2

Contents

Acknowledgements................................................................................................... 2Foreword................................................................................................................. 3Acronyms................................................................................................................. 5Executive Summary.................................................................................................. 61. Introduction...................................................................................................... 82. Overview of CTC.............................................................................................. 10

2.1 The History of CTC in Malawi.......................................................................................... 102.2 CTC: The Concept............................................................................................................ 112.3 Expansion of the CTC Approach..................................................................................... 112.4 Cost of CTC Programmes............................................................................................ .... 13

3. CTC in Emergency and Development Settings.................................................... 143.1 CTC in an Emergency Setting: the Case of Mangochi (SC-US)............................................ 143.2 CTC in a Development Context: the Case of Dowa & Nkhotakota....................................... 15

4. Going Beyond NRUs with CTC........................................................................... 174.1 Reviewing use of RUTF in NRU......................................................................................... 174.2 CTC Scaling-up Process at Moyo House........................................................................... 194.3 OTP Scaling-up – Thyolo (MSF-Belgium)........................................................................... 21

5. Local Production of RUTF.................................................................................. 21

6. Strategies for Scaling-up CTC............................................................................ 266.1 Incorporation of CTC within WHO Global Guidelines .................................................... 266.2 Integrating CTC into the EHP............................................................................................ 266.3 Partnerships ................................................................................................................... 276.4 Support Services for CTC: CAS and VALID ...................................................................... 27

7. CTC Integration: The Way Forward................................................................... 287.1 CTC Integration into District Health Services – Balaka........................................................ 287.2 Planning for the Introduction of CTC in a District ............................................................... 29

8. Annexes........................................................................................................... 32I. Agenda of the CTC Review Workshop .............................................................................. 32II. Acute Malnutrition Statistics.............................................................................................. 33III. List of Participants............................................................................................................. 34

References............................................................................................................... 33

AcknowledgementsConcern Worldwide acknowledges the assistance given in the writing of this report by the following people: thepresenters at the Review Workshop who cooperated in the finalisation of this document, Dr D Namate, Directorof Health Technical Services (MoH), Catherine Mkangama, Chief Nutritionist at the Ministry of Health, and –in large measure – the Country Office staff of Concern Worldwide. Notable among these are: Fiona Edwards(Country Director), Shahnewaz Khan (Assistant Country Director), and Stanley Mwase, Programme Manager,of CTC Advisory Services.The country representatives of WHO and UNICEF – Dr Matsidisho Moeti and Aida Girma respectively – havelent to this report the authority that the Ministry of Health considers it deserves, and are gratefullyacknowledged for this. We are also indebted to Celia Swan who put the whole document together.This report was made possible through the support provided by the USAID. The views expressed herein arethose given by the contributors and do not necessarily reflect the standpoint of the funding agency.

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Over recent years Malawi has had persistent episodes of food shortages and other humanitariancrises, on top of endemic disease and the HIV/AIDS pandemic. The Essential Health Package (EHP)is the government’s strategy for delivering basic health services to all Malawians. Community-levelhealth care is fundamental to the EHP, and Community–based Therapeutic Care (CTC), based as it

is on public health principles, has proved to be a highly effective measure in combating acute malnutrition inunder-five children.

CTC is a vital complementary strategy, following the Global Strategy for Infant and Young Child Feeding laiddown by the World Health Organisation (WHO). The advantages of CTC are manifold – active and early casedetection by community-based service providers; better follow-up of patients in Outpatient TherapeuticProgramme (OTP); easing congestion in Nutrition Rehabilitation Units (NRUs), thus improving the quality of careto the inpatients suffering from Severe Acute Malnutrition (SAM) with complications.

For CTC to be extended to all districts more involvement by more partners is called for. A consensus onmodalities for the scale-up is needed, and the CTC Review Workshop has provided a platform for discussionamong all stakeholders on the burning issues. We welcome the establishment of CTC Advisory Services (CAS)as an effective back-up service to those districts planning to introduce or expand CTC, through the setting up ofmore OTPs.

There is a very great deal of work lying ahead and the key to success lies in the strong links existing betweenthe government health service at national and district levels, WHO, United Nations Children’s Fund (UNICEF)as key partners, and the leading Non–Governmental Organisations (NGOs) in the field of CTC – ConcernWorldwide (CWW), Valid International (VALID), and others.

We acknowledge the enthusiasm expressed by the Country Representative of WHO for CTC, and WHO’sreadiness to make technical contributions based on experience in other countries, joining the advisory work inMalawi and offering policy guidance. UNICEF has reiterated their enthusiasm for the CTC approach, and willmaintain their technical support. UNICEF will ensure that CTC will form part of the Accelerated Child Survivaland Development Strategy.

