CTC in North Darfur, North Sudan: challenges of implementation (Special Supplement 2)

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

People waiting at a clinic in Darfur, North Sudan.

Child eating plumpynut® in Darfur, North Sudan.

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.

*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.

Key programme activities

Phase 1 care in a rural hospital in Darfur, North Sudan. Figure 2. Pictorial card

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

The challenging landscape of Darfur North.

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

One of the OTP decentralised distribution sites in Darfur, North Sudan.

Transportation of UNIMIX for the OTP and SFP programmes in Darfur, North Sudan.

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.

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.