Letter on community mobilisation in outpatient management of severe malnutrition, by Saul Guerrero and Steve Collins

Community mobilisation at the core of outpatient treatment of severe malnutrition

Dear Editor,

There is now a robust evidence base demonstrating that the outpatient care of children with severe acute malnutrition using the Community-based Therapeutic Care (CTC) model - with its emphasis on community mobilisation - is a high impact intervention. For CTC programmes, impact refers primarily to; high cure rates, high programme coverage, low death rates and low default rates. The evidencebase is comprised of data collected through operational research in CTC programmes in a variety of contexts - all of which had a community mobilisation component in one form or another. This comprehensive evidence base has been central to the changing of national, UN and NGO policies towards the treatment of acute malnutrition. In November 2005, the WHO/UNICEF/SCN Informal Consultation on Community-Based Management of Severe Malnutrition in Children concluded that:

Engaging with a traditional healer in Wulla

".community-based management of severe malnutrition is an effective intervention to treat a large number of children suffering from severe malnutrition with a very low case fatality rate, provided adequate dietary and medical treatment is delivered, close follow-up is ensured and early detection is implemented at community level"¹

The endorsement by WHO has led to a rise in agency implementation, and widespread adoption of the CTC model.

Community Mobilisation and the Success of CTC From the outset, and regardless of the context, CTC programmes have consistently involved communities in the process of sensitisation (awareness-raising), case-finding (community-based screening) and follow- up (of defaulters and absentees). How this is done has varied from context to context, and from programme to programme. CTC programmes in Ethiopia, for example, have successfully tapped into existing volunteer networks in the communities - thus reducing the problem of replication and the creation of parallel systems. CTC programmes in Darfur and Niger, on the other hand, have identified key community figures (including traditional healers, crier publique and femmes relais) capable and willing to play a role in mobilising their communities. The resources involved in conducting these activities have been comparatively low; some of the most effective CTC community mobilisation endeavours have been accomplished by a small team (2-3 people) of carefully selected local people, able to move independently around the communities.

What is the impact of Community Mobilisation on CTC programmes?

We see community mobilisation as central to the CTC model because of the clear, tangible and positive outputs produced by such activities. First, community mobilisation increases appropriate presentation of cases thereby increasing overall coverage. This requires a comprehensive sensitisation campaign - with basic messages about malnutrition, using local nomenclature to highlight signs and symptoms, and clear information about programme locations, the treatment available and how somebody might access that treatment. We have seen that such campaigns substantially increase the number of severe/ moderately malnourished children being selfreferred by the communities. Secondly, effective mobilisation decreases inappropriate presentation of ineligible cases, therefore decreasing congestions at the distribution sites. This in turn helps relieve the pressure and workloads of on-site staff, improve the care provided during outpatient therapeutic distributions and through reducing workloads improve staff morale. Thirdly, the creation of an outreach support network linked to the programme leads to increased compliance with treatment, thereby helping to increase recovery rates. The combination of increased coverage and improved recovery rates result in substantially increased impact. If mobilisation is addressed in an appropriate manner, relatively low inputs are required to achieve these positive results making mobilisation a highly cost effective activity.

Is Community mobilisation always possible?

CTC experiences to date indicate that community mobilisation is always possible. Evidence from a wide range of contexts, including emergency and development programmes in Malawi, North and South Sudan, Ethiopia, Niger, Indonesia and Zambia, all suggest that community mobilisation can and should play a role - albeit in different forms. Mobilising communities to engage with CTC programmes requires that implementing agencies have the necessary local knowledge and connections in the field to adapt generic mobilisation techniques to each specific context. During the five years of CTC development we have never encountered obstacles that prevent community mobilisation activities altogether although the form of mobilisation has had to vary a great deal.

A second question is whether community mobilisation is always advisable or are there times when mobilisation can prove to be counter-productive? Based on our experience, this seems unlikely. Regardless of the context, interaction with communities has always proved feasible and positive in terms of its contribution to traditional programme indicators. A central element in community mobilisation is increasing knowledge about how communities deal with food stress and malnutrition and it is difficult to see how this could be counter-productive. In our experience, the more agencies know about how communities deal with issues surrounding food and nutrition, the better.

Outpatient Treatment and Community Mobilisation

Recently MSF-France have been developing a model of domiciliary care commonly referred to as Outpatient Treatment (see Field Exchange 28). This model draws heavily on many of the design features of CTC, emphasising high coverage and decentralisation but does not include any measures of community mobilisation. "Outpatient care (synonymous with ambulatory care)" write Latti & Grobler- Tanner "focuses on the outpatient treatment of the majority of severely malnourished children and seeks to maximise coverage in the short term. Community based therapeutic care (CTC) has similar aims but differs in that it places considerable emphasis on community mobilisation and participation that aims to maximise coverage and ensure the longer term viability of the programme" ² This same piece then goes on to highlight some of the reasons why programmes might opt for one or the other, describing how: "due to insufficient staffing or other programme obstacles, active case finding of malnourished children may not be feasible in every situation. For example, MSF enrolled 60,000 children in Niger without community outreach activities beyond active participation by mothers (caretakers) themselves".