CTC has effectively helped to improve recovery rates among the beneficiaries. It is the intention of theMinistry of Health (MoH) to see standardised and focused implementation of CTC for the benefit of the targetedacutely malnourished children and their care-givers.

(Ministry of Health)Malawi

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The Nationwide Nutrition Survey of December 2005 indicated that malnutrition is still a huge challenge inMalawi. 42% of the children were observed to be short for their age, and global acute malnutrition was foundto be 6.2% while in some four districts rates above 10% were recorded. Global acute malnutrition, which is acomposite of severe and moderate acute malnutrition, requires immediate action ranging from supplementaryfeeding to therapeutic feeding in Nutrition Rehabilitation Units or at community level through OTP.

The treatment of severe acute malnutrition in NRUs has been successful, but the implementation has had someproblems. Firstly admissions are limited by the distance and number of NRUs as well as the number of beds inthose centres. Secondly, care–givers have to leave their other siblings at home for about 30 days. CTC as anew strategy for therapeutic feeding addresses the two problems just mentioned and complements the effortsbeing made through NRUs.

UNICEF also acknowledges the limitations of implementing CTC in the absence of global guidelines andsuggests continued implementation in a way that ensures careful analysis of performance indicators, qualitycontrol and documentation of lessons learnt as we work towards coming up with state-of-the-art guidelines onCTC globally. UNICEF Malawi will continue to support the Ministry of Health and NGOs in the implementationof CTC both technically and through provision of supplies.

Foreword

4

Severely malnourished children are at high risk of mortality. Thus, interventions to reach more of thesechildren beyond NRUs through CTC are an important contribution to the national and global effort foraccelerated child survival and development.

(Message from UNICEF)Malawi Office

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Severe malnutrition is an important cause of death in infants and young children, but one that is increasinglyopen to successful management.

Effective interventions for the management of severe malnutrition with adequate coverage of affectedpopulations could prevent hundreds of thousands of child deaths each year, thus contributing to theachievement of the Millennium Development Goals (MDGs) for poverty and child mortality reduction. WHOwelcomes the initiative to expand community management of severe malnutrition in Malawi and will work withthe government, NGOs and partners in providing technical support to scaling–up the CTC approach.

(Message from WHO)Malawi Office

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The management of sick and malnourished children is a vital component of nutrition programming. UnitedStates Agency for International Development (USAID) supports a range of approaches to rehabilitatemalnourished children, such as CTC and the PD Hearth Nutrition Model.

CTC is a new approach to managing Severe Acute Malnutrition (SAM) in emergencies and beyond. The CTCapproach treats the majority of acute malnutrition cases at home. It also focuses on outreach and communitymobilisation to improve case identification and promotes appropriate behaviour change to address the rootcauses of malnutrition. Central to the home-based care of children with acute malnutrition is the provision ofready-to-use-therapeutic food (RUTF), a fortified, prepared food which is easy to administer at home.

Comparison to date between CTC and traditional Therapeutic Feeding Centres (TFC) suggests that CTCachieves greater reductions in mortality and default rate (about 10 to 50% of TFCs) and coverage rates two tothree times greater than TFCs. These promising results from CTC implemented in a number of countries (Malawi,Ethiopia, Sudan and others) along with local production of the RUTF have generated great enthusiasm andsupport among communities, UN agencies, Governments and donor agencies.

CTC should be included as an integral part of improving nutritional status in both short-term and chronicsituations.

(Message from USAID)Malawi Office

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CWW in partnership with VALID and the MoH commenced the first CTC intervention in Malawi in 2002.Since then the approach has been well received by the MoH and has been replicated both within the countryand the region. The MoH has both led and driven the institutionalisation of the CTC and the CTC reviewworkshop has provided a unique opportunity for the many and varied operators in CTC to come together andbuild on the initial successes.

CWW remains committed to supporting the MoH in the further treatment and prevention of malnutrition inMalawi and believes that CTC provides a unique opportunity to bring lasting positive changes in the nutritionscenario of Malawi. The organisation has been fortunate in the financial support of USAID which enabled thislearning opportunity to take place. We feel sure that this report will be shared widely among organisations andgovernments around the world as the CTC approach gains acceptance. Malawi is providing important lessonsand strategic direction for many countries embarking upon this approach.

