CTC Approach (Special Supplement 2)

by Steve Collins (Valid International)

2.1 Main principles of CTC

Community Therapeutic Care (CTC) is a community-based model for delivering care to malnourished people. CTC seeks to provide fast, effective and cost efficient assistance in a manner that empowers the affected communities and creates a platform for longer-term solutions to the problems of food security and public health. Central to CTC are basic public health and developmental principles. The most important are:

• Coverage achieved by providing people with good access to services and engaging with local communities and infrastructure.
• Engagement with, and the participation of, local communities and structures.
• Appropriate levels of intervention, commensurate with resources.
• Sectoral integration.
• Capacity building.
• Timeliness.

All CTC programmes aim to treat the majority of severely acutely malnourished people in their homes, not in Therapeutic Feeding Centres (TFCs) or Nutritional Rehabilitation Units (NRUs). The aim is to utilise and build on existing capacities, using only a few highly professional staff (few expatriate staff) to facilitate the process, rather than using large external teams and creating parallel structures. In doing so, CTC helps equip communities to deal more effectively with future periods of vulnerability. CTC is complementary to traditional TFCs and Supplementary Feeding Programmes (SFP), integrating them into a broader framework that better takes into account the social, economic and political realities of food insecurity and malnutrition. Through decentralizing distributions, engagement with communities, working with local health care providers and outreach, CTC improves access to services, case finding and follow up, all traditional weaknesses of the 'Therapeutic Feeding' model of intervention (10).

Most of the interventions that make up a CTC programme are usual elements in humanitarian relief operations, i.e. SFP, TFC, RUTF, outreach, food security interventions and nutritional surveys. CTC combines these traditional elements with new interventions, such as Outpatient Therapeutic Programme (OTP), specialised coverage surveys and the local production of RUTF. The approach directs and prioritises resource allocation between them, according to strong public health and developmental principles such as coverage, local ownership and participation.

An important principle in CTC is that programmes must be adapted to the context in which they operate. Consequently, CTC programmes take many different forms, depending on opportunities and constraints. In its simplest form, a CTC programme consists of a SFP, OTP, and measures to engage with and encourage the participation of the local community. Other CTC programmes might include the fuller range of intervention instruments, such as SFP, OTP, mobilisation & engagement, outreach, SC, food security and local production of RUTF.

2.2 CTC classification of acute malnutrition

During the development of CTC, a modified classification of acute malnutrition has emerged that fits better with the new range of therapeutic options that CTC proposes. The present WHO classification consists of moderate and severe categories, defined according to anthropometry and the presence of bilateral pitting oedema (1). This classification was appropriate and operationally relevant when the modes of treatment were inpatient Therapeutic Feeding Centres (TFC) for severe acute malnutrition, and outpatient Supplementary Feeding for moderate acute malnutrition. However, CTC has three treatment modes and in order to be operationally relevant, the new system of classification adds a category of 'malnutrition with complication' to the present severe and acute categories. This new classification is presented in Table 2.

Malnutrition with complications is characterised by anorexia and life threatening clinical illness. It can occur in either severely or moderately acute malnourished people. In practice, the assessment of whether malnutrition is complicated or not dictates whether patients are admitted for inpatient care or treated as outpatients from the start. A failure to use the 'malnutrition with complication' category results in several negative consequences for both patients and nutritional projects. The data from CTC programmes to date demonstrate clearly that children with severe acute malnutrition but no complications, do not require inpatient care in order to recover (see table 3). Admitting such patients into TFCs needlessly exposes them to additional risks of nosocomial infections, while forcing the carer, usually the mother, to separate from her family and other children. This increases malnutrition in siblings and undermines the economic activity and food security of the household (5). In addition, unnecessarily admitting people without complications into inpatient TFC care, takes up space at TFCs. At the same time, by not invoking a category of 'malnutrition with complications,' programmes do not admit cases of moderate malnutrition with complications into inpatient care, thereby leading to increased morbidity and mortality.

2.3 CTC Nomenclature

There is a clear nomenclature describing the differing constituent elements of a CTC programme. This allows us to be more specific about how CTC works in practice, and clear/transparent/obvious about vital differences in prioritisation between CTC and other Home Based or Ambulatory Treatments (HBT) and TFCs (12).

