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Printed in: Supplement 2
Page: 14
Date: November 2004

Categories: None

Keywords: None

Type: Special Supplement

Author: Kate Golden, Tanya Khara, Kate Sadler, Alem Abay, Anna Taylor, Jennifer Martin and Ed Walker

Countries: Ethiopia; Malawi; Sudan

Case Studies (Special Supplement 2)

3.1 CTC in Ethiopia- Working from CTC Principles

By Kate Golden (Concern Ethiopia) and Tanya Khara (Valid International)

In December 2002, nutrition surveys carried out by Concern Worldwide, in collaboration with Amhara Region Disasters, Preparedness and Prevention Bureau (DPPB), reported acute malnutrition levels of 17.2% global malnutrition and 3.1% severe malnutrition (based on weight for height in z scores) in Kalu and Dessie Zuria districts, South Wollo. At the same time, the Federal Disasters, Prevention and Preparedness Committee (DPPC) led multi agency crop assessment reported the harvest to be below 25% of normal, and identified half (50%) of the population as in need of food aid.

The districts have a total population of around 450,000, the vast majority of which live in chronically food insecure rural villages, spread over a densely populated and poorly accessible mountainous terrain (260,000 hectares, population density 180 people/sq km). Concern have worked in South Wollo for the last 30 years, in nutrition, health, agriculture, water and livestock programmes. In response to the 1984 famine, they implemented SFP and TFC feeding programmes in the area and still retain some of the staff who remember those days. Partly due to this legacy, Concern were eager to explore a new approach which might offer some solutions to bringing services to the population of such an inaccessible area.

Initiating CTC

In December 2002, Concern began blanket supplementary feeding in response to the emergency and in January 2003, replaced this with a targeted supplementary feeding programme, providing a two weekly ration of a local blended food. The programme was spread over 18 decentralised sites. When Valid International supported the set-up of the CTC programme in February 2003, an Outpatient Therapeutic Programme (OTP), facility for inpatient care, and an outreach programme were integrated into this existing SFP intervention. The Concern/Valid team worked on an initial target of 2500 severely malnourished children, which was calculated using November 2002 nutrition survey results.

Key features of the programme, reflecting the basic principles of CTC, were:

• Timely set up
  Within just a few days, it was possible to add the OTP component to each existing SFP site, with all sites becoming activated within a six week period.
• OTP
  Treatment for severely malnourished children consisted of a weekly health check, provision of a RUTF ration according to weight, standard medical treatment, and basic nutrition education for carers.
• Formal training
  Training of Concern and Ministry of Health (MoH) staff to implement the programme required only two days. This training covered the basics of malnutrition, identification of severe malnutrition, medical assessment, feeding and drug protocols, RUTF education, and record keeping.
• Sites at existing health facilities
  Sites were then set up at existing SFP sites, using clinic or health centre facilities wherever possible, for weekly health checks.
• Ongoing support
  Close supervision and ongoing training at the distribution sites was then carried out by Concern and MoH supervisors.

Concern outreach workers (who would live and work in the communities they were serving) were also trained on basic malnutrition, the structure of the programme, referral (using MUAC and oedema assessment) and follow-up through home visits for children not responding well to treatment.

Focus on achieving high coverage and good access to services

It was hoped that maximum access to services for the whole population would be achieved by setting up OTP sites quickly, and focusing the activities of outreach workers on mobilising communities through local contacts (traditional leaders, community workers), as well as active case-finding. The aim was to provide OTP services within three hours walk of all villages. In a minority of 'difficult access' areas, carers were given the option of attending sites on a two weekly, rather than weekly, basis thus avoiding subsequent default.

The aim of the strategy in the initial phase of implementation was to focus staff and resources on the OTP, and not to set up any new inpatient care for the severely malnourished until good coverage had been achieved. The provision of inpatient care, for the minority of complicated cases, was established through rapid but low level support for the MoH central hospital and is discussed in more detail in section 5.3

From the outset, the Concern and MoH team worked to maximise the profile and understanding of the programme in the community, by encouraging carers of registered children to take on an informal mobilisation role in their villages, encouraging others, with children in a similar condition, to attend. During the rainy season, when access roads to some sites became impassable, Concern went to great lengths to maintain SFP/OTP distributions, by employing donkeys and prepositioning food. These actions were vital to avoid interruptions in treatment and maintain carers' confidence in the programme.

Some months into the programme, the team started to conduct Focus Group Discussions (FGDs) at sites to investigate barriers to uptake of the programme. These proved extremely useful, as feedback during the sessions revealed access issues in particular areas and led to the opening of extra sites. FGDs also highlighted dissatisfaction amongst some carers, generated by confusion over the use of MUAC (village level referral) and WFH (admission) selection criteria. This 'bad feeling' was discouraging some carers, after initial rejection, from bringing their children back to the site if their condition deteriorated. It was also deterring others in the community from attending. Based upon these findings, we adopted a system of compensation (soap) for those referred to the programme through outreach workers using MUAC, but who, due to the difference between the MUAC referral criteria and standard weight for height admission criteria, were not subsequently admitted. We received very good feedback on this strategy.

This commitment to maximising coverage bore fruit and a survey, carried out in June 2003, estimated OTP coverage at 77.5% (C.I 65.7% to 86.2%). The survey employed a new method for estimation of coverage using a stratified design, with strata defined using the centric systematic area sampling approach and active case-finding (see section 4.4). A calculation, based on revised targets from a March 2003 nutrition survey (severe malnutrition rates had fallen by this time to 1% based on z scores), shows a similarly high estimate of coverage at 67.7% by May 2003, only three months into the programme.

Integration with, and support of, the existing health structures

Despite running feeding programmes in response to emergencies in the area for the last 30 years, Concern had not previously established close links with the District or Zonal Ministry of Health or involved them actively in programmes. As part of the CTC programme, Concern sought advice from both District and Zonal health departments and began to forge links during planning and implementation of the OTP. The Valid/Concern team jointly decided that Concern would train existing MoH clinic workers to carry out the OTP, linking with Concern SFP distribution teams. Medical supervision for the OTP would be split between Concern Medical Workers and MoH Supervisors, seconded from the district health offices. Though existing commitments and turnover of MoH staff necessitated periodic retraining and increased Concern supervision, both parties continue to be extremely positive about the partnership. The benefits have continued as the process of handing responsibility for the treatment of severe malnutrition over to health facilities now begins.