(Message from CWW)Malawi Office

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AAH Action Against Hunger

AIP Area Improvement Plan

ART Anti-Retroviral Therapy

ARV Anti-Retroviral

BMI Body Mass Index

CAS CTC Advisory Service

CBCC Community-based Child Care

CBM Community Based Management

CDA Community Development Assistant

CHAM Christian Health Association of Malawi

CI Confidence Interval

CMVs Complex Minerals and Vitamins

CT Counselling and Testing

CTC Community-based Therapeutic Care

CU Concern Universal

CWW Concern Worldwide

DH District Hospital

DHMT District Health Management Team

DHO District Health Office(r)

DIP District Implementation Plan

DOTS Directly Observed Treatment Shortcourse

EHP Essential Health Package

EPI Expanded Programme of Immunisation

FAO Food and Agriculture Organisation

GMP Growth Monitoring Programme

GMV Growth Monitoring Volunteer

HAART Highly Active Anti-Retroviral Therapy

HIV Human Immuno Deficiency Virus

HSA Health Surveillance Assistant

IEC Information, Extension and Communication

IM Intra-Muscular

IMCI Integrated Management of Childhood

Illness

ITN Insecticide Treated Net

IV Intra-venous

KCH Kamuzu Central Hospital

MA Medical Assistant

MAM Moderate Acute Malnutrition

MASAFMalawi Social Action Fund

MoH Ministry of Health

MSF Médecins sans Frontières

MSH Management Sciences for Health

MUAC Middle Upper Arm Circumference

NGO Non-Governmental Organisation

NRU Nutrition Rehabilitation Unit

OPD Outpatients Department

OTP Outpatient Therapeutic Programme

PEA Primary Education Adviser

PMTCT Prevention of Mother-to-Child Transmission

PPB Project Peanut Butter

QECH Queen Elizabeth Central Hospital

RUTF Ready-to-use Therapeutic Food

SAM Severe Acute Malnutrition

SC Stabilisation Centre ( = NRU)

SC-US Save the Children - US

SFP Supplementary Feeding Programme

SWAp Sector Wide Approach

TB Tuberculosis

TBA Traditional Birth Attendant

TFC Therapeutic Feeding Centre

UN United Nations

UNICEF United Nations Children’s Fund

USAID United States Agency for International

Development

VCT Voluntary Counselling and Testing

VHC Village Health Committee

WFP World Food Programme

WH Weight for Height

WHO World Health Organisation

Acronyms

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The community-based management of severemalnutrition was originally initiated as aresponse to emergencies in Sudan andEthiopia in 2000, in order to treat large cases

of severe malnutrition in young children. The MoHintroduced this CTC approach in Malawi in 2002 inDowa and Nkhotakota districts with support fromCWW in partnership with VALID. At the same time,the St Louis Project, in partnership with the Collegeof Medicine, brought support for home therapy invarious NRUs and districts in Southern Malawi.

CTC has gained ground as an effectivecomplementary measure for detecting, treating andpreventing severe malnutrition. In 2004 adissemination meeting was held and as a result theCTC approach was expanded. It was decided at thattime that it would be necessary to gather moreevidence on the effectiveness of CTC, and todocument experiences so that lessons could belearnt. The progress towards wider implementationof the programme has been sustained, through thestrong partnership between the MoH (bothnationally and in the targeted districts), and otherkey players – UNICEF, WHO, CWW, VALID andother NGOs.

CTC Review WorkshopAnd so, in order to prepare the stakeholders for thescale–up of CTC in the country, the MoH, incollaboration with CWW, and with funding fromUSAID, organised a CTC Review Workshop. It washeld on 19 April 2006, and its specific objectiveswere to:

• orient District Health Officers (DHOs) and otherdistrict managers on the CTC programme

• share lessons learnt on CTC implementation inMalawi

• introduce the CAS and• plan a way forward for scaling up the CTC

programme.

In attendance were 38 district health managers andother health staff, as well as senior officials from theMoH and some 40 partners from a broad range oforganisations based in Malawi – the College ofMedicine, Christian Health Association of Malawi(CHAM) institutions, UNICEF, WHO, and NGOs.The full agenda is in Annex I, and the list ofparticipants in Annex II.