Many of the elements in a CTC intervention are normal relief interventions and most of the terms used in CTC are the same as those used in the WHO or other manuals on nutrition. However, there are important differences. The section below uses the definitions of "stabilisation" and "Outpatient Therapeutic Programme" to highlight important differences between the implementation of TFCs and HBT on the one hand, and that of CTC on the other.

Stabilisation

The stabilisation phase in CTC is the initial inpatient phase of treatment of severe malnutrition with complications. The aim of stabilisation is to identify and address life-threatening problems¹, begin to treat infections, start correcting electrolytic imbalances and specific micronutrient deficiencies, and begin feeding. This is the same as in the WHO guidelines for the initial treatment of severe malnutrition (1). However there are important differences between TFC and HBT:

1. In CTC, the stabilisation phase of treatment only applies to patients with acute malnutrition with complications (see table 2). By contrast, all standard TFC guidelines and the Home Treatment model of ACF recommend that all cases of severe acute malnutrition are admitted into inpatient care.
2. In CTC, patients are discharged from the stabilisation phase into outpatient care as soon as their appetite returns and signs of major infection disappear, irrespective of their weight for height or whether they are gaining weight or not. This is different to documented TFCs and the HBT models (3;13).
3. Resource allocation to stabilisation care is accorded a lower priority than the resource allocation to outpatient therapeutic care. CTC programmes only direct resources towards stabilisation care once sufficient resources are available to ensure good outpatient therapeutic programme (OTP) coverage and good community understanding and participation. The articles on community mobilisation, Ethiopia, and South Sudan in this supplement discuss more issues surrounding prioritisation.

In practice, this represents fundamental differences in the prioritisation of resources. In CTC, stabilisation care is restricted to a very small and select group of patients, with the aim of providing good access to outpatient care in a timely manner before children have developed complications. In practice, experience shows that only 10-15% of severe cases require stabilisation care (see table 3). This clearly defined narrow role means that stabilisation centres (SC) are small, require little in the way of infrastructure and need only one or two skilled staff. By contrast, TFC phase 1 care treats ten times more patients and must take place right from the start of TFC programmes.

The difficulties of trying to mix the TFC model of care with CTC became apparent in Malawi, where the national TFC/NRU strategy resulted in an early introduction of inpatient care for all cases of severe acute malnutrition. These inpatient centres soon became crowded and less efficient and drew heavily upon resources and staff time, diverting attention away from coverage, participation and mobilisation activities (see section 5.1.2). The result was that SC staff had more children to treat and less time to devote to each child, leading to reduced levels of care and increased recovery times. This decreased patient throughput, which in turn increased overcrowding. This vicious cycle only stopped when of necessity, CTC was prioritised, with patients admitted and discharged according to the CTC criteria.

Outpatient Therapeutic Programme (OTP)

OTP admits people suffering from severe acute malnutrition defined, essentially, according to standard WHO definitions². There are two groups of admissions into OTP; those who are admitted directly to OTP from the community and those admitted indirectly via a stabilisation centre.

Direct OTP admissions are people with severe malnutrition without complications, admitted into the outpatient programme with no period of inpatient stabilisation treatment. In practice, this category accounts for approximately 85% of OTP admissions (see table 3). It is essential to admit these uncomplicated cases directly into OTP in order to enable CTC programmes to achieve coverage. Direct admission into OTP without inpatient care is an important difference between CTC and HBT.

Indirect OTP admissions are people who presented suffering from malnutrition with complications and who received initial inpatient stabilisation care in a stabilisation centre before being transferred into OTP.

2.4 Coverage

In 2003, specific coverage indicators for selective feeding programmes were included in the SPHERE project's humanitarian guidelines for the first time (14). Impressions from the field and existing data strongly suggest that TFC coverage is usually very low. For example, in one of the few published studies looking at TFC coverage in humanitarian crises, Van Damme estimated coverage rates for TFC programmes treating severely malnourished refugees in Guinea to be less than 4% (6). The recent coverage data obtained during the emergency response in Malawi estimated coverage rates as often only reaching 10% in the rural areas, after 10 months of interventions (15). In some situations, such as camps or urban centres, coverage may be higher. For example, in 2003 in Blantyre, Malawi, coverage rates of 60% were reported (15).