 

The team decided against setting up separate inpatient facilities at the beginning of the programme. Based upon prior experience in other CTC programmes, it was felt that this prioritisation was vital in order not to divert the attention of the field teams away from outreach, mobilisation and the OTP. However, due to the need for inpatient care for a minority of cases, the issue was discussed with the director of the Zonal hospital¹ who agreed for the paediatric ward to act as a referral unit for the phase 1 treatment of severely malnourished requiring inpatient care (those with severe medical complications, poor appetite or severe oedema).

Though initial progress in gaining acceptance of updated therapeutic feeding and drug protocols was slow, close dialogue with the medical director and respect for the constraints being experienced by staff led to great improvements in the care of the severest cases. This is demonstrated in the outcome indicators achieved (see table 6) with hospital mortality rates falling within Sphere standards despite the cohort of children representing the most severe cases. Before the start of the programme, the medical director of the hospital had reported that 50% of severely malnourished children treated in hospital died.

Outcomes

To date (Jan 2004), outcome indicators for the CTC programme in South Wollo have compared favourably with the Sphere Project's international standards for therapeutic care (table 6).

Weight gains and Length of Stay

Initial calculation of average weight gain of children discharged and recovered was 4.4g/kg/d and total length of stay was 81 days. The long length of stay and low weight gains in the programme reflect some of the challenges faced by a home-based programme, as factors inherent to the home environment (e.g. poor water sources, endemic malaria, poor quality family foods and sub-optimal caring practices) will affect the recovery time of some children. It also reflects using 85% WFH as discharge criteria, despite the presence of the SFP² to minimise readmissions. However, subsequent CTC programmes have successfully used 80% WFH as discharge criteria where an SFP is in place. Though testing for TB in the hospital identified some cases, the predictive quality of the testing was poor and therefore the impact of chronic diseases, such as TB and HIV/AIDS, on length of stay is likely to be more significant than data suggested.

Outreach

A system of outreach home visits, using a checklist for discussion and observation, was put in place at the beginning of the programme. The aim of these visits was to investigate possible reasons for non-response and offer support in terms of health and nutrition education. Efforts were also made to make sure, through advocacy with government and community targeting committees, that all OTP beneficiaries were registered for EGS³. This process was complicated by the community targeting process, which is based mainly on economic vulnerability (i.e. doesn't necessarily identify households with a malnourished child as vulnerable), and the fact that targeting normally takes place periodically (every 3-6 months), whereas families were entering the OTP every day. Though the general consensus of follow-up visits and of an anthropological study carried out by Valid International was that sharing of RUTF was not a major issue, it is likely that a degree of hidden sharing was happening, and that the root of this lay in resource scarcity rather than lack of knowledge.

Outreach workers followed up all defaulters within the programme in order to better understand the causes, encourage return and to uncover any 'hidden' deaths (table 7). The main reasons found for default were that the mother or child was sick or that the carer had moved out of the programme area. Particularly during the rains, lack of access to sites also became a main cause of default, but one that all efforts were made to reduce.

 

Table 6: CTC Interim Outcome Monitoring data, Ethiopia (Jan 03 - Jan 04)
Exit	Hospital		OTP		Combined
	n	%	N	%	N	%
Discharge	152	90.5%	440	66.0%	440	74.6%
Default	-	-	57	8.5%	57	9.7%
Death*	16	9.5%	28	4.2%	44	7.5%
Transfer**	-	-	93	13.9%
Non-recovered***	-	-	49	7.3%	49	8.3%
Total	168	100%	667	100%	590	100%
Still in project	0		204		204

* All OTP deaths were followed up. All were in the under 2 age group and did not occur in the early stages of treatment (average length of stay was 50 days). Ten were children admitted with oedemas, 10 occurred in children who had already spent some time in the hospital and 3 occurred when the carer refused to be transferred to the hospital. The main causes of death reported by the families were diarrhoea and suspected malaria and cough.
**The percentage of transfers from the OTP to the Hospital is high, partly due to a proportion of children with poor weight gain being sent for investigation of underlying chronic disease (e.g. TB). Of 93 transfers, 19 returned with positive TB results (based on x-ray) and subsequently continued in the OTP whilst receiving standard Directly Observed Treatment Short Courses (D.O.T.S). The outcomes of all transfers are represented in the combined results.
***After 4 months in the programme, cases who had not yet attained the discharge criteria of ?85% WHM were reviewed by the supervisory team. Those over 80% WHM were discharged non-recovered if their weight was remaining stable and if all alternatives (counselling, home-visit, or hospital referral for investigation of chronic disease), had been pursued. Many of these cases were found to be children with some physical disability.

Future Challenges: moving into a period of handover

Following a relatively good harvest for most of the population at the end of 2003, the need for an acute emergency response in this project area is diminishing. The CTC programme has begun a six-month transition period to gradually hand a more streamlined programme over to the community and the government health structure. Planning this handover has required the active participation of all stakeholders, with the Concern team and partners in the MoH and the community coming together to plan roles and responsibilities, and jointly predict and solve problems.

Priorities over this transition period are:

1. To work closely with the MoH to strengthen their capacity to manage and supervise the programme and to maintain a simplified monitoring and reporting system.
   