Presentations delivered in the workshop:• Dr Paluku Bahwere, VALID• Alice Nkoroi, CWW• Sylvester Kathumba, District Nutritionist, Dowa

District

• Dr James Bunn, College of Medicine and MoyoHouse

• Dr Marko Kerac, College of Medicine andVALID

• Dr Leopold Buhendwa, Medicins San Frontieres-(MSF) Belgium

• M Chiwamba, MCH Coordinator, MangochiDHO

• Frank Linzie, Deputy DHO, Balaka District• Carol Lin, PPB and St Louis Project• Dr Susan Kambale, WHO

Themes explored in the workshop• Experiences and data from CTC programmes in

a development setting (Dowa and Nkhotakota)and an emergency setting (Mangochi)

• Experiences of a District Health ManagementTeam (DHMT) in adopting CTC (Balaka)

• Experiences of implementing CTC in aprogramme of outpatient treatment of HIV/AIDS(Thyolo)

• Challenges and sustainability of local productionof RUTF in the context of the scale-up

• Analysis of the cost implications of CTCprogrammes, and of the scale-up

• Experience of integrating CTC programmes withinpatient treatment in the NRU

• Issues and challenges in integrating CTC withinprimary health care / Integrated Managementof Childhood Illness (IMCI)

• Scoping linkages with community structures• The modalities for extending CTC within

decentralised health services• The steps needed for WHO to adapt existing

protocols in order to incorporate CTC.

The workshop updated participants on the progressof CTC scale-up. It was made clear from the outsetthat this process will entail more technical supportfor advocacy and social mobilisation, service

Executive Summary

A recovered baby with RUTF

, ,

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standardisation, capacity-building, monitoring,documentation and dissemination of best practices.The issues and challenges of the scale-up wereexplored at the workshop in discussions betweenNGOs, the district health managers and otherpartners.

Outcomes of the workshopThe meeting confirmed that CTC is on track forintegration into Malawi’s primary health careservices.• The MoH re-affirmed its commitment to

incorporate CTC into the EHP, because of theproven success of the present CTC programmesin improving recovery rates. Both WHO andUNICEF voiced their full support for andcommitment to the initiative.

• The stage has been reached for CTC to beincorporated into national and global guidelineson the treatment of SAM. The WHO recognisesits effectiveness as a strategy that is in line withthe WHO Global Strategy for Infant and YoungChild Feeding and complements the WHOGuidelines for Management of the Child with aSerious Infection or Severe Malnutrition. TheInterim National Guidelines on CTC are beingfinalised, and harmonised with the NationalGuidelines on the Management of AcuteMalnutrition.

• The progress towards institutionalisation of CTCwithin district health provision is furthestadvanced in Dowa and Nkhotakota districts,where CWW is reducing its presence, having

built up considerable local capacity both at DHOand community levels. Valuable evidence waspresented to those districts intending to follow asimilar path; CAS plays a crucial role in thedocumentation and sharing of this evidence. TheDHOs were given the opportunity to raise theirconcerns and pose their questions, and throughgroupwork they began to formulate plans ofaction for the adoption or expansion of CTC intheir districts.

• The commercialisation of RUTF production is anissue for further negotiation and research;commercialisation could lead to markets for localfarmers and therefore economic benefits to thecountry, and this aspect should be developed.

• There is a call for training manuals in CTC for thevarious levels of health staff and volunteers whodeliver the service.

In summary, CTC comes at a cost. Treating largernumbers of SAM children will naturally cost morethan is currently being spent. However, improvingservices to the most vulnerable members of thecommunity lies at the heart of health care provision,and with CTC the cost per patient is lower thanin–patient treatment in the NRU. CTC makes itpossible to reach more SAM children with effectivetreatment, and prevent more children fromdeveloping medical complications. As the SectorWide Approach (SWAp) expands to cover all healthcare provision, it is hoped that CTC can be properlyprioritised within the EHP and be funded through theSWAp.

Moyo House NRU, Blantyre (Kerac)

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Malnutrition is a major direct killer ofunder-five children all over the world,and increases the risk of death fromother diseases. It is a chronic problem

in Malawi, where persistent episodes of foodshortages are compounded by problems of endemicdisease and HIV/AIDS. Of the 2,319,000 under-fivechildren in Malawi, 48% are stunted, and of these18% severely so. 22% are underweight, with 7% ofthem severely underweight; 5.2% of under-fivechildren are wasted, of these 1.6% severely so.During the last food crisis, in December 2005, theglobal acute malnutrition rate in the country was6.4% (CI 6.1–6.7), or an estimated 102,614 acutelymalnourished children. (see Annex III, MoHNational Nutrition Survey).

