CTC in South Sudan - A Comparison of Agency Approaches and the Dilemmas Involved (Special Supplement 2)

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

OTP child with mother, South Sudan.

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.

Transport challenges for Tearfund OTP teams in South Sudan.

OTP sites are accessed by boat and motorbike in South Sudan.

General ration supplies are air dropped by WFP in South Sudan.

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.

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.

The South Sudan landscape.

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.

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