Low coverage can also occur in CTC programmes. Interim results from a CTC programme in South Sudan in 2003 found that a combination of insufficient attention to community mobilisation at the start of the programme and a difficult context, resulted in coverage rates of 35%. Similarly in Malawi 2003, insufficient attention to engaging with the local communities at the start of the programme resulted in coverage rates not rising above 30% for the first three months of the programme (see section 3.2).

Attaining good coverage in emergency CTC programmes requires certain essential steps to ensure physical access, understanding, acceptance and participation:

• Distribution sites should be as decentralised as possible, and where feasible, sited only after dialogue with the communities that they serve. The article on the CTC programme in Darfur (section 3.3) discusses the issues and compromises that must be made to balance decentralisation and physical access, with cost and practicalities.
• Experienced staff should engage in a two way dialogue with local communities to inform them about the programme and listen to their concerns. Where possible, the concerns of the local population should direct programme design. This process of negotiation is central to CTC, and several of the articles in this supplement describe different aspects of this.

Attaining a reasonable coverage of the target population is essential if selective feeding interventions are to achieve impact. The negative impacts of low coverage are hidden; children suffer and die quietly in their homes without ever being registered in a programme or being seen by local workers, at best they appear as abstract mortality statistics. By contrast, those admitted to inpatient facilities become very visible, and form one to one relationships with staff in whom their plight elicits powerful emotions. This all produces considerable pressure to direct resources towards inpatient care, even at the expense of overall programme impact.

The clinical focus of therapeutic feeding research has also directed attention away from coverage. The new manuals based on recent research have increased the medicalisation of therapeutic interventions, proposing treatments that are more complicated (16). In small, well staffed and well run centres these new techniques undoubtedly improve the outcomes for individuals suffering from severe complicated malnutrition. However, the reality of resource and capacity constraints in the contexts where severe acute malnutrition is common, means that this intensity of treatment can only be delivered to a very small proportion of the severely malnourished. Attempts to base large scale strategies on these new protocols alone in Malawi in 2002 and Ethiopia 2003, without instituting widespread OTP programmes, have resulted in very low coverage and as a result, low impact (17). Mature CTC programmes require high quality inpatient stabilisation care. Embedding SCs within CTC helps such protocols work with other interventions to maximise impact, rather than compete with them and divert resources towards only a small percentage of those who need care. To maximise impact through optimising the balance between coverage and individual intensity of treatment, programme planners must ensure that OTP for uncomplicated cases is prioritised and reserve these intensive inpatient techniques for those with complicated severe acute malnutrition.

The absence of a suitable tool to assess coverage has deflected attention away from this vital issue. Previously, an adaptation of the WHO Expanded Programme on Immunisation (EPI) coverage survey method was recommended for assessing the coverage of selective feeding programmes. This method has many disadvantages and results in very imprecise estimates of programme coverage, that have wide confidence limits and are often biased or inaccurate (18). To address this, the CTC programme has invested in developing new survey techniques and in this supplement we present a new method of assessing coverage. This new technique has applications beyond selective feeding programmes and promises to be influential in improving targeting and resource allocation in a range of humanitarian and developmental interventions.

2.5 Participation

Involving local communities and the local health infrastructure from the start of CTC programmes is vital. For example, in Malawi, anthropologists researching CTC and NRU programmes concluded that the existing social fabric of a Malawian village and the support networks therein are still, in spite of the HIV/AIDS epidemic, the most important resource available with which to alleviate the individual and social burden of malnutrition and HIV/AIDS (19). At the beginning of an intervention, time spent working with the local communities and the local MoH might appear to slow down initial implementation. However, in all CTC programmes to date, the ultimate benefits have greatly outweighed these initial frustrations.

CTC projects described in this supplement demonstrate that simple measures enacted in appropriate ways at the right time can minimise the alienation, disempowerment and undermining of community spirit often associated with externally driven interventions. Such measures have greatly increased impact and the potential for successful handover of CTC programmes in the medium term.

2.6 Prioritisation during emergency

This section tries to clarify how emergency CTC programmes prioritise the individual programme elements.