Prevalence of SAMOf these 102,614 acutely malnourished children inDecember 2005, the National Nutrition Surveyestimated that some 46,500 were SAM,representing 2.9% (CI 2.7–3.1) of the under-fivepopulation. The months between November andApril are the “hungry season” in Malawi, andeach year brings alarming figures of under-nutritionand malnutrition in young children. Cases ofmoderate acute malnutrition (MAM) among theunder-fives reached over 10% in Machinga Districtlast December. The prevalence of SAM is mainlyhigh in the rural areas, with the Central andSouthern Regions suffering more than the North.However, problems of hunger are also found inurban areas, and the greatest challenge to serviceproviders is to reach the pockets of need that mayexist within an otherwise relatively food-secure area.

NRUsThe traditional approach to treating SAM is throughinpatient care in the NRUs. There are 95 NRUs inMalawi, whose role is to treat SAM. In December2005, UNICEF recorded the number of admissionsin 86 of the 95 NRUs as 2,303 children. Theresulting congestion posed risks of nosocomialinfections, and overstretched staff and otherresources.

Some SAM children were treated at outpatientclinics of health centres, in places where home-basedtherapy is in place. But the efforts of the limitednumber of NRUs and scattered community-basedprojects run by NGOs are inadequate to reach themass of SAM children suffering at home. It isestimated that only about 20% of SAM children

Figure 1: Total number of admissions in NRUs June2004 – Feb 2006

are being reached with health care. A community-based approach is clearly called for.Malnutrition is a highly complex problem involvingmany players, and the community-based approachaddresses the economic and social aspects,

recognising that malnutrition is not just about food.CTC increases the capacity of communities torecognise and manage malnutrition, and to takesteps to avoid it.

The aims of CTC 1. To treat severe acute malnutrition – both

marasmus and kwashiorkor. Inpatient care in the NRU is complemented byearly discharge to OTP. CTC assists the healthstaff in NRUs, by enabling them to focus betteron those SAM children who have clinicalcomplications and are in most acute need.

2. To provide easy access for populations in needby decentralising the service.

1. Introduction

Eating RUTF for the first time

Months (# of NRU with available data)

9

An OTP clinic may be attached to a hospital ora health centre, thus using existing healthinfrastructure. A medical assistant (MA) and/orcommunity nurse trained in the CTC approachare responsible for the OTP. Health SurveillanceAssistants (HSAs) are being trained in how todiagnose and refer cases of SAM in instanceswhere no other health staff are present. (Staffresources and capacity-building are criticalissues in a situation of general serious shortagesof qualified health staff.)

3. To ensure that, as much as possible, care shouldbe provided at home to complement that infeeding centres or hospitals, enabling the care-giver to attend to other family responsibilitieswhile attending to the malnourished child.

4. To mobilise communities using both formal andinformal networks, including traditionalpractitioners.Information Education and Communication(IEC) is crucial to the success of the CTCapproach; the community itself is trained todetect and refer cases of malnutrition in time.Protocols are simplified so that volunteers aswell as health workers can develop thenecessary competencies for screening. As wellas identifying cases of SAM, they follow upOTP clients in order to minimise defaulting.

5. To treat SAM children with RUTF. RUTF has lainbehind the CTC initiative from the start. Knownas plumpynut, and resembling the local foodchiponde, it has enormous benefits in terms ofeffectiveness and ease of use. It is produced inthree production units in Malawi, and theworkshop addressed the issues of extendingproduction capacity, commercialisation of RUTFproduction, and exploring options for differentingredients.

CTC national structuresThe decision-making and advisory body for CTC isthe CTC Steering Committee, with representativesfrom the MoH, WHO, UNICEF, USAID, CWW /CAS, Save the Children (SC)-US and VALID. TheCAS has recently been set up as a technical teamfrom CWW and the MoH which offers support todistricts adopting CTC (see Chapter 6).

The government’s Targeted Nutrition Programme(TNP) also has a technical working group on CTC.

Progress towards integration into PHCCTC has now been piloted in 16 districts in thecountry. The current aim is to encourage its adoptionin the unserved parts of those districts, and to extendit to the remaining 12 districts. The decentralisationof health services offers opportunities andchallenges for this process. CTC is clearly based onpublic health principles, and thus fits well within thestated aims of the EHP to extend health services asmuch as possible to community level, reaching thepopulation that is hardest to reach.

It is expected that RUTF will in due course be put onthe Essential Drugs List, for procurement,warehousing and delivery by Central MedicalStores, through the district health systems.

“I think I like it”

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Contributors: Dr Dorothy Namate, Director ofHealth Clinical Services, Ministry of Health; DrPaluku Bahwere, Valid International; Alice Nkoroi,CWW; Dr Brian Bramson, University of NorthCarolina (UNC) Project, Lilongwe.

