Adopting CTC from Scratch in Ethiopia (Special Supplement 2)

By Hedwig Deconinck (SC-US Ethiopia)

Save the Children USA (SC-US) implemented an emergency health and nutrition programme in Sidama zone of SNNP region of Ethiopia, in response to the 2003 food crisis. Historically Sidama was one of the most food secure zones of Ethiopia, classically a rich coffee growing area, situated in the enset¹-belt of Ethiopia. Over the last few years, however, erratic rainfall associated with an exhausted economy has led to failing agriculture, decline of coffee and livestock markets, reduction in land holdings and subsequently, threatened lives and livelihoods. Other contextual factors in the region include inadequate health access, inappropriate child feeding and caring practices, poor water and sanitation and high population pressure. During 2003, these factors combined to produce a rapid deterioration in the nutritional status of the population. A nutrition survey carried out in Awassa Zuria district in April 2003, gave alarming results² and triggered our emergency response.

SC-US started health and nutrition response activities on April 20, 2003 and over the next seven months, opened 12 centrebased Therapeutic Feeding Centres (TFCs). These were followed by three outpatient therapeutic programme (OTP) sites, and eight supplementary feeding programme (SFP) sites in 11 woredas.

CTC Implementation

On the first of August 2003, SC-US opened the first therapeutic feeding centre (TFC) at the Malgano health post compound in Hulla Woreda. This centre admitted 357 severely malnourished children during the first six weeks of opening, pushing its capacity limits to a critical level. In response, in mid- September, with the assistance of Valid International, SC-US transformed the existing nutrition programme to a Communitybased Therapeutic Care (CTC) programme. The team chose Hulla Woreda as the pilot site because the TFC was overcrowded and there was a shortage of water (2.6 litres per beneficiary, well below Sphere standards of 20 litres water/per day/per person) and collapsed latrines. The SFP was also about to be opened in Hulla and it was felt that the conversion of the therapeutic feeding centre (TFC) to a stabilisation centre (SC), and integrating an outpatient therapeutic feeding (OTP) and outreach programmes with the SFP, was a logical step.

The neighbouring districts of Arbegona and Bensa started CTC later, in October and November 2003, respectively. Figure 3 shows the map of the three districts with OTP/SFP distribution sites. All of the CTC programmes used the single, Hulla-based stabilization centre for referral of medically complicated cases. In each site, the CTC programmes included an extensive health education element, addressing child nutrition, hygiene, malaria prevention and control, intergrated management of HIV/AIDS and childhood diseases for beneficiaries and communities. The education element included traditional leaders, health workers, traditional healers and birth attendants. In addition, food security strategies were discussed and promoted involving Ministry of Agriculture extension workers.

Programme Results

By February 2004 1,470 severely malnourished beneficiaries had been treated in the OTP, of which only 264 (18%) had to be admitted to the SC because of complications. In addition, 5,558 moderately malnourished beneficiaries had been treated in the three SFPs. Important increases in beneficiary numbers came as a result of intensive community sensitisation, extension of active case-finding and outreach activities, and the opening of new decentralised distribution sites. Figures 4 and 5 show the monthly OTP and TFC/SC admissions and discharges, while table 14 summarises some of the performance indicators for all components of the CTC programme.

In December 2003, Valid International conducted an anthropological survey in Hulla district, to determine the acceptability of the CTC programme to the beneficiaries and strategies for improving coverage. The survey revealed that no systematic barriers to the programme existed. In addition, the community showed a remarkable consistency in understanding the types of malnutrition and the need for referral.

In January 2004, Valid International conducted a coverage survey, using the centric systematic area sampling (CSAS) approach to assess CTC programme coverage in Hulla and Arbegona districts. The coverage results were excellent, OTP coverage was 78.3% and SFP coverage 86.8%. The success of the CTC programme in accessing the population can be attributed mainly to the intensive outreach programme, where outreach workers closely monitored children of affected communities and provided health education at grass root level.

Lessons Learned

Transition to community-based intervention

During the peak of the food crisis, the response activities were concentrated on saving lives. Prior to CTC, severe malnutrition was treated as a deadly individual clinical condition, disregarding the needs of the wider family or community. The opening of many centres initiated a growing concern within the SC-US team about creating parallel structures, without involving and empowering communities or building upon existing community structures, such as health posts, EPI teams, community health workers. The momentum was created within the team to look for a more communitybased response and therefore, a more sustainable approach.