To date, the majority of research and development into CTC has focused on the emergency model of CTC, adapted to a rapid nutritional response in times of food crisis. This emergency model of CTC contains six basic elements that evolve over time: Supplementary Feeding Programme (SFP), Outpatient Therapeutic Programme (OTP), Community mobilisation and sensitisation, Stabilisation Centres (SC), Food Security (FS) and other sectoral interventions and local production of Ready to Use Therapeutic Food (RUTF). To ensure that the underlying principles of high coverage, community participation, and high impact are met, CTC involves a hierarchy of intervention that governs the allocation of resources and prioritisation of activities. A basic public health hierarchy for emergency relief programmes, that prioritises lower-input interventions with a large coverage of the vulnerable population above high-input services treating a relatively few, is well accepted (14). Few would argue that in food insecure areas, giving people access to sufficient basic food, usually through general ration distribution, should almost always be prioritised over therapeutic feeding. Further down the hierarchy, SFP should also be prioritised over therapeutic feeding³. CTC extends that hierarchy to within selective feeding, particularly to within therapeutic feeding.

During the initial stages of an emergency intervention, a CTC programme starts as three basic elements: SFP, OTP and community mobilisation. The SFP and OTP elements are designed in a decentralised manner, with multiple distribution points served by mobile registration and distribution teams. An active prioritisation of community involvement in programme activities must accompany these (see section 5.1.2). Some of the negative effects on coverage and on programme impact of not prioritising community involvement from the outset, are described in the article on South Sudan (see section 4.1).
An important lesson from many of the CTC programmes is that community mobilisation and participation is often possible with sufficient commitment, even during the most extreme nutritional emergencies where there may be high degrees of social disruption and fragmentation. However, CTC had not been implemented in highly insecure areas, in areas where access to the population is extremely limited or where there are very dispersed populations. These are contexts that led to the development of the initial CTC concept in 1998 (see section 1). It is only through attempting to promote participation and mobilisation under these conditions that what is feasible can be determined. This is one of the priorities for the next two years of the CTC research and development programme.

During the early stages of an emergency, CTC programme stabilisation care or purpose built TFCs are not prioritised. Experience shows that once dedicated stabilisation centres are set up, the project staff's compassion and desire to help the children they see before them, almost inevitably leads to them diverting a disproportionate amount of time and resources towards the few sick inpatients. Until there is good coverage and access for the majority of people with uncomplicated malnutrition, this diversion of time and resources decreases programme impact (see section 3.3). An important lesson from the CTC programme is that in this context, decisions over prioritisation must be made rationally and implemented through considered programme design, rather than left to the individual choice of overworked project staff in highly emotionally taxing situations. The article on the CTC programme in Ethiopia describes a positive approach to this difficult dilemma (see section 3.1) The article on integration with health services describes some lessons from this experience (see section 5.3).

Once OTP and SFP coverage have been attained and steps to promote community participation and ownership are well established, more resources can be diverted towards other interventions. At this stage, programmes increase attention towards providing inpatient care for those suffering from acute malnutrition with complications, developing the local production of RUTF, and implementing a wider range of activities aimed at addressing food security and other public health interventions.

2.7 Flexibility

Making CTC programmes work as effectively as possible with local people, health providers and infrastructure, requires flexibility. The core treatment protocols in OTP are dictated by objective physiological and medical requirements and are, therefore, fixed. Although short and simple the basic OTP protocols are only three pages long and can be taught to local primary health care workers in a day. The way in which these OTP protocols are delivered is, however, context specific. The staffing of OTP teams, the number and location of distribution points, the frequency of distribution, the selection methods for community nutrition workers, links with traditional practitioners; links with MOH structures, etc., all vary greatly, depending on the opportunities and constraints of the programme location.

By contrast, the TFC model of intervention must, of necessity, be more fixed and less flexible. Current TFC manuals run to 100 - 200 pages and contain highly detailed instructions that must be followed closely in order for a TFC to operate successfully. These rigid guidelines are necessary as TFC contain many immuno-compromised patients in close proximity to one another, an environment where the risks and the potential for cross infection are high. If treatments are to be successful and epidemics avoided, there must be strict adherence to generic measures for hygiene and sanitation, delivery of drugs and foods, water and supervision.