   • In order to maintain a manageable system for clinics, all children will now be seen on a 2 weekly basis.
   • Concern will likely continue to provide RUTF over the next year but is currently in the process of setting up local RUTF production. This will dramatically reduce costs and therefore, open up possibilities for government purchase.
   • The provision of medicines for OTP will also be an issue. At present it is not known whether the MoH will be able to maintain the free OTP service and if they cannot, what impact this will have on service uptake and compliance. A government 'free paper' welfare system does exist to cover hospital expenses for the poor and part of the strategy will be to improve this system (currently takes 3 days to receive the paper) for critical cases referred from the clinics.
   • Logistical support for the delivery of supplies to the dispersed network of clinics will likely need to continue initially for the short term, although alternatives are being investigated, particularly those involving more community participation. The system for referral to the zonal hospital of cases of complicated malnutrition, previously transported by Concern, is also being discussed.
2. To hand over sustainable screening, referral and follow-up activities to community volunteers at the village level.
   • At the time of writing, more than 2,000 volunteers have been elected by their communities and trained in the use of MUAC and confirmation of oedema, so they may continually screen and refer severely malnourished children to the nearest clinic for treatment. At present, paid Concern outreach workers are still in place to support these volunteers, but it is hoped that local and district level administrators will be able to assume responsibility for overseeing and motivating these volunteers so that referrals are sustained in the future.
   • The strategy of using MUAC as entry criteria, rather than WFH, came from consideration of the problems of having different referral and admission criteria and the need for a practical measure that community volunteers could use at a village level. The rejection issue, discussed above, is heightened due to the absence of the SFP and the compensation strategy would be impossible for the MoH to sustain. We are currently investigating the implications of this strategy and of lowering height cut-offs for the use of MUAC in a stunted population.
   • We also hope that working links can be forged between community volunteers and the clinics for effective followup of absent or sick children and other activities, e.g. vaccination campaigns.
3. To make modifications to the programme to compensate for the lack of an SFP.
   • The high logistic demands of a decentralised SFP programme preclude this being implemented by the government as a normal activity.
   • As all aspects of the programme will now be handled through the clinics, a system for nutrition education, both at the point of entry into the programme and subsequently linking through community volunteers/carer groups, will be needed.
   • One concern, in the absence of the SFP, is that without assistance for the continued recovery of the OTP beneficiaries after discharge, readmissions will increase. As the harvest was fairly good for most areas, improved food security within the household should mean that children are able to continue their recovery through the use of local foods at home. An education programme promoting the preparation of quality complementary foods and continued breastfeeding, through clinic workers and community volunteers, is being developed to try to aid this process. However general food security and the nutrition situation, including the level of readmissions, will need to be closely monitored in order to identify and act if the situation deteriorates.

Table 7: Information on Defaulters, Ethiopia (Jan 03 - Jan 04)
Total defaulters	Traced	Average time to default	Deaths*
n	n (%)	days	N
57	45 (79%)	78	6

*Including these deaths in the overall statistics would give a mortality rate of 5.1% for OTP.

 

3.2 Integrating CTC in health care delivery systems in Malawi

By Kate Sadler & Tanya Khara (Valid International), Alem Abay (Concern Malawi)

In February 2002, the Malawi government declared a national nutritional emergency and the UN launched an international appeal for emergency assistance. The national Ministry of Health and Population (MoHP) and the humanitarian community began to develop strategies for the treatment of the large numbers of severely malnourished that were predicted. Nationally, a strategy of upgrading the 115 Nutritional Rehabilitation Units (NRUs) across the country was adopted, with the aim of each NRU being able to provide centre-based therapeutic treatment by the end of the year. UNICEF and several non-governmental organisations (NGOs) provided therapeutic products, training and support for this strategy. At the same time, the MoHP gave Concern Worldwide and Valid International (Valid) permission to pilot CTC in two districts in central Malawi.

In Dowa District, the CTC programme was set up for delivery through the existing health system, with Concern and Valid providing mobile CTC teams to deliver training and on the job support for health system staff. The programme consisted of:

• Decentralised supplementary feeding programmes (SFP) delivered through 17 MoH/CHAM (Christian Health Association of Malawi) health units on a fortnightly basis.
• Decentralised outpatient therapeutic feeding programmes (OTP) delivered through 17 MoH/CHAM health units on a weekly basis.
• Stabilisation centres (SC) for phase 1 treatment delivered through four nutritional rehabilitation structures.
• Community-based case-finding, referral and beneficiary follow up using traditional authority structures, mother-to -mother networking and community based health staff.
• Integrated agricultural extension through Concern's food security programme.
• Local production of RUTF at one CHAM health unit.

Outcome Indicators

To date (Dec 2003), outcome indicators for this CTC programme compare reasonably well with the Sphere Project's international standards for therapeutic care (table 8).

Importantly, CTC programme coverage, a key determinant of impact in any humanitarian intervention, is high, approximately three times greater than TFC coverage achieved with international NGO support in the neighbouring District of Mchinji¹, and far higher than the national average. These findings are summarized in table 9.

This combination of acceptable outcome indicators and high coverage has produced high impact for the emergency CTC programme. However, in the context of Malawi, where poverty and under-nutrition are long-term structural problems, this short term impact, achieved with high levels of external input, ultimately bears little relevance to the main problems facing the state and people. From the start, one of the main attractions of the CTC model has been the possibility that short-term emergency interventions may lay a foundation for longer term, more sustainable, benefits. The rest of this article focuses on the post-emergency measures that were taken to try and realise this potential.

Table 8: Interim monitoring results from Dowa District, Malawi, CTC project, Aug 2002-Dec 2003
	Stabilisation Centre		OTP		Combined
Exits	n	%	N	%	N	%
Discharged	1299	87	1160	69	1160	69
Death	101	7	47	3	148	9
Default	25	2	242	14	267	16
Referred to hospital/SC	50	3	217	13	50	3
Other	20	1	26	2	46	3
Total	1495		1692		1671

 

Table 9: Direct estimations of CTC coverage in Dowa and TFC Mchinji districts, Malawi, March 2003
Project	CTC in Dowa	TFC in Mchinji
No. of severely malnourished identified	76	136
No. of children in feeding programme	46	29
Coverage (%)	61	21
95% Confidence interval (%)	48.7 - 71.6	14.8 - 29.2
Coverage WFP/UNHCR method (%)	73	28
95% Confidence interval (%)	63.6 - 80.1	20.8 - 35.8

 

Integrating CTC services into the district health system and community

One of the central principles of the CTC model is for CTC programmes to integrate with local health structures and services. This bridges the natural friction between the priorities of a short term, high input emergency intervention and those of a longer term, resource scarce development intervention. For this, a strong partnership at a District Authority management and supervision level is essential, if local services are to commit to CTC in the longer term. From the outset, the Dowa programme worked well with the existing MoPH and CHAM structures, supporting primary health care unit staff to carry out OTP and SC protocols. However, the majority of the day to day planning, problem solving and supervision was done solely by Concern, with very little input from District Authority managers. To some extent this has hindered the full integration of CTC services into Dowa health structures.

