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

Isolated village in the highlands of South Wollo, Ethiopia.

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

In December 2002, nutrition surveys 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.

A mother and child wait to see the OTP nurse in Ethiopia.

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

• Timely set up
  Within just a few days, it was possible to add the OTP component to each existing SFP site, with all sites becoming activated within a six week period.
• 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.

Concern outreach workers measuring MUAC of potential beneficiaries in their villages, Ethiopia.

Concern outreach workers measuring MUAC of potential beneficiaries in their villages, Ethiopia.

All equipment needed for the OTP distributions (apart from the SFP food) fits on top of a landcruiser in Ethiopia.

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

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

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.

Mountainous terrain proved a challenge to gaining access to the population of South Wollo, Ethiopia.

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

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

Future Challenges: moving into a period of handover

The South Wollo highlands, Ethiopia. Ethiopia

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

Priorities over this transition period are:

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.

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

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.