The CTC Advisory Service: Supporting the Countrywide Scale-up of CTC in Malawi

By Gwyneth Hogley Cotes

Gwyneth Hogley Cotes holds an MPH from Tulane University, with a focus on child health and nutrition. She has worked with the CTC Advisory Service in Malawi as a Health and Nutrition Advisor for the last two years. Previous assignments include coordinating nutrition programmes in Darfur and supporting immunisation programmes in Ghana.

The author would like to thank Kate Golden of Concern Worldwide, Tapiwa Ngulube of the Malawi Ministry of Health, and Roger Mathisen of UNICEF for reviewing and contributing to this article.

In response to a food shortage in 2002, Concern Worldwide and Valid International piloted a Community-based Therapeutic Care (CTC) project in two districts in Malawi. The two pilot projects were largely considered a success based on coverage, community acceptance, and treatment outcomes. In 2004, the Malawi Ministry of Health (MoH) agreed to expand CTC to additional districts in order to assess different approaches to implementing the programme.

When a second food shortage occurred in 2005, the MoH encouraged other organisations wanting to contribute to the emergency response to use the CTC approach. Four organisations responded, setting up CTC programmes in 10 additional districts.

At the beginning of 2006, a national stakeholder workshop was held to share experiences from all CTC programmes in Malawi and to review the evidence in support of scaling up CTC in a non-emergency context. The review found that CTC programmes achieved rates for cure, death, and default that were within Sphere standards and that CTC had the potential to reach more children than the traditional inpatient therapeutic feeding approach. Although CTC programmes had been solely implemented by non-governmental organisations (NGOs) up to that point, the review found that there were favourable conditions for scaling up CTC nationally, including local production of Ready to Use Therapeutic Food (RUTF) and existing community outreach structures.

Itayi Nkhono of CAS conducts an interview to investigate reasons for default.

As a result of this workshop, in April 2006 the MoH publicly confirmed its intention to scale up CTC to all 28 districts in Malawi, and to integrate CTC into the Malawi health system to make it more sustainable.

The Challenge: National Scale-Up

Although the MoH had endorsed the scale-up of CTC, a number of challenges were evident. Key among those was the wide variety of approaches being used by different organisations, poor communication among stakeholders, and a lack of involvement of government staff at the district level. Stakeholders and donors also had serious concerns about the sustainability of the programme, given the high cost of RUTF.

It became clear that a number of things had to happen for CTC to be effectively scaled up in Malawi:

1. A standardised approach, including clear protocols, national guidelines and a monitoring and evaluation system, was needed across all districts.
2. Extensive technical support and capacity building was needed at the national and district levels to support government staff to take up CTC services and maintain quality.
3. A national system for monitoring and evaluating nutrition programmes was needed for planning and to ensure the quality of CTC.
4. Coordination and communication among all stakeholders needed to be improved to promote learning and programme effectiveness.
5. Strategic planning and advocacy within the MoH and among partners was required to integrate CTC into the health system functionally, in order to ensure future funding and improve cost-effectiveness, and thereby make CTC more sustainable for the government to manage.

The Approach: CTC Advisory Service

A recent article on how to achieve wide-spread change in global health emphasised that simply spreading information on the success of a new approach is not enough to ensure it is scaled-up effectively. The authors noted that "Even when health care systems leaders or clinicians become aware of a promising innovation, their ability to introduce it is often severely constrained by limitations of time, resources, and skill." The authors concluded that "most innovative technologies. must be actively, not passively, spread, or they may not spread at all."¹

This was certainly the case in Malawi - although the MoH took on primary responsibility for scaling up CTC, it was obvious that limited resources, time, staff and expertise within the MoH would be a major barrier. Recognizing these limitations, the MoH chose to take an active approach to scaling up CTC and in 2006, formed the CTC Advisory Service (CAS) in partnership with Concern Worldwide.

CAS was conceived as a 5-year project, with a team of experienced nutrition and monitoring and evaluation (M&E) officers who act as a technical arm of the Ministry of Health's Nutrition Unit to facilitate the scale-up of CTC, while building the capacity of the government to take on CTC management.

Under a simple Memorandum of Understanding (MOU) with the government, CAS was given the mandate to coordinate, monitor, and evaluate CTC activities, provide technical support and capacity building for CTC at the national and district level, standardise tools and materials used for CTC in the country, and continuously advocate for the scale-up and integration of CTC into the health system.

The MoH provides leadership and direction for CAS activities, while Concern Worldwide is responsible for the day-to-day management and administration of activities. The project has been funded by several donors, including USAID, UNICEF, and Irish Aid.

Main achievements

In the last two years, CTC has spread more rapidly than was originally expected. Since CAS began operating, it has provided support to 25 districts to initiate and carry out CTC. As of November 2008, 21 districts, out of 28 in the country, have started CTC and six more are in the stages of training or planning.

CAS has been instrumental in facilitating the development of national CTC guidelines, along with standardised reporting forms and job aids, which have been printed and disseminated to all districts by UNICEF. These tools are now being used by all districts.

CAS has also taken the lead on developing a national monitoring and evaluation system. District HMIS (Health Management Information System) officers have been trained to compile monthly health centre data using a national database that incorporates reports from Outpatient Therapeutic Programmes (OTP), Nutritional Rehabilitation Units (NRU), and supplementary feeding programmes. The MoH has taken on responsibility for collecting CTC programme data, but CAS still supports with analysis and reporting. Districts that show poor performance are prioritised for CAS support.