Although now in the process of trying to integrate all aspects of CTC delivery into the District health system and community structures in Dowa district, this is presenting further challenges and has highlighted some of the strengths and weaknesses of the initial CTC implementation in Dowa. The lessons learnt from this process will direct systems for the expansion of CTC into other Districts in Malawi.

Platform provided by the emergency programme

Several aspects of the emergency CTC programme are aiding the transition process:

• CTC now appears to be very popular with the target population. Though mistakes were initially made due to the programme's failure adequately to consider community structures in the rush to implementation (see section 5.12 on community mobilisation), figure 1 shows that uptake of services remains as high now as it was one year ago². This is important, as since July 2003, presentation of cases to the CTC has been as a result of mother-to-mother notification and mobilisation by the traditional authority structures, in collaboration with MoH community health workers (Health Surveillance Assistants - HSAs), rather than active outreach performed by NGO workers. This method of mobilisation can be sustainable.
• Data from anthropology studies conducted in March 2003 indicate that there had been a shift in the perceptions of traditional practitioners. This group are now more likely to attribute malnutrition to nutritional causes and refer people to the CTC for treatment. Traditional practitioners represent the first line treatment of malnutrition in Malawi and are therefore, potentially a vital outreach and referral resource. This method of case finding could be sustainable.
• There are now a large number of trained community and government health workers who understand OTP protocols and are able to implement them, and a widespread network of clinics that are already delivering the OTP protocol every week with minimal input from Concern staff.
• There are three stabilisation centres run by local partners that provide high quality phase one care.
• Links are developing between CTC and general strategies being developed in Malawi for the support of HIV affected people.
• Now that RUTF local production is well established, there is good potential to make production self-sustaining by using cheaper local ingredients, such as soya beans and chickpeas.
• The reputation of Concern and of the CTC programme within Dowa and at the MoH in Lilongwe is now very good. The success of the programme has generated a sense of pride in all those who have been involved in its implementation. As a result, the MoH at national level is keen for CTC to expand to other districts and the Dowa District Health Office is enthusiastic to establish the programme in the longer term.

Existing Challenges

In order to complete a successful handover, a scaled down Concern team are trying to focus on a number of key areas of weakness.

Supervision and monitoring of service delivery and impact

Both the District Health Officer (DHO) and the MCH coordinator for the District were consulted in the planning and implementation of the emergency programme. However the degree of collaboration needs to move from one of information sharing, to active involvement in the planning, supervision and reporting process. At present, the MCH coordinator makes ad hoc supervisory visits to health centres and NRUs implementing the CTC programme. The DHO (a clinician) makes monthly visits to each health centre as part of his existing work, during which time he reviews children in the OTP who are not responding well to treatment. However, all supervision and reporting implemented by Concern has, to date, happened in isolation of that implemented by DHO staff. This must be a focus for changeover in the coming months. Regular joint planning and problem solving meetings will give the DHO an opportunity to direct Concern to areas where they need extra support.

Scheduling of joint field supervision visits with existing/established checklists will help the MCH co-ordinator to gradually take on responsibility for this role. This must be coupled with improvements in the sharing of programme monitoring statistics and reporting, both with the DHO and clinics. The strengthening of this system of information sharing is a prerequisite for development of the central reporting role of the DHO in the future (see section 5.3).

Stock movement and accountability

At present, Concern moves both supplementary food and RUTF to health centres and NRUs. In June 2004, the supplementary feeding programme will phase out. This will reduce the weight of food commodities requiring delivery by over 72%, leaving only RUTF requiring transport from the district production site to the local distribution points.

The CTC support team will focus on two potential systems for RUTF delivery in Dowa:

1. Integrating delivery into community-based systems. A Valid anthropologist will explore possible mechanisms for community-based transport systems in Dowa.
2. It is feasible that RUTF, along with F100 and F75, be included on the list of essential medicines for Malawi. In this case, it could be delivered through the existing drug delivery mechanism in Malawi.

Local health staff at the health centres and NRUs are currently implementing Concern's systems of stock control and Concern is collecting data and monitoring stock usage. Many centres have already implemented WFP SFP distributions according to WFP guidelines. Thus, similar modified stock control systems could be developed, presenting little change from those already familiar to centre staff. At a higher level, the Concern CTC team is increasing support to the DHO for central stock control and reporting, in order to facilitate their future accountability to MoH/donor agencies.

Delivery of CTC from health centres and NRUs

All health centres and NRUs are now implementing CTC with little input from Concern. At the centre level, however, the need for support is very variable according to each centre's staff capacity, caseload and motivation. To better focus inputs, the CTC support team is conducting capacity assessments at each site to identify areas that require strengthening. It is likely that strengths at some centres can provide lessons to address weaknesses in others. At this stage, it will be important to look at centres individually and come up with flexible strategies for these issues. This is somewhat of a departure from the previous focus on general protocols. A general challenge at this level is systems of communication. Good follow up of children referred between NRUs and health centres requires some rigour and a functional communication system. Communication is also difficult between health structures and the DHO. Improving communication would improve feedback and enhance the ability of the system mangers to learn and solve problems.

Community-based support systems

From the start of the programme, HSAs have been very involved in the delivery of treatment from health centres, in working with the Traditional Authorities on community sensitisation, following up those in the programme, and tracing defaulters. However, HSAs already have a high workload in Malawi, being responsible for all vaccination, growth monitoring, community outreach and education. The CTC programme in Dowa is now in the process of strengthening links with the non formal sector, as an alternative mechanism for sustaining referral follow up and support at community level. Experience suggests that the high levels of 'positive feedback' associated with recovery from acute malnutrition provide a potent force to generate enthusiasm and motivate individuals at the community level to get involved (see section 5.12)

The evidence is that referrals can be maintained through mother-to-mother networking and the Traditional Authority structures. In addition, HSAs are now beginning to strengthen and, to some extent, formalise their links with networks of volunteers, already active at community level. Volunteers include community growth monitors, traditional birth attendants, agricultural extension workers, village health committee members and mothers that have been in the programme. These volunteers are helping to maintain case finding and referral at village level. However, it is being found that volunteers do require some small incentives if their role is to include assisting the HSAs in the follow up of children in the programme and of those that default from treatment. With the DHO, the team are considering the suitability of providing materials that help communities associate these volunteers with the programme.