Table 3: Summary Information for CTC programmes
									Outcomes OTP and SC combined
Country	Year	Agency	Figures for Period	Ongoing or completed	No. SAM treated (OTP + SC)*	No. MAM treated (SFP)	Direct OTP Admission %	Coverage ^	Recovery	Default	Death	Transfer**	Non-recovery	Comment^^
Ethiopia - Wolayita +	2000	Oxfam	July 00 - Jan 01	Completed	1185	-	100%	-	-	-	-	-	-	see note +
Ethiopia - Hadiya***	2000	Concern	Sept 00 - Jan 01	Completed	170	3000	100%	-	85.0	4.7	4.1	-	6.5
N Sudan - Darfur	2001	SCUK	Aug 01 - Dec 01	Completed	836	25633	98%	30-64%	81.4	10.1	2.9	5.6	-
N Sudan - Darfur	2002	SCUK	Sept 02 - May 03	Completed	446	6019	69%	> 60%	65.1	6.5	7.9	20.5	-
Malawi - Dowa	2002	Concern	Aug 02 - Dec 03	Ongoing	1900	7564	19%	73.0% ^	69.4	15.0	8.9	3.0	2.8
Ethiopia - South Wollo	2003	Concern	Feb 03 - Dec 03	Ongoing	794	11573	95%	77.5% ^	74.6	9.7	7.5	-	8.3
Ethiopia - Wolayita (Damot Weyde)	2003	Concern	Apr 03 - Dec 03	Completed	194	3346	24%	-	69.6	5.2	7.3	10.5	-	4 registered on closure
Ethiopia - Wolayita (Offa)	2003	Concern	Aug 03 - Apr 04	Ongoing	445	4359	94%	-	83.5	5.3	1.5	9.6	-
Ethiopia - Sidama	2003	SCUS	Sept 03 - Feb 04	Ongoing	1232	3571	81%	78.3% ^	83.8	4.4	1.3	10.1****	0.5
Ethiopia - Hararge (Golo Oda)	2003	SCUK	Apr 03 - Jan 04	Completed	232	2332	99%	80.6% ^	85.8	6.0	4.9	3.3	-	49 registered on closure
South Sudan - BEG	2003	Concern	Jun 03 - Jan 04	Completed	610	3844	92%	-	73.4	17.3	1.4	4.2	3.7	39 registered on closure
Ethiopia - Hararge	2003	Tearfund	Jul 03 - Nov 03	Completed	696	5,433	71%	-	81.8	15.4	1.4	1.4	0.0	58 registered on closure
	2004	Care US	Mar 04 - May 04	Ongoing	280	-	-		Too early in the programme for meaningful outcomes
Total					9,020	76,674	-	-	76.5%	10.6%	4.8%	-	-

 

* for ongoing programmes total treated includes children still registered in the programme and for closed programmes those still registered on closure
** This represents transfers out of the programme to another agency TFC or a hospital that is not supported by the organisation
*** This was the only OTP programme with little mobilisation or community engagement
**** Includes those transferred to the SCUS TFC as we don't have separate TFC/hospital transfer figures.
^^ Children still registered on programme closure are not included in the outcome calculations
^ calculated using centric quadrant sampling design and 'optimally biased sampling' and using a recent period coverage calculation (see Section 4.4)
+ Data for this programme is excluded from the table. Many children were transferred to a TFC opened half way though the programme. As there was no follow-up of these children outcome data is misleading (Recovery 42.0%, Default 31.0%, Death 2.0%, Transfer 24.8%)

2.8 Choice and rights

The development of CTC has increased the range of options for individuals and communities affected by acute malnutrition. It has also increased the alternatives open to agencies and governments trying to address the problems of acute malnutrition.

The data from CTC programmes to date demonstrate that cases of severe uncomplicated acute malnutrition can be treated successfully in OTP programmes without the need for any inpatient care (see table 3). Upholding the rights of all those affected by severe acute malnutrition to access OTP treatment must be prioritised over providing those with uncomplicated malnutrition the choice of more expensive inpatient care. In all programmes where we have experience, almost all have opted for OTP. For those suffering from severe malnutrition with complications, our experience suggests that approximately three-quarters of the carers of children offered inpatient stabilisation, accept the offer.

