Integrating CTC in health care delivery systems in Malawi (Special Supplement 2)

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.

Integrating CTC services into the district health system and community

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

HSAs helped by Concern supervisors record the progress of OTP children in Malawi.

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

Platform provided by the emergency programme

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

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

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.

A traditional healer in Malawi.

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

Stock movement and accountability

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

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

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.