Changing perceptions

The success of the consolidation and handover process is not just reliant on the relationship Concern manages to build with the DHO, MoH health staff and HSAs. Communities' understanding of the handover process and of the increased responsibility of the MoH are vital if they are to remain committed to and engaged in the programme. Communities have recently expressed their concern with the lack of transport for referrals between NRU's and OTP sites, as this was carried out during the old programme. Using existing communication channels, it will be important, throughout the handover process, to inform and involve community leaders in programmatic changes (see section 5.12)

Multi-sectoral programming

The close links between Concern's food security programme and CTC are providing an opportunity to tackle some of the root causes of malnutrition in Dowa District CTC (see section 5.21). In principle, CTC is also well suited to providing support for those affected by HIV/AIDS in Malawi, for example:

• CTC provides a mechanism by which people can be cared for in their homes. The opportunity costs associated with home care are less, which could help households and communities affected by HIV/AIDS maintain economic productivity. Care and psycho-social support are also easier to provide in familiar surroundings.
• By treating common complications of HIV/AIDS, such as acute malnutrition, in the home rather than in hospitals or TFCs, CTC has the potential to decrease the frequency and shorten the duration of inpatient admissions, helping to relieve pressure on hospitals. In addition, maintaining people in their home environment reduces exposure to foreign pathogens and should reduce the frequency of nosocomial infections.
• The programme provides new, specially designed, therapeutic diets and medical protocols. There is emerging evidence that the provision of high quality therapeutic foods of a high energy density and an optimal balance of essential micro-nutrients prolong productive life and increases the time before HIV/AIDS leads to illness and death.
• A large proportion of the CTC caseload already comprises people living with HIV/AIDS (PLWHA). A previous study showed that approximately one third of severely malnourished children admitted to a central Malawi NRU were HIV positive³. The study took place at the height of the hungry season and the proportion of admissions with HIV would be expected to be higher in the non-hunger periods. HIV infected children are found within families already affected by HIV, therefore using CTC as an entry point could focus initial interventions towards HIV affected families.
• CTC can provide an entry point for health care workers to establish a presence at community level and give them space to plan interventions. This is important as the stigma attached to HIV/AIDS in Malawi society makes identifying affected families very difficult. At the same time, experience has shown that interventions that involve spending long periods researching and planning, without providing visible assistance rapidly, become unpopular in Malawian villages.
• CTC identifies and develops existing social support networks. Malawi and Bantu culture is based around the interdependence of individual, family and village. Caring for people in their community, instead of removing them to hospital, is more culturally acceptable.

 

3.3 CTC in North Darfur, North Sudan: challenges of implementation

By Kate Sadler (Valid International) and Anna Taylor (SC-UK)

North Darfur state lies 1000 km to the west of Khartoum. It is an area the size of France but is inhabited by only 1.4 million people. The state has considerable variation in vegetation, ranging from desert in the north (average annual rainfall of less than 100 mm), to arable land in the south (average annual rainfall of 100 - 300 mm).

The state is divided into six food economy zones, each representing an area where a different livelihood strategy is dominant. The majority of the population practice traditional, subsistence-orientated rain fed agriculture, predominantly of millet. In addition to subsistence farming, there are pastoralist communities who depend on camels, cattle, sheep and goats, and cash crop farmers who cultivate chewing tobacco, sesame, groundnuts, vegetable and watermelon seeds.

The area has a long history of severe food shortages. Major famine, resulting in widespread loss of life, occurred in the late 18th century, 1913-14 and more recently in 1984 - 85. Since this time, there have been cyclical episodes of drought, which have gradually eroded traditional coping mechanisms. In October 2000, annual assessments of food needs concluded that crop production in two thirds of the North Darfur villages was poor or very poor. Subsequently, nutritional surveys implemented by Save the Children UK identified rates of acute malnutrition of > 20% in the under 5 population, and a severe food security situation.

In response to this situation, SC UK, with support from Valid International, began implementing a community based therapeutic and supplementary feeding programme, sited in ten of the worst affected districts. The programme was very decentralised, where 104 distribution sites allowed beneficiaries good access to treatment without requiring them to spend prolonged periods away from their fields. Six mobile teams assessed children and provided medical and nutritional treatment at weekly outpatient sites while a network of community nutrition workers screened and followed up children in the villages.

This programme was a short term emergency response to high levels of acute malnutrition. Although it allowed local structures and communities to experience the benefits of such a decentralised approach, it was not without consequences. The sudden programme closure was a de-motivational force for the many community workers and health staff trained to work on the programme. In addition, such a short timeframe does not make efficient use of the high inputs required to train and organise a large field team.

Revisiting CTC in North Dafur

In 2001, annual food needs assessments in North Darfur once again predicted large shortfalls in food availability for 2002. Following nutritional survey assessments in May 2002, SC UK and Valid International again began implementation of an emergency nutrition response. Evaluations of the previous year's community based therapeutic and supplementary feeding programme had highlighted a number of potential advantages for North Darfur over a more centre based treatment programme:

• Decentralisation of treatment sites improves access for a target population who are widely dispersed over a large target area.
• Minimal existing capacity in local health structures favours the set up of small, simple units rather than larger, more resource intensive centres.
• The home-based treatment regimen requires much shorter stays in centres. This reduces disruption to subsistence farming and other activities in the home.

The same approach was therefore adopted for intervention in 2002. Based on recommendations made in the 2001 programme's evaluations, some adaptations were made in 2002 to programme methods and protocols.

A team of four SC UK national staff (managers and nutritionists) and one expatriate advisor, trained 16 field staff and 20 staff from local health structures in the first three weeks of the programme. During the subsequent three week period, the programme scaled up to operate through a system of 57 decentralised distribution sites, positioned strategically to maximise beneficiary access across the target area. From these sites, the SC UK field staff conducted anthropometric screening to identify patients, and administer nutritional and medical treatment for all those registered on the programme. A network of community nutrition workers (one from each village in the target area) provides follow-up support at home. A high proportion of these workers had been trained during the previous year's programme and were keen to be involved in the intervention again. This made the re-activation of community screening and follow-up easier as both staff and beneficiaries were already familiar with the programme's objectives and methodologies. SC UK also supported four small stabilisation centres (SCs). Based in local health structures, they provided phase 1 care only to children with severe complicated malnutrition whose carers agreed to their being admitted as inpatients.

