Temporal Integration - Demand driven CTC (Special Supplement 2)

By Steve Collins

A small scale market in South Sudan

Early CTC programmes prioritised the timely provision of an appropriate level of care to a large proportion of the target population and monitored this using the standard SPHERE indicators plus assessments of coverage. The CTC principles of sectoral integration and capacity building through engagement, dialogue, exposure and training (see introduction), received a lower prioritisation.

More recently CTC programmes have demonstrated that it is essential to work with 'community resources' and local health care providers right from the earliest planning phases of intervention if impact and the potential for sustainability are to be realised. Such engagement requires planning, specialised human resources and prioritisation. Currently formal indicators are being developed with which to monitor and assess the extent that any CTC programme is actively promoting participation and understanding.

An important strength of CTC programmes is that they offer a high potential (far greater than centre based interventions) to motivate mothers and health care workers. Investigations are underway on how better to harness this motivation to promote longer term improvements in health and nutrition, through developing local demand for CTC. These CTC programmes are prioritising exposure, dialogue engagement and training over coverage and timeliness.

The dangers of a supply side drive

Achieving rapid coverage and impact requires high levels of external human and material resources and a detailed formal implementation plan. During the first few CTC projects, pressure to achieve fast results diverted attention away from engagement and dialogue towards logistics and screening. In several projects, external pressure to admit all severe cases into inpatient care exacerbated these problems, diverting additional resources towards inpatient care. This may be typical of all emergency interventions.

This 'supply side' pressure to disperse large quantities of external resources in a short space of time successfully facilitated rapid programme expansion and OTP coverage. However it caused many unwanted and damaging side effects, tending to alienate local people; undermine local ownership and community participation; shift the focus towards individuals and away from affected communities and remove responsibility for caring for the sick away from the community towards 'professional' paid extension workers. These undermined traditional support mechanisms and created a damaging link between the motivation to care for or follow-up sick children and financial gain.

Experiences to date demonstrate that it is essential to involve local health care providers (usually the MoH) right from the planning phase of programmes in a manner that ensures they feel some ownership over the programme and to ensure that where possible, CTC activities are integrated with existing services. At the beginning of a programme, time spent working with the local MoH may not produce immediate tangible results and can appear frustrating, giving the impression of slowing down the initial implementation. For example, bureaucratic requirements might delay start-up of OTP sites; local officials might be difficult to track down and meet etc. However in all CTC programmes to date, the benefits of these early interactions have greatly outweighed the initial frustrations both in the shorter term and later, as programmes attempt a transition towards a more sustainable footing.

Motivation and credibility

CTC programmes have demonstrated clearly that if caught early before complications develop, severe acute malnutrition is usually very easy to treat. Treatment requires little more than the regular provision of high quality food, something that is universally understandable. This realisation has allowed the de-medicalisation of treatment for most cases of acute malnutrition, reducing the need for medical expertise, reducing the cost of treatment per patient and allowing access to treatment to be more decentralised. This makes CTC potentially more attractive to the local health service providers, communities and those suffering from malnutrition. The realisation that if caught early enough, most cases of severe acute malnutrition are easy to treat, has allowed CTC programmes to return the responsibility for care to mothers, families and communities. In the vast majority of cases, simple understandable care delivered by parents, creates marked changes in mood, appearance and activity within a very short space of time. These positive changes are obvious to parents, health care workers and the wider communities and are an extremely powerful motivating force. The power of this motivation is profound and stimulates demand for and uptake of CTC. If nurtured and used appropriately, this motivation encourages mothers and traditional practitioners to refer children to CTC and improves compliance to treatment regimes (see section 5.1.2). It is also apparent that linking the successful treatment of individuals by their families with local health care workers motivates these workers and enhances their credibility amongst the local people. This credibility is often lacking, but is vital if CTC interventions are to move from the present supply side approach to an approach where people are demanding CTC and supporting its service delivery. The challenge facing CTC now, is how to harness effectively this motivation and credibility to deliver CTC at district and national level through existing health structures over the long-term.

Positive deviance (Success breeds success)

One of the mothers helping to identify other severely malnourished children in her community in Ethiopia. Valid International, 2003.

The key to stimulating demand is exposure of people to the positive effects of CTC at both the individual and institutional levels. The original CTC concept contained a strong element of positive deviance, similar but not identical to the hearth principles, wherein carers who had treated their children successfully were supposed to support and mentor other carers entering the programme. In practice, the low density of severe acute malnutrition in villages has generally precluded the formation of CTC mothers and carer groups. Instead, programmes have successfully worked with mothers who have already been through CTC and consequently understand the CTC regime of how to recognise severe acute malnutrition. In several programmes such women have successfully supported carers as their children pass through the CTC programme, and performed case finding and followup activities.

The positive deviance principle can also work at a structural level and can be harnessed to facilitate the roll out of CTC programmes to a wider population. Successful OTP sites, implemented by local health care providers are a pre-requisite for linking the motivation and credibility associated with well functioning CTC to longer term programming at district and national levels. Current CTC programmes attempting to create longterm programmes are looking at the effect of focusing on well run, well motivated OTP sites rather than waste efforts on sites with little chance of success. These successful 'starter sites' become demonstration and training facilities to expose a wider audience of key actors to the realities and benefits of successful CTC interventions. Successful starter sites can only be chosen with full participation of the local actors, or in the case of transition, after lengthy observation of the actual function. The next priority is to expose key people to these sites creating interest and stimulating demand. Initial experience indicates that once local, district and national health staff and community leaders have seen CTC they are motivated by the success they see and they