We believe there are two important issues here. The first is to understand that active case-finding and community mobilisation are not the same thing. Some CTC programmes have found it necessary to limit the amount of active case-finding in order for example, to prevent MOH clinics just starting up programmes becoming overrun with cases before they are sufficiently established to handle the numbers. However, this has never meant that mobilisation has not remained a high priority and in practice fragile MOH start-ups require increased mobilisation in order to try and help reduce the numbers of inappropriate referrals to distribution sites. CTC programmes in Ethiopia, for example, have placed an emphasis on increasing awareness in the communities by disseminating key messages about the programme through formal and informal channels of communications. By increasing awareness and clarifying who is eligible for admission and also where the services can be accessed, these programmes have seen a gradual and manageable rise in appropriate presentations resulting from self-referrals (passive case finding) - without more formalised active case-finding mechanisms creating an initial rush of new patients. The second source of confusion is mobilisation requires substantial amounts of resources. In our experiences of implementing CTC programmes in a large number of emergencies, staffing levels have seldom been a major problem preventing mobilisation activities, including active case finding. This is because a small, locallyrecruited team of motivated and influential individuals can help facilitate a much larger process of community involvement. This activist approach although less resource intensive does require more strategic thinking and a better understanding of how information flows within communities on the part of implementing agencies.

In the articles quoted above there appears to be an underlining belief that because one programme has achieved high admission numbers without mobilisation, it follows that mobilisation is not a fundamental requirement for programme uptake or effectiveness. The evidence for outpatient care certainly appears encouraging. The MSF programme in Maradi (Niger) admitted over 63,000 severely malnourished children - making it the largest nutritional intervention in the organisation's history³. A programme of such scale (and quality - with its 91.4% recovery rate) is a major achievement and demonstrates the huge potential of the outpatient treatment of SAM. However, to evaluate the public health impact and the potential utility of this model requires more information. In particular, information on coverage and cost is required in order to evaluate whether such a model could be replicated effectively. The experience of implementing CTC in Niger (in Maradi, Zinder, Tahoua) suggests that the scale of the crisis coupled with highly visible interventions led to significant numbers of community self-referrals. Given the high number of admissions to the MSF programmes in Niger, it is likely that most of those in need were somehow passively sensitised to the existence of the MSF programme. However, just because this happened in one high-profile and extremely large intervention does not mean that it will necessarily happen in other less high-profile interventions. Our experiences indicate that this probably will not be the case and we believe that more evidence is required before generalisations can be made from this specific, hitherto unique, experience. As programmes evolve from emergency into longer term interventions, passive case finding be-comes increasingly important as the resource constraints of most MOH primary health care programmes seldom if ever allow for the employment and supervision of sufficient numbers of outreach staff to provide effective active case finding over the long-term.

Evidence Based Change - why data should shape trends

Evidence-based practice is having important positive impacts across the whole of medicine. In humanitarianism, the change from inpatient therapeutic feeding centres (TFCs) to CTC is a good example of how a large evidence base, collected over several years, can radically improve practice. However, there is still huge room for the improvement of selective feeding interventions and a great need for further evidence. The new MSF data makes an important contribution to that process. However, now that we finally have an evidence-based model for selective feeding, changes to that model should be based on appropriate evidence that allow for comparisons of effectiveness. As yet, there is no evidence base to support the hypothesis that outpatient care in the absence of community mobilisation is more effective that the standard CTC model. The available data from the MSF Niger outpatient treatment programme shows that a well equipped INGO can treat very large numbers of children; far larger numbers than previously possible using an inpatient model of care. It also demonstrates that outpatient care can achieve good outcomes. However, the data presented to date do not tell us whether the absence of community mobilisation led to lower coverage rates or higher costs/cure. Decisions over the importance of community mobilisation require this evidence and in its absence the standard of care should be to include community mobilisation. The role of an outpatient care model without community mobilisation needs to be further investigated.

Training female outreach workers in Sudan

There are currently an estimated 10-13 million cases of severe acute malnutrition worldwide, accounting for between one and two million unnecessary deaths⁴. Decentralised models of outpatient care, armed with the introduction of new Ready to Use Therapeutic Foods (RUTFs) are providing us with an unprecedented ability to make a real difference. Ensuring that all those who need it receive care will require that delivery models are appropriate to the primary health care setting in developing countries. There are now several CTC programmes that have been going for more than 4 years and are largely implemented by National MOHs and evidence is mounting that to be effective over the long-term these require a more meaningful partnership with beneficiary communities, beyond the traditional provider-beneficiary model of humanitarian programming. This may ultimately prove a more challenging paradigm for emergency nutrition agencies to accept than the shift to outpatient treatment. At a time when more and more CTC programmes are looking to transition over to MOH control, downplaying the role of community mobilisation based on a single, large-scale humanitarian programme implemented by a wellresourced INGO, is premature.

Regards,
Saul Guerrero and Steve Collins,
Valid International

¹WHO, UNICEF and SCN. Informal Consultation on Community- Based Management of Severe Malnutrition in Children. (Geneva, 21- 23 November 2005, Meeting report, Draft 1, our emphasis)

²Latti, K & Grobler-Tanner, C (2006). Highlights from MSF-hosted meeting on outpatient and community based therapeutic care. Field Exchange 27, Emergency Nutrition Network (p. 15)

³Tectonidis, Milton, et.al (2006). Scaling up the treatment of acute childhood malnutrition in Niger. Field Exchange 28, pp.2 - 4, July 2006

⁴Collins, S, Dent, N, Binns, P, Bahwere, P, Sadler, K, Hallam, A (2006). The management of severe acute malnutrition in children. (The Lancet, 2006, in print)