Table 10: Combined SC and OTP Outcomes (March 2003)
	%
Programme outcomes	(n=299)
Mortality	7
Default	6
Recovery	61
Transfer*	26
Coverage	50-100

*Transfer: The high transfer rate at this stage of the programme is predominantly the result of a protocol introduced to identify children demonstrating poor weight gain. These children were all transferred back to a stabilisation centre in order that any underlying infection could be treated and weight gain improved before programme end, when all children were to be discharged.

Table 11: The proportion of children in the community screened
District	% coverage from CNW reports (Nov 2003)	% coverage from mid-term coverage survey (Nov 2003)
Mellit	61	93
El Fasher	77	90
Sayah	95	92
El Kuma	75	88
El Malha	90	55

 

Key programme activities

Dry supplementary feeding is provided for all moderately malnourished children under five years old. Each child receives 4kg of a fortified blended food (UNIMIX) mixed with oil and sugar, according to national and international protocols.

Medical screening and treatment of all malnourished children is carried out, with subsequent referral for those with complicated malnutrition who are too sick to be managed at home and agree to a period of inpatient admission.

Each distribution team includes a medical assistant who screens patients for acute illness, verifies measles vaccination and vitamin A status and provides a single curative dose of an anti-worm drug. Children found to be ill or unvaccinated are referred to the nearest clinic or dispensary.

 

An OTP is available for all children under five years with uncomplicated severe malnutrition. The programme team identify all patients who are severely malnourished. After identification, they will either register them into the OTP or refer them to one of the four SCs. Whether the child is referred to the OTP or SC depends on the physical condition of the child, appetite, existing capacity at referral centres and the agreement of the mother for the child to go to inpatient care. Key elements of the treatment of those admitted to the OTP are outlined in Box 1. Treatment in SCs is based on the standard WHO inpatient treatment protocols for initial re-feeding (phase 1) and transition phase. This includes the use of formula milks (F75 and F100) adapted for the treatment of severe malnutrition and systematic medical treatment.

However, instead of transferring children in to a phase two protocol within the SC (as recommended by WHO), children are discharged from the SC into the OTP when their appetite has returned and infection is under control. This speeds up patient turn around in the SC, making them less crowded and allowing a good staff to patient ratio. Depending on the preference of the carer, this also allows the carer and their child to return to the rest of the family as soon as possible.

Impact indicators

At March 2003, outcome indicators from the CTC programme in Darfur compared well with the Sphere Project's international standards for therapeutic care (see table 10).

Using the nutritional surveys conducted during the implementation of this programme, it was difficult to measure coverage with any precision. However it can be confidently stated that overall, coverage (measured in March 2003) at least met the new international Sphere standard of >50% for rural communities. In the context of the scale of North Darfur and the widely dispersed and pastoral population, this is quite an achievement for a selective feeding programme, especially given the number of children screened by the programme team in the first 3 months of implementation (table 11).

The mid-term coverage survey showed that in all Districts, apart from El Malha, a high percentage of under 5s had been screened at least once during the past 3 months. Figures taken from the CNW weekly reporting at the end of November also show high results.

Future challenges for CTC in North Darfur

Cost versus coverage

The North Darfur programme highlighted the issue of diminishing returns in the balance between coverage and cost. To improve accessibility for both beneficiaries to the OTP sites and for CNWs to their target population, the number of districts and the number of CNWs could be increased. However, in a context such as Darfur, where large distances exist between very small centres of population, the present programme systems could not expand to reach all those in need without huge logistic overheads. The experiences of the distribution centre in El Malha demonstrate this. Here, 45% of children registered from this small community came from the village in which the distribution site was operating. The seven other villages covered by this OTP site were between 2 and 6 hours away by donkey. House to house visits in two of these outlying villages found that only 10% of children under five in households had been visited by a CNW. Under present programme systems, it is likely that some trade-offs for coverage against cost have to be made here. This highlights a limitation in the present 'centre working outwards' model of CTC implementation. Work is currently ongoing to develop models of 'CTC in situ', wherein local communities are responsible for case selection and the delivery of OTP protocols (see section 2).

Integration of CTC into community based health and referral systems

Integration is an important principle in CTC (see section 2). If capacity can be adequately transferred to the affected population and the service providers, then there will be less need for externally driven responses in future. Save the Children in Darfur already relies entirely on Darfur based national staff to run the emergency feeding programmes. After a CTC programme in the same area in 2001, CNWs employed in 2001 were rehired in 2002. An attempt was made to second the same MoH staff again in 2002, but MoH insisted that other staff be given this opportunity. However, implementing the North Darfur CTC programme required very strong logistics in order to deliver the feeding programme inputs (i.e. drugs, Plumpynut, F75 etc) and the trained staff to the distribution points.

Health care systems in Darfur have a weak infrastructure and are very poorly resourced. It seems unlikely therefore, that these systems would be able to sustain emergency CTC services without considerable external facilitation. However, CTC has significantly increased capacity within MoH staff and community based workers for the identification, treatment and follow up of severe malnutrition. In addition, the positive attitude towards CTC created during the 2001 and 2002 experience has generated an enthusiasm and demand for CTC from local staff, health workers and the general population. This makes it a lot easier for external support agencies such as SC UK to re-activate emergency CTC interventions in the future.

In the longer term, case finding, referral and follow up might be integrated into community-based systems that require a less intensive, but longer term, support. This could include community-based surveillance and early warning systems that would use many of the local people with experience of CTC.

3.4 CTC in South Sudan - A Comparison of Agency Approaches and the Dilemmas Involved

Tanya Khara (Valid International), Jennifer Martin (Concern Worldwide), Ed Walker (Tearfund)

Introduction

In 2003 both Concern Worldwide and Tearfund asked Valid International to support them in the setting-up of CTC programmes to address high rates of acute malnutrition in South Sudan¹. Initially questions came both from within Valid and the NGOs themselves. How would teams receive the new approach? Would the decentralised nature of CTC work in such a logistically challenging setting? How would severely malnourished children recover at home given the famously egalitarian sharing culture of the Dinka? What were the implications of the lack of health services in South Sudan on the CTC principle of sectoral integration?