2.9 Cost effectiveness

CTC and TFC approaches differ with regard to core expenditure and the potential for economies of scale. The TFC model is a 'fixed capacity model' and once a centre is full, other centres must be built. Apart from some economies relating to central offices and logistical support, building a second or third TFC requires a similar investment in terms of finance, materials and skilled staff, as building the first. This limits the potential for economy of scale. By contrast, the CTC model has high initial and fixed costs to recruit, train, equip and provide transport for the mobile teams, institute the decentralised logistics for food, and interact and mobilise populations. However once these are in place, a CTC programme can expand to treat several thousand severely malnourished people with little more than the extra costs of food and medicine (see section 4.5). These differences mean that the emergency CTC approach is not really suitable in areas with a low prevalence of acute malnutrition or in highly dispersed populations (see below).

2.10 Limitations of emergency model of CTC

The problem of decentralisation

The emergency CTC approach requires that OTP/SFP points are highly decentralised, located near to where the target population lives. The aim is for over 90% of the target population to live within a one day return walk of a point of access. The approach uses mobile teams that rotate between points on a weekly or fortnightly basis to facilitate the delivery of the OTP protocols, either directly themselves or where possible, supporting local clinic staff to do so. A pre-requisite is that teams have physical access to the OTP/SFP points. In our experience, this is not always possible and heavy rains making roads inaccessible, or insecurity, can prevent access. This is an important problem. In order to catch cases of severe malnutrition before they develop complications, people must have good access to OTP sites and must understand and have confidence in the programme. When carers and children have made great effort to attend an OTP distribution, a failure of the mobile team to turn up undermines this confidence, decreases attendance in subsequent distributions and increases barriers to early presentation and treatment. Such problems are partly responsible for the relatively low coverage rates of under 50% in the South Sudan programmes in 2003.

Low density of malnutrition

Even where access is possible, a low prevalence of acute malnutrition or highly dispersed populations make it difficult to balance ensuring access with maintaining cost effectiveness. In dispersed populations or those with a low prevalence of malnutrition, as coverage increases, there is a diminishing return, in terms of impact, of additional investments to create more sites or more mobile teams. For example, in North Darfur in 2001, the SC-UK team opened 110 distribution points using ten mobile teams to serve a population of under 500,000. On average, each OTP distribution site cared for only eight severely malnourished children during the five months of the programme, and could have easily dealt with five times that number with little additional costs other than for RUTF. This suggests that in areas with a low prevalence of acute malnutrition or highly dispersed populations, the emergency CTC model is not appropriate. Approaches are currently being developed to address some of these problems (see section 5.4).

Fragmented or absent communities

It is likely that there will be occasions where weak, absent or fragmented communities may reduce the potential for participation and mobilisation. However, even in the most extreme emergencies involving massive social upheaval, insecurity, displacement and destruction of classical communities, -'community' in terms of factors that contribute to identity, common understanding of meaning and experience, and common cultural perspectives -remain. This sense of community is robust against upheaval and may even be strengthened by external pressure. CTC can work with this wider definition of community to encourage participation, understanding and mobilisation.

Absence of health infrastructure

In some situations there is an absence of a formal infrastructure system of health care delivery. This situation is described in the articles on South Sudan (see section 3.4 and 4.1). However even in South Sudan, networks of health care providers; traditional healers and traditional structures with a health care function exist and their participation should be actively sought.

2.11 The CTC research and development programme

The CTC research and development programme aims to research, develop and promote the CTC approach to addressing the problems of acute malnutrition. The programme consists of core research, implemented by Valid International (Valid), and operational research/implementation field projects, implemented by a variety of NGO partners technically supported by Valid. The programme began in 2000 with collaboration between Valid, Concern Worldwide (Concern) and Oxfam, to implement initial projects in Bedawacho and Bollosso Sorie woredas in the highlands of Ethiopia. In May 2001, Valid again teamed up with Concern to implement a pilot CTC project in Damot Weyde woreda, Ethiopia, and with SC UK to implement a larger CTC project in North Darfur, Sudan. Although monitoring data and evaluations of these initial projects were positive (20), we felt that the research inputs and data collection were insufficient to really analyse their impact and learn better how to implement the model. Consequently, their use in changing international humanitarian nutrition policy was limited. To address these short-comings, in January 2002 Valid formalised the development process of CTC and started the CTC programme. Within this framework, Valid provides CTC support in the form of project design, improved data collection instruments, and research nutritionists working with the programme specifically to ensure that data collection is appropriate and of a high quality and to provide expert data analysis. These measures have successfully improved data quality and comprehensiveness, furnishing us with a large evidence base with which to improve practice. In July 2002, Concern joined Valid as partners in the CTC research and development programme. Todate, there have been ten com-ponent CTC projects (see table 4). In addition, since 2003, Valid has supported various NGOs to implement other emergency, transition and developmental CTC projects (see table 5).