2.1 The History of CTC in MalawiCTC was introduced in Malawi initially as anemergency response to increased levels of acutemalnutrition. Ambulatory feeding programmes hadbeen started in Ethiopia and Darfur in 2000, withthe assistance of CWW, Oxfam and Save theChildren (SC)-UK, and the food crisis in 2002attracted similar initiatives in Malawi.

It had been discovered in Ethiopia and Sudan thatthe inpatient treatment of SAM needed to becomplemented by an outreach approach. TFCs areresource-intense; carers of malnourished childrenhave to travel long distances to access their servicesand coverage is low. Moreover, the congregation ofsick and malnourished children in centres leads tothe spread of infection, increasing morbidity andmortality. The equivalents of TFCs in Malawi are the95 NRUs, located in areas where there tend to bemost cases of acute malnutrition. Problems of poorcoverage and congestion at peak periods leading tothe risk of nosocomial infections also apply to NRUs.

Components of CTC ProgrammesCTC is an innovative concept that mobilisescommunities and supports local health services toeffectively treat those with acute malnutrition in theirhomes. A typical CTC programme comprises fourelements:• Community mobilisation, including screening for

referral• OTPs for cases of SAM without clinical

complications• Inpatient care for those with clinical

complications in the NRU• Supplementary feeding for those with moderate

malnutrition to prevent them from becomingseverely malnourished, and for cured outpatientsto prevent relapse.

Over time, CTC has been modified for application intransition contexts, otherwise called non-emergencyor developmental contexts. Malawi has been apioneer in this, with the ongoing support of CWWand VALID.

Figure 2: The original concept of CTC

Global guidelines on community-based treatment ofmalnutritionThe integration of CTC into other primary healthcare services is central to its effectiveness andsustainability. By 2003 WHO had proved its supportfor community-based management of severemalnutrition in their Global Strategy for Infant andYoung Child Feeding, which was adopted byUNICEF.

RUTFCTC was made possible because of a RUTF calledplumpynut. Its primary advantage is that it needs nopreparation and does not spoil, because it is oil-based. Plumpynut is manufactured by Nutriset, inFrance, and now local equivalents are produced inMalawi. Plumpynut bears a strong similarity in tasteto chiponde, a groundnut paste mixed with salt,which has long been enjoyed by children in Malawi.Plumpynut is a mix enriched with dried milk powder,oil and Complex Minerals and Vitamins (CMVs)giving SAM children the calorific value andmicronutrients that they need for recovery.

CTC Admission CriteriaThe CTC approach makes a distinction between theSAM child with clinical complications, who must betreated as an in-patient, and the SAM child with nocomplications, who may be treated at an OTP. (see table 1)

2. Overview of CTC

Extract from WHO Global Strategy for Infant and YoungChild Feeding (2003)

…searching actively for malnourished infants and youngchildren so that their condition can be identified and treated,they can be appropriately fed, and theircaregivers can be supported;

… promoting development of community-basedsupport networks to help ensure appropriateinfant and young child feeding, for examplemother-to-mother support groups and peer orlay counsellors, to which hospitals and clinicscan refer mothers on discharge.

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Table 1: CTC admission criteria

2.2 CTC: The Concept The four pillars on which CTC is built are: highcoverage and good access, timeliness, sectoralintegration and capacity-building.

1. High coverage and good access The health staff need to consider those children notin the programme who are in danger of dying athome. The number of CTC distribution points has tobe increased to the level projected by the WHO, i.e.not more than 10km round trip from home, in orderto reach the maximum number of children. Theproximity of health care provision is a critical factorin decreasing barriers to access (Figure 3).

Figure 3: Impact of relative proximity of health careprovision

With more OTP sites there is better follow-up, butdefault rates of around 15–17% remain a problem.In Malawi it is difficult to trace patients who moveacross district borders. Stronger communityawareness that SAM can be effectively treated closeto home is one answer to this challenge.

2. Timeliness CTC attacks the problem of late presentation, whenthe child may have developed complications andmay even be beyond medical help. CTC has

simplified protocols, so that community volunteerscan be trained in the task of active early detection.CTC is a pro-active approach, and cases of SAM areactively sought.

3. Sectoral integrationMalawi has pioneered CTC in a developmentsetting; it is demand-driven. It contrasts withemergency responses, where design andmanagement tend to be external, outreach is bypaid professionals, RUTF is imported and theoperation is resource-intensive. Those implementingCTC in a development setting use the structures thatare already there, and mobilise communities in theearly detection of cases of malnutrition. All thosewho have responsibility for the care of youngchildren are oriented in the identification of severemalnutrition. Linkages are made with extensionworkers from other ministries (notably Agricultureand Gender, Child Welfare & Community Services),who are also oriented in CTC. Families who havereceived care and treatment are linked withcommunity food security initiatives.