Both Tearfund and Concern programme areas are in the Bahrel- Ghazal, region of South Sudan, a lowland area of rivers and swamps where access during the rainy season is extremely problematic². The region is chronically food insecure and the population vulnerable to rapid deterioration in nutritional status. Previous nutrition programmes run by both NGOs in the area had concentrated on decentralised supplementary feeding distributions with Tearfund also implementing central TFCs.

The comparison below, aims to describe some of the differences in approach as the two agencies came to grips with the CTC model and thus highlight some of the key dilemmas encountered and subsequent lessons learned.

Programme Outcomes

There are many difficulties facing programmes trying to treat severely malnourished children in Bahr El Gazal and consequently these programmes often have extremely low coverage rates and relatively poor clinical outcomes. For example in Ajiep in 1998, coverage of the TFC was estimated by Epicentre as 12.5%. In Wau an evaluation of the MSF-H TFC programme estimated 10% coverage and in 1999, nutrition survey estimates of 33% coverage were reported in Panthou (9). In 2001 when Tearfund implemented TFCs in Aweil South and East they treated a total of 252 severely malnourished children. This is less than half that treated last year with CTC. Given this context the outcome data achieved by the Concern and Tearfund programmes is encouraging (see table 12.).

Staffing considerations

The primary issue for both agencies at programme start-up was staffing. The lack of a health structure in South Sudan meant that adequately trained local personnel were not available. While Concern opted to train and work with Community Health Agents (previously trained by an NGO supporting the health system), Tearfund brought in nurses from Kenya with prior experience in Therapeutic feeding. In the Concern programme, reliance on local staff adhered to principles of strengthening local capacity by training local people to carry out the Outpatient Therapeutic Programme (OTP). Though Concern managed to produce extremely good results using this strategy the poor clinical skill base of the community health workers placed considerable pressure on the supervisory team of more experienced Concern staff to attend all distributions. This created gaps in other areas of the programme, in particular the outreach strategy (see discussion below).

By contrast, the experience of the expatriate nurses employed in the Tearfund programme meant that there was greater confidence in the clinical decisions they made, particularly on the referral of complicated cases to the Stabilisation Centre (SC). However as the nurses were not local to the area, they had to work through translators and this may have limited their understanding of the complex social reasons for non-response. This helped recognition that the background and skills of the translators themselves were key to the acceptability and effectiveness of the CTC interaction.

Maintaining access to the population

1. Organisation of distributions and teams

In the Tearfund areas maintaining access to sites during the rains proved difficult with teams missing some scheduled distributions and 3 sites having to close due to cars not being able to reach them across swamp. One site however was maintained through flying teams into the area by plane. In comparison, in the Concern area, due to the network of rivers, the team was able to keep sites open using boats to transport teams and supplies. Additionally, as teams were comprised of local workers, they were able to stay out in the field for extended periods moving from one site to another by foot and thus keeping open sites that would otherwise have been logistically inaccessible.

Missed distributions, confusion due to changed distribution schedules and increased travel times/perilous journeys for the beneficiaries caused by site changes is likely to have had considerable negative effects on the programmes. Beneficiaries may judge the costs of attending in terms of time for other household/livelihood activities to outweigh the benefits and either default, or they may fail to attend in the first place. It is likely also, that where beneficiaries continue to attend more distant sites they themselves bear the increased burden in terms of opportunity costs and risks (of accident or injury). This is a cost that does not enter into programme statistics. Default rates were high in both programmes but in the absence of a coverage survey it is not possible to assess the effect on non attendance. During a Valid anthropology study however the main reasons given for nonattendance were access due to rains and harvesting activities. These concerns will be more pressing where travel times are longer.

The example brings out one of the key dilemmas experienced by teams in the field implementing CTC, that of striving for rapid programme quality versus prioritising effectiveness past the initial stage. The lesson learnt from South Sudan is that the ability to be flexible, to accept less than perfection in order to reach more children and to reach them in a dependable and potentially sustainable way results in a more effective programme.

The Concern strategy of working with local teams, may have meant that teams took longer to get to grips with the OTP protocols and required heightened supervision at the outset, but ultimately they were able to maintain access to the programme for the population at minimised cost through maintaining decentralised sites dependably. In terms of lives saved therefore, some compromise whilst maintaining good quality of the programme through supervision, seems warranted.

2. Involvement of the community

Both programmes learnt that it was vital to involve the community both during the initial setup and on an ongoing basis during implementation if good access to the population was to be established and maintained. Before starting, the programmes consulted local leaders/key figures in their areas to inform them about the programme and illicit help with the initial location of sites. Despite this there were problems encountered as mentioned above which led to high default rates during the rains. It was therefore clear that a more detailed process involving the community in the profiling of sites under various different rain scenarios would be useful and that even after the programmes had started there was a pressing need for continual consultation and adjusting programmes accordingly. The anthropological study gave some insights into potential barriers to access but a system of routine consultation through meetings with benficiaries and elders would have alerted staff to the issues much sooner.

Importance of the Outreach Strategy

The CTC model has always seen outreach and community mobilisation as vital elements in successful programmes. However experiences in South Sudan are that despite this emphasis on outreach many factors can get in the way of implementing successful outreach programmes. Some of the most important lessons that we have learnt, are how to avoid these pitfalls.

1. Selection of Outreach Workers

Outreach workers were recruited in both programmes to mobilise the community and to conduct case-finding and follow-up of children through home-visits. In the Tearfund area literacy was a condition of this recruitment with the result that mainly young men were hired. This meant that reports could be filled in correctly. However the young male outreach workers were poor at understanding the issues surrounding poor response to treatment and were therefore inappropriate as support and advice givers to mothers in the home.

Conversely Concern chose outreach workers from mixed backgrounds and literacies, including some women. A system of teaming groups of 3 outreach workers, one of whom was literate was put in place to facilitate reporting. However supervision of the system was poor and was not prioritised. Therefore although impressions were that women from the local communities would make far more appropriate outreach workers, Concern did not capitalise on this potential for more appropriate home visits.