Attendees of the 7th CTC Learning Forum practice conducting supervision at an OTP session.

Another achievement is the development of a team of national CTC trainers, along with a draft training manual for CTC. A total of 46 health staff from throughout the country has been trained to provide training and technical support on CTC. This is an important step in ensuring that the work of CAS can be continued by the government once the project ends. While CAS continues to monitor training quality and mentor the national trainers, all district-level trainings are now conducted by MoH staff.

Finally, CAS has played an important role in coordinating CTC activities and facilitating better communication among stakeholders. The CTC Learning Forum, which brings together people involved in CTC several times a year, has been an effective tool for sharing and replicating best practices and lessons learned.

Challenges

Although a great deal of progress has been made over the last two years, there is still much work to be done before CTC is fully scaled up and integrated into the health system.

There was no initial strategy developed to guide the scale-up process, and as a result scaleup has occurred rapidly and haphazardly. Scale-up and support from CAS has been reactive, driven largely by demand from district health offices and supporting NGOs. CAS recently developed criteria for prioritising districts for support visits, but no such criteria were used to guide the scale-up process. CAS is currently facilitating the development of a national plan of action for carrying out the work that is remaining, focusing on integrating CTC into the Malawi health system. The plan will include specific actions for achieving the plan, and will specify the roles and responsibilities of all stakeholders.

From the outset, there has been confusion over the role of CAS. CAS's mandate was not clearly communicated to districts, and initially some NGOs did not welcome CAS involvement in the CTC programmes that they supported. The MOU developed with the Ministry lists general areas where CAS is supposed to take the lead, but does not specify how roles and responsibilities should be divided between MoH and CAS. Also, CAS is not the only agency providing technical support on nutrition programmes in Malawi and roles sometimes overlap. In particular, there is a need for better coordination of programme monitoring and support by CAS, WFP and UNICEF.

Supervision of nutrition activities has been a particular challenge due to a lack of time and staff at the national level, and a consequent lack of accountability at the district level. Although Malawi now has a team of national CTC trainers, these trainers need ongoing support and mentoring to ensure that they are ready to take over training and technical support activities.

As a result of poor supervision, the quality of service provision remains a problem in many districts. Although cure, default, and death rates have stayed within Sphere standards in most districts, there are issues with children being admitted even though they do not meet criteria, or not being discharged properly. The shortage of nurses and clinicians in the country mean that children are frequently not assessed by a clinically trained health worker.

Finally, there remain significant obstacles to direct management by the MoH. Among those are the cost of RUTF and other supplies and the availability of human resources. In 2007, about 400 MT of RUTF was used for CTC programmes in Malawi, costing about 1.6 million dollars. This covered 35,724 children treated in OTPs and NRUs. However, the price of locally produced RUTF increased in 2008, and the CTC caseload is expected to rise by about 30%, once CTC is fully scaled up. Then, the projected cost of RUTF provision alone will be about 2.6 million dollars a year. There will likely be a need for external support for the purchase of RUTF for some time. CTC services need to be better streamlined and incorporated into existing health services - such as drug procurement systems and pre-service training for health staff - to make it affordable for the government to manage. CAS is currently working with the MoH to advocate for inclusion of RUTF funding into the national SWAp funding system (Sector-Wide Approach).

Lessons Learned

Participants of a CAS-supported training give their feedback after a practical field session.

Having a separate support unit within the MoH to focus on issues of scale-up has been essential to the rapid progress achieved in Malawi, as the demands of scaling up generally exceed existing resources. However, there are several things that could be improved on if the approach were replicated in another country.

A clear strategic plan for scaling up and integrating CTC into the health system is needed right from the beginning. This plan should prioritise districts in order of when they should start CTC, determine how resources will be procured, and should clarify roles and responsibilities of all stakeholders.

The terms of reference for the support unit need to be very clear and specific. They should lay out how the responsibilities of CTC management will be divided between the MoH and the support unit. Once the agreement is finalised, the MoH should disseminate the agreement to all district health officers and supporting NGOs so that they are familiar with the support unit and know how to access support. In the second year of the project, the CAS unit was provided office space by the MoH, which has led to greater acceptance of CAS support.

It is important that the support unit emphasises capacity building of local and national partners in all its activities. Although it is often easier and quicker to use NGO resources to manage and coordinate CTC activities, it is critical that the government is involved in all aspects of the programme right from the beginning, to ensure a sustainable handover of the programme.

District health offices have also expressed a need for better tools and support on planning and budgeting CTC activities. Capacity building needs to focus on issues of logistics, budgeting, and monitoring and evaluation, not just training and technical support. Tools such as a standard budget template and guidance on estimating costs and caseloads for CTC would be very valuable.

The CAS approach has been working well in Malawi, despite the challenges, and continues to refine and improve its approach. The approach could be appropriate for other countries wanting to scale up and integrate CTC, but will need to be adapted. In emergencies, for example, the rate of scale up may need to be accelerated and more logistical and staffing support provided.

In about half of all districts in Malawi, CTC is now managed entirely by the district health office, using the existing health systems. While some issues of quality remain, these districts have shown that they are capable of managing CTC activities largely on their own, provided they have initial technical support and training, good ongoing supervision from the national level, and funding support for RUTF and other supplies.

For more information, contact Gwyneth Hogley Cotes, email: gwyneth.cotes@concern.net

¹McCannon, C.J., Berwick, D.M., Massoud, M.R. "The Science of Large-Scale Change in Global Health" Journal of the American Medical Association, October 24/31, 2007. Vol 298, No 16.