Follow-up is more effective when carried out bycommunity workers, and has reduced relapse rates.RUTF can be manufactured locally, integratingtreatment with the local economy and the wholeoperation uses fewer resources.

4. Capacity building Health staff and volunteers have to be trained in anappropriate way, where necessary using simplifiedprotocols, and building on their existing knowledge.

Staff are overburdened in NRUs, and CTC iseffective in taking some of the pressure off them,ensuring better quality of care for those cases thatcannot be treated in OTP. There are shorter lengthsof stay (around 7–12 days), and so the caseload isreduced.

2.3 Expansion of the CTC Approach

CoverageThe following table shows the current extent of CTCactivity in Malawi.

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Table 2: CTC coverage in Malawi

Success rates for CTC The recovery rate for CTC globally is high, takingtogether figures for inpatient and outpatient care. Asurvey was made of all CTC programmes runbetween 2001–4

1and Malawi’s experience in

2002–3 was comparable to successes elsewhere,with a recovery rate of 69.4%.

Weight gain is slower under CTC. This could bebecause of the sharing of RUTF in food-insecurefamilies, or perhaps with the increased physicalactivity in the home setting. However, follow-upstudies have shown that the weight gain is moresustained, with lower rates of relapse

2.

Table 3 : Global outcomes of CTC programmes(SC/NRU and OTP combined)

Development of guidelinesIn the absence of national CTC guidelines, it isdifficult to harmonise implementation by partners.

With the impending scale up there is need to comeup with national guidelines. As such Malawi is in theprocess of drafting national CTC guidelines and thisworkshop offered an opportunity for comments tothe latest draft. Besides WHO produced guidingprinciples for developing CTC guidelines and hencewill be vital in the finalisation of the national CTCguidelines.

RUTF and the HIV-Infected SAM child Advances are being made in the treatment of theHIV-infected SAM child, and there are movestowards routine HIV testing. Recovery rates andfatalities are therefore being tracked at MoyoHouse, the NRU at Queen Elizabeth CentralHospital (QECH); in 2004, 48.8% of HIV-infectedpatients died and 34.2% recovered, compared with15.9% of HIV-uninfected patient deaths and 66.7%recoveries. There is need for studies on the quality ofthese patients’ response to nutritional treatment,with and without administering cotrimoxazole oranti-retrovirals (ARV), in terms of contributing toimproving paediatric care in cases of HIV.

RUTF and the treatment of HIV-InfectedadultsThe roll-out of ARVs to 60 health facilities acrossMalawi is accompanied by the giving of nutritionalsupport. With assistance from the Global Fund,large deliveries of RUTF from Nutriset in France arearriving in Malawi. CTC is a programme for under-five children and their care-givers, and there is aclear and important linkage to be made with theARV programme for adults.

Use of RUTF in PMTCT programmesThe UNC Project at Kamuzu Central Hospital (KCH),Lilongwe, is carrying out a weaning programme forHIV-positive mothers. The study is underway anddata is not yet analysed. There are 600 infants in theproject, and RUTF is being offered as a breast-milksubstitute for children between 6-12 months whosemothers are HIV-positive and have been advised tostop breast-feeding. They have found that it is anacceptable breast-milk substitute, but it is verydifficult to sustain.

- Malawi Demographic Household Survey 2004/5 - Defined as severe wasting (WH of < -3 SD NCHS/WHOreference) or oedema or a Mid Upper ArmCircumference (MUAC) of < 110cm

2.4 Cost of CTC programmesThe initial outlay in setting up a CTC programme will

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include:• Recruitment and training• Equipping and providing transport for mobile

teams• Setting up decentralised logistics• Interacting with and mobilising populations.Once the above components of the programme arein place, the ongoing costs are mainly on medicinesand RUTF.

A CTC programme builds on current structures,offering in-service training for health workers andusing established health facilities. The capacity of aCTC programme is not limited in the way that NRU

care is limited by thenumber of beds andother inpatientfacilities. CTC doesbenefit fromeconomies of scale;where there is aconcentration ofneed, the cost oftreating each SAMchild can be muchlower than keepingthat child for the fullduration of treatmentas an inpatient. Thegreatest challenge interms of ongoing costis the purchase of

RUTF.