Table 4 Summary of CTC programmes to date
Project site	Partner agency	Activity	Funding	Timing	Status
Ethiopia	Concern	Small CTC pilot with emphasis on transition phase	USAID/FANTA, WHO, Concern & Valid	2001-2	Data analysis
N Sudan	SC-UK	CTC	SCF & Valid	2001-3	Data analysis
DRC	SC-UK	CTC	CIDA, SC-UK & Valid	2002	Discontinued
Oxford	Oxford Brookes University	Quality control of Malawi local RUTF Development & testing of 2 alternative RUTFs	IA & Concern	2002-3	Write up
Oxford	Oxford Brookes University	Development & testing of 2 alternative RUTFs	USAID/FANTA	2003	Write up
Malawi	Concern	CTC	IA & Concern	2002-4	Data analysis
Ethiopia	Concern	CTC	USAID/FANTA	2003-4	Data analysis
Malawi	MoH & Queen Elizabeth Hospital Malawi; Washington State University, USA	Home treatment	USAID/FANTA	2003	Write up
Malawi	Concern	Integration of CTC and HIV	USAID/FANTA/SARA	2004	Ongoing
Malawi	Concern	Field testing of alternative RUTFs	IA & Concern	2004	Ongoing

 

2.12 Future developments for CTC

The existing data indicate that emergency CTC can achieve high coverage and good recovery rates, when implemented in an emergency context with the support of international NGOs (21). There remains a need to test the approach in a wider variety of emergency contexts such as in areas of high insecurity or in an urban environment. However, a more important challenge is adapting CTC to make it more suitable for implementation by local governments and other local actors on a longer term basis. Central to achieving this is to develop mechanisms that encourage demand for CTC and devolve responsibility for implementing CTC further towards the community (see section 5.4).

Table 5 Other Valid supported CTC projects
Project site	Partner agency	Activity	Timing
Ethiopia	SC-UK	Emergency CTC project	2003
South Sudan	Tear Fund	Emergency CTC project	2003
South Sudan	Concern	Emergency CTC project	2003
Ethiopia	SC-US	Emergency CTC project	2003-4
Ethiopia	CARE	Development CTC	2004
Malawi	Concern	Development CTC	2004
Malawi	MoH & Queen Elizabeth Hospital Malawi	Home treatment	2003-4

 

CTC 'in-situ'

In order to address the problems of dispersed, inaccessible populations, attempts are being made to develop an 'in-situ' approach to CTC. This approach further devolves responsibility for delivering care from staff at distribution sites to the villagers themselves. Teams are investigating how community nutrition workers can screen and admit children to CTC using MUAC alone and how the community can organise local transport (donkey, camel, etc) to collect the RUTF and supplementary food and distribute it to those who require it. Teams are also looking at how the medical input and quality control aspects can be performed by an OTP health worker, travelling from village to village by appropriate local transport. Developing this approach will take some time. There are ongoing studies into the use of MUAC by community nutrition workers, the means of selecting representative and competent community nutrition workers (CNW), and the development of suitable and transparent local structure to oversee the implementation of CTC at village level. Pictorial cards are also being developed to enable illiterate carers to better monitor and record the progress of children in a programme. Elsewhere, teams are looking at the feasibility of having more field-based teams moving from site to site by foot and mule, coupled with pre-positioning of RUTF and supplementary foods.

Closer integration with existing MoH programmes

The article from Dowa district Malawi (see section 3.2) describes how the CTC programme already operates through the same health centres, staff and community agents as the national growth monitoring programme (GMP) in Malawi. At present, the Dowa GMP has excellent coverage of children less than one year of age. This presents an opportunity to target these young children, who are susceptible to moderate malnutrition and stunting, through the existing MoH structure using the current weight for age criteria.

