
• CTC provides a legitimate role for health care workers to establish a presence at community level. The stigma attached to HIV/AIDS in Malawi society makes identifying affected families very difficult. However, experience has shown that programmes that spend long periods researching and planning interventions, without providing visible assistance, rapidly become unpopular in Malawian villages.
• CTC treats common complications of HIV/AIDS, such as acute malnutrition, in the home rather than in hospitals or therapeutic feeding centres. Home care 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.
• CTC develops caring networks using a variety of mobilisation techniques, where possible integrating together existing support systems. Care and psycho-social support is easier to provide in familiar surroundings than in the hospital environment.
• CTC identifies and develops existing social support networks. Caring for people in their community instead of removing them to hospital is more compatible with fundamental Bantu views of the interdependence of individuals, families and communities.

The risks of home based care

Caution must be exercised, as the inappropriate implementation of home based models also has the potential to compete with and undermine existing social support structures. An important finding of research in Malawi is that external support provided by NGOs can have extremely negative effects on more traditional/community-based sources of assistance to HIV affected households. There is often uncertainty around the long-term continuity of NGO's programmes. As external organisations target HIV affected households, family and community networks may gradually feel less responsible for the welfare of the sick. There is no guarantee that community support structures will re-emerge in the event of a withdrawal of external NGO-led programmes.

The philosophy behind CTC is (wherever possible) to work through and strengthen existing formal and non-formal systems and structures. Currently, research in Dowa, Malawi, is looking at how to maximise this potential and minimise the risks of damaging existing support mechanisms. The research also involves examining proxy indicators, used to target programmes in the absence of biological HIV testing, and to estimate the effectiveness of the existing CTC programme in identifying people and households affected by HIV and delivering appropriate and acceptable care. A central element in the research is to examine how best to use the legitimacy provided by the successful treatment of acute malnutrition to avoid the stigma associated with HIV.

Efficacy of RUTF in treating HIV infected malnourished children

In Malawi, many nutritional support programmes for PLWHAs use mixed flour blends which, when made into porridge, have a low nutrient density. These supplements are not ideal to meet the increased nutritional requirements appropriate for HIV infected people, especially HIV infected children (44;45). Blended flours require considerable cooking and therefore labour to collect firewood; cooking destroys many of the vitamins making it difficult to use these foods to deliver the high doses of vitamins and antioxidants required to slow the progression of HIV/AIDS and the energy density is low making it particularly difficult for children, with their small stomach capacity, to eat a sufficient quantity to meet their increased nutritional requirements. The use of RUTF has overcome many of these limitations. RUTF is energy dense, can be made with the appropriate balance of micronutrients. and does not require cooking. Thus vitamins are preserved and no additional labour demands are placed on families.

Home Treatment with RUTF has been shown to be effective in Malawi, where in the 2001-2002 hungry season, the Queen Elizabeth Central Hospital in Blantyre, used home care with RUTF to replace the phase 2 inpatient treatment after the initial phase 1 stabilisation (39). Eighty percent of the children receiving a full diet of RUTF reached their 100% weight for height goal, including 59% of HIV positive children and 95% of all HIV negative children (39). Similar encouraging results were observed for the 2002-2003 hungry season in seven different sites in Malawi with 80% of children recovered within an average of 6 weeks including 56% of HIV positive children (38-39).

In Malawi, a 'Nutriset' produced recipe of RUTF is also used for the nutritional rehabilitation of malnourished TB and HIV infected adults by MSF-Luxembourg (46). The impact of this protocol has not yet been evaluated but empirical observations have indicated that most of these adults are gaining weight (46).

At present in Malawi, the production of RUTFs from locally available grains and pulses, at a small district hospital, is being investigated. Such locally produced RUTFs will be cheaper (probably less than one-third of the price of the commercial product) and by stimulating local agricultural markets and manufacturing industry, may be better able to integrate the support for PLWHA into local economies.

Research is also taking place into the addition of synbiotics (a combination of high dose acid resistant probiotics and prebiotics) to RUTF (28). It is hoped that current trials will demonstrate that these new synbiotic enhanced RUTFs are effective tools, allowing further reduction in mortality and morbidity and speeding the recovery of those malnourished HIV infected children (see section 4.3) (47)

The introduction of ARV treatments for the HIV infected in Africa will also demand special attention to nutritional status. Research has shown that this treatment in itself can aggravate nutritional problems such as wasting and cause other problems related to fat deposition (48). Ready to use supplementary and therapeutic foods could help ensure stable nutritional status throughout treatment.

Integrating responses to HIV related nutritional problems

The HIV pandemic is changing the face of malnutrition and reinforcing the need to combine both relief and development responses. As well as contributing to massive mortality and morbidity, HIV/AIDS increases and changes the spectrum of underlying vulnerabilities. Combined with underdevelopment, it increases the risk of acute events to promote malnutrition,(49) both directly through infection and indirectly, through increasing poverty and vulnerability and decreasing economic reserves. In countries such as Malawi, for example, up to 35% of severely malnourished children are now HIV positive. Children aged between 6 and 36 months form a high proportion of the caseload as a consequence of mother to child transmission of HIV (36). The proportion of orphans is also increasing and in the Dowa CTC programme, 9.3% of admissions were orphans (unpublished data).

CTC's combination of emergency and developmental principles is well adapted to a mixed emergency and development response. For example, in Dowa, CTC treated thousands of acutely malnourished people in a few months, whilst reinforcing the capacity of local health systems, families and community, to take care of malnourished patients, including those infected by HIV. Importantly it also demonstrated that the formal health services have the capacity to treat wasted individuals with relatively small opportunity costs to their families. This has all encouraged local people, traditional leaders and even traditional practitioners, to refer cases of malnutrition to the CTC access points early, and in far greater numbers. This community-based case finding and referral system requires no input from either Concern or the MoH and is sustainable. Ensuring the MoHP clinic system has the capacity to continue the delivery of RUTF and the OTP protocols though their clinic system is the next step, and so far, the signs are good. Local MoHP staff are now running most aspects of the programme, including all OTP distributions, and are comfortable and enthusiastic with the prospect of taking it over entirely. The strong links developing between the CTC nutrition, food security and HIV strategies for Dowa district, and the establishment of local RUTF production in the district, will hopefully further increase the chances that the local communities can sustain the project.

 

5.3 'Institutional Integration' of CTC with existing clinical health systems

By Emily Mates (Concern Ethiopia)

Therapeutic Feeding Centres (TFCs) are often highly effective in treating individual cases of severe malnutrition. Their exacting r