Simplification of reporting as well as teaming up illiterate and literate outreach workers could reduce the requirement for literacy. Currently Valid is investigating this and the use of pictoral reporting forms for the future.

2. Prioritisation

Both programmes suffered from a lack of outreach development in terms of incoherent case finding strategies and inadequate systems to follow-up poor responders and tracking of children transferred between programme components (SC, OTP). The root of these problems was the lack of prioritisation given to these activities due to staffing and time constraints. In both areas teams suffered from high staff turnover and their need to focus on mastering the new protocols. For the Concern programme, the stabilisation centre made huge demands on the expat project managers and diverted their attention away from the less tangible and less obvious issues surrounding outreach and mobilisation. The implications of this were erratic case finding, poor follow-up of defaulters, and uncertainty over the outcomes of transfers between programme components.

The prioritisation of the outreach system and of developing a comprehensive strategy with strong supervision and management, is vital. However for over-worked supervisory staff on the ground, making a choice between children and mothers in front of them or those still outside the programme is almost impossible.

"If I had to do it over a gain, I'd take a day away from supervision to add to mobilisation - but it wouldn't be easy to do with children and mothers in front of you needing help." - Expat Nutritionist Concern Worldwide

This has been a vital lesson learned in the South Sudan context and has led both NGOs to place greater emphasis on outreach in terms of staffing and strategy development in proposals for next year.

Implications of the Wider Food Security Context

Discussion with beneficiaries and staff revealed sharing of plumpynut to be widespread throughout the programmes. However despite this, the proportion of recoveries (>85% WFH) was reasonably good (table 12). Length of stay was calculated midway through the two Tearfund programmes in Malualakon and Tieraliet to be 40 days and 68 days respectively. However both teams reported a reduction in recovery rates coinciding with a 3 month gap in WFP food distributions as a result of logistical difficulties. Whilst 50% of the population was targeted to receive a 50-75% ration based on WFP needs assessments, from July to September (traditionally the hunger period) WFP were only able to provide less than 10% of this planning figure. This raises important and long debated issues of the appropriateness of this or indeed any feeding programme in the absence of a general ration.

The CTC model very clearly places CTC within a hierarchy of interventions, the first and foremost of which is the general ration. In the absence of a general ration the food supplied within the CTC programme is at times the sole source of nutrition for the whole family. This example highlights the interdependence of selective feeding and general ration.

Table 12: Outcomes of Concern Worldwide and Tearfund CTC programmes, South Sudan
	Concern Worldwide3						Tearfund4
	SC		OTP		Combined		SC		OTP		Combined
Exits	n	%	N	%	n	%	n	%	n	%	n	%
Discharged	190	92.2	419	64.6	419	73.4	216	93.5	522	78.1	522	81.8`
Death	5	2.4	3	0.5	8	1.4	6	2.6	3	0.4	9	1.4
Default*			99	15.3	99	17.3			98	14.7	98	15.4
Transferred to Hospital/SC	11	5.3	107	16.5**	24	4.2	9	3.9	45	6.7	9	1.4
Other (nonrecovered)			21	3.2	21	3.7
Total	206		649		571		231		668		638
Registered on closure	0		39		39		0		58		58

Notes:

*Some mortality in the OTP will be hidden in the defaulter category. Without adequate follow-up it has not been possible to estimate the extent of this.
**The rate of transfer to SC/Hospital for the Concern programme is particularly high as children not recovering well in the OTP were transferred to the Concern SC (94 transfers-14.5%) for a short period to aid their recovery.

Future programmes

One of the core features of the CTC approach is integration with the existing health system and with other programmes. Given the lack of any national health structure in Bahr El Ghazal, integration at this stage can realistically focus only on other NGOs, longer term projects and on community structures. Some achievement in this area came through Concern's training and involvement of CHAs in the programme thus creating a potential future resource. Future programmes may try and integrate some OTP sites with the sparse NGO supported health units. In addition, Tearfund developed a close working relationship with the MSF nutrition programme in their area, linking with the TFCs for referrals.

One of the key tasks for future programmes will be to maintain decentralised sites, thus minimising costs to beneficiaries and maximising coverage whilst ensuring that site numbers are kept at a minimum to allow for increasing participation of other NGO supported health structures. This can only take place if interventions occur in a timely manner that allows sufficient time for community engagement from the planning stage as well as for logistical pre-planning, site profiling and pre-positioning of food. For any selective feeding interventions to be successful timeliness is vital.

---

Case Study 1

¹Serves a population of 2.4 million.

²On discharge from the OTP children were referred to the SFP for a minimum of 2 months.

³Employment Generation Schemes - form by which General Ration is distributed in Ethiopia.

Case Study 3

¹Feeding Programme Coverage Survey for Severely Malnourished Children Dowa and Mchinji Districts, Malawi. April 2003. T. Feleke & M. Myatt.

²Nutrition surveys have highlighted that there is no significant difference in rates of severe acute malnutrition over the seasonal hungry period of 2002 and 2003. Nutrition survey results were 1.1% (CI: 0.1-2.0) in Jan 2003 and 0.7% (CI: 0.2-2.2) in Jan 2004.

³The impact of the human immunodeficiency virus type 1 on the management of severe malnutrition in Malawi. L. Kessler et al; Annals of Tropical Paediatrics (2000) 20, 50-56.

Case Study 4

¹Concern nutrition survey March 03 Aweil North and West - GAM 24.3%, SAM 4.7%. Tearfund nutrition surveys February 03 Aweil South - GAM 22.6%, SAM 3.1%. Aweil East - GAM 25.0%, SAM 5.6% (all in z-scores).

²Concern work in Aweil North and West from a central base at Mariel Bai and Tearfund in Aweil South and East from two separate bases in Malualkon and Tieraliet.

³Programme implemented from June 03 to January 04

⁴Programme implemented from April 03 to November 04

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Kate Golden, Tanya Khara, Kate Sadler, Alem Abay, Anna Taylor, Jennifer Martin and Ed Walker (2004). Case Studies (Special Supplement 2). Field Exchange, Issue No 102, November 2004. p14. http://fex.ennonline.net/102/chapter3