We hope that the development of new recipe, low cost, locally made RUTF, nutritionally adapted to supplementary feeding, might enable the same MoH clinics to target children with acute moderate malnutrition in a cost effective way. Providing a relatively low cost effective supplement could stimulate the uptake of the growth monitoring programme in this older age group and help integrate the longer term treatment of malnutrition within existing services. Using local crops and local facilities to make RUTF should help to improve local markets for farmers⁴ and stimulate local economies. Producing these foods at local hospitals or clinics is extremely cost efficient and provides a potential to generate small scale economic benefits for these institutions.

RUTF

RUTF is an energy dense mineral/vitamin enriched food that was originally designed to treat severe acute malnutrition (22). It is equivalent in formulation to Formula 100 (F100) currently recommended by the WHO for the treatment of malnutrition (1). Recent studies have shown that it promotes a faster rate of recovery from severe acute malnutrition than standard F100 (23). RUTF has many additional properties that make it extremely useful in treating not only malnutrition, but also chronic illness such as HIV. It is oil based with a low water activity that, in practice, means it is microbiologically safe, will keep for several months in simple packaging and can be made easily using lowtech production methods. It can have a wide range of protein content and, as it is eaten uncooked, it is an ideal vehicle to deliver many micronutrients.

Hitherto, RUTF has been made from peanuts, milk powder, sugar, oil and a mineral/vitamin mix, according to a recipe, called Plumpynut, developed by Nutriset (22). Until 2003, the only source of Plumpynut® was from Nutriset's factory in France at a cost of approximately $USD 3500/MT, plus additional cost for transport from Europe. The high price and European manufacture of RUTF was an important barrier to the cost effectiveness and wide-scale uptake of CTC. The CTC research programme has therefore facilitated the development of fairly large scale local manufacture in Malawi, at both urban and district levels⁵. This local manufacture has approximately halved the price and also meant that economic benefits go to the target countries, rather than remain in Europe. We are also developing alternative form-ulations that do not contain milk powder or peanuts and can be made from a range of local grains and pulses. These new RUTF are eaten uncooked and have a low water content, making them suitable vehicles to deliver not only vitamins and antioxidants, but also probiotics and prebiotics. Probiotics are usually bacteria from the lactobacillus family that have many beneficial therapeutic functions, greatly reducing the incidence of post operative infection, shortening recovery times and reducing the need for antibiotics in immuno-compromised patients (24;25), and treating lactose intolerance, viral diarrhoea and antibioticsassociated diarrhoea in other patient groups (26). We believe that probiotic enhanced RUTFs have huge potential in the fight against HIV/AIDS and are currently researching the effectiveness of these in Malawi.

Developing new RUTFs that can be made locally from local crops and used locally to treat malnutrition and HIV is central to the future of CTC. There is great potential for locally produced RUTF to bind the treatment elements of CTC more closely with food security/ agricultural interventions, local income generation and Home Based Care for HIV (see below and sections 4.3 and 5.2.2).

CTC offers several important opportunities to integrate the treatment of malnutrition into wider home-based strategies to address HIV/AIDS. It is hoped that the new locally produced probiotic enhanced RUTFs will prove to be an effective therapeutic food improving the nutritional management of HIV/AIDS and helping to reduce diarrhoea (see section 5.2.2). The community focus and credibility of CTC with local people also offers a valuable entry point for home-based care of people living with HIV/AIDS (PLWHA). There are many different approaches of home and community-based care, but all have, in common, a holistic view of the problems of PLWHA and their families. At present, however, stigma and the lack of a suitable entry point at community-level often provide barriers to the successful implementation of these projects. CTC projects in Malawi are now examining culturally appropriate and practical ways of capitalising on the credibility afforded by the successful treatment of acute malnutrition to examine working with local structures to deliver longer-term support to PLWHA and HIV/AIDS affected families (see section 5.2.2).

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¹Hypothermia, hypoglycaemia and dehydration.

²We are also investigating the admission into OTP using MUAC criteria.

³Highly insecure areas wherein provision of a general ration can provoke attacks and oppression of the target population are a possible exception to this basic rule.

⁴The absence of farmer markets has been identified as a major factor behind the 2002-3 food crisis in Malawi.

⁵Agreement is required with the patent-holder, Nutriset. Normally, Nutriset will permit local production up to 50 tonnes p.a. by a signed agreement with the producer.