Perception at the community level

No community resistance was encountered when transitioning from TFC to OTP, apart from among the TFC staff, who feared losing their jobs. Carers and community leaders could see the valuable reduction in opportunity costs and therefore, the potential positive impact of the home-based approach on the families and the community in general, particularly as the planting season was starting. During the first days of CTC start-up, caregivers were given the choice of joining the outpatient care programme or staying in the centre. All caregivers opted for going home. An informal poll was taken a few weeks later, among outpatient caregivers who previously had been in centre-based care. This revealed that the great majority of caregivers were satisfied with the new type of home treatment. A major recognised advantage was the ability for caregivers to participate in resolving the malnutrition themselves, "I start to live without worry", "My heart rested".

* This includes children transferred to the TFC or to the Hospital due to deterioration

Donor and government interest

A father brings his child to the OTP site in Ethiopia.

At an early stage of the 2003 emergency response, UNICEF implemented a nation-wide training programme on the inpatient management of the severely malnourished. In June 2003, a consensus building meeting, including government officials, UN/NGOs, academics and donors, agreed the adoption of the centre-based therapeutic feeding centre model as the national protocol. Given the adoption of an exclusive inpatient strategy for the treatment of severe malnutrition in Ethiopia, and despite some interest, there was a generally circumspect attitude towards the community-based approach. Clinicians within the TFC programmes were initially reluctant to move towards the new CTC approach. However, once CTC was started, all the clinicians soon saw for themselves the positive outcome of the outpatient care and the vast community advantages possible, with little compromise on clinical treatment protocols. Government officials in SNNPR were flexible and showed increasing interest in the CTC implementation, expressing the wish to learn more and have access to research information or publications. Donors, who were consulted and informed prior to the change in strategy, were open-minded and encouraging and followed the CTC implementation with interest.

Sensitisation and empowerment of national services and the community

A volunteer demonstrates how to cook FAMIX for SFP and OTP carers in Ethiopia.

The CTC approach promotes intensive collaboration and sensitisation of local government, communities and families from the beginning. Our experience in the three districts has shown that increased involvement of local officials resulted in increased commitment and interest. Moreover, the innovative approach excited and empowered officials and broadened their interest to be involved in the nutrition response. At the community level, the programme involved local leaders, elders, traditional healers and birth attendants as active partners, hence increasing the flow of eligible beneficiaries into the programme. Conflict and distrust sometimes emerge during emergency nutrition programmes when the community is not aware of, or does not understand, the programme protocols. The Valid anthropological study in Hulla has shown that informing people about targeting, admission and discharge criteria, and malnutrition management provides a firm understanding and creates a momentum for achieving integration.

Sustainability in the longer term

The CTC programme strategy is based on the idea that emergency programmes should 'leave something behind', i.e. lead into development programming and sustainability.

Children registered in the OTP programme receive a test dose of plumpynut® on each distribution day in Ethiopia.

The emergency programme of SC-US in Sidama may not develop into a longer-term development programme. Nevertheless, district officials of Arbegona and Bensa have expressed their commitment for health facilities to take over the outpatient programme and the transfer process has started. Unfortunately, Hulla district has very few staffed health posts so that integration into the local structures will be more difficult. However, at least the stabilisation centre is now fully integrated in the health centre of the district capital. An important factor adding considerably to CTC sustainability is that from the start, zonal and district health staff were seconded to the CTC programmes. We believe they are potential trained collaborators for the continuation of CTC, both in response to future emergencies (where NGO support may again be available) or for a longer term ministry operated programme in the future.

¹"Enset ventricosum", is a separate genus of the banana family, thus named 'false banana'. The pseudostem and leaf midribs are scraped to pulp and fermented to prepare a low protein steam-baked flat-bread consumed as a staple or co-staple food.

²Awassa Zuria, April 2003, DPPC 18.7% global acute malnutrition, 2.2% severe acute malnutrition, under-five mortality rate 3.0 deaths per 10,000 per day, while the next harvest was not expected for another 2 to 4 months.