Figure 4: OTP and NRU cost in Nsanje district CTCprogramme (2006)

Dr Steve Collins wrote in Nov. 2004: “Given the different aims, structure and timeframeof CTC and TFC interventions, a comparison on apurely cost-per-beneficiary basis is difficult andlargely inappropriate. It is also important to includehidden costs when estimating cost-effectiveness.Humanitarian aid managers are often guilty of only

including the direct costs of their programmes intheir analysis of cost-effectiveness, and ignoringother costs borne by the communities being helped.Traditional TFC programmes incur substantial costsfor the families and communities of programmebeneficiaries which need to be included in anycomparative analysis of CTC and TFC approaches.In the latter, mothers are removed from theirfamilies for up to a month, in order to stay with theirchildren in the TFC. Siblings of the malnourishedchild are deprived of maternal care during thisperiod. Furthermore, the mother is unavailable towork in the fields or participate in other income-generating activities during this time. All of thisimposes a significant opportunity cost on the familyand on the community – a cost that is largelyavoided in the CTC model”(Extract from “CTC A newparadigm for selective feeding in nutritional crises”.Commissioned and published by the Humanitarian PracticeNetwork at ODI Nov 2004).

Looking forward to RUTF treatment (Kerac)

An outpatient at MoyoHouse (Kerac)

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Contributors: Sylvester Kathumba, DistrictNutritionist, Dowa; M Chiwamba, MCHCoordinator, Mangochi

3.1 CTC in an Emergency Setting:the Case of Mangochi (SC-US)

Support was given by SC-US, who helped the DHOset up an emergency project, which began inJanuary 2006 in response to the emerging foodcrisis in the district. Through timely intervention, itaims to treat both malnourished children and alsohighly vulnerable malnourished HIV-infected adults.Specifically, it focuses on:• increased access and coverage of services for the

treatment of acute malnutrition. The coverage wasincreased from the previous provision through onlythree NRUs, to 36 health facilities currentlyoffering CTC;

• increased capacity of the DHO in communitymanagement of acute malnutrition. Training wasgiven to nurses, MAs and HSAs on supplementaryfeeding programme (SFP) and OTP guidelines;

• improved quality of nutritional care and supportfor HIV-infected adults.

The MoH nutritional survey had estimated thefollowing target population:• 8,432 MAM children• 1,700 severely malnourished children• 300 chronically ill malnourished adults.

Community mobilisationA step-by-step approach to community mobilisationwas used. Firstly, the chiefs were sensitised, thenother local leaders. Growth monitoring volunteers

(GMVs) were identified as the community group bestplaced to be trained in active case-finding, and sothey were able to complement the work done byHSAs, using MUAC and oedema measurements. Itwas important to maintain community mobilisationthrough continued screening at community level,with careful follow-up of beneficiaries.

Performance indicatorsSuccess has been remarkable. With reduced lengthof inpatient stay, the NRUs have been less congestedand therefore more effective in treating cases. Theyhave been able to admit a total of 1,881 childrenbetween 23 January and end-March. Meanwhile,over one month (Jan–Feb 06) 1,350 children weretreated via the OTP. Thus, the performance ofMangochi district is within the Sphere indicators; byend-March, the cure rate was 76.3% and the deathrate 5%. The defaulter rate of 13.6% remains achallenge and could be improved upon.

ChallengesAs would be expected, the project has facedconsiderable challenges, not least the difficulty ofaccessing more remote areas in heavy rains. SC-UShelped with vehicles, but transport costs are high.The very low number of NRUs posed a majorchallenge for accessing treatment for the mostcritically ill children. At the peak of the hungerseason, therapeutic food may go astray.Some food items were stolen by health centre staff,

and also it was noticed that RUTF was being sharedamong family members. In order to address this,each care-giver was given 8kg of gramil (a finelyground and milled maize flour) and 4kg of beans atthe same time as the RUTF was given.

CTC for the chronically illThe initiative to pilot RUTF among 300 chronicallyill/HIV-infected adults deserves comment. So farthere are 64 people registered. Selection for theprogramme is based simply on a MUAC of <21cm,with Body Mass Index (BMI) only being introducedlater in monitoring at the health facility. The patternis that adults become very sick and may seek

3. CTC in Emergency and Development Settings

Training extension workers in Balaka District (Linzie)

OTP distribution in progress (VALID)

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medical help before they know their status;Counselling and Testing (CT) is offered and thennutritional support. Research will be conducted onthe effectiveness of RUTF for these patients. Clinicsoffering Anti-retro viral Therapy (ART) are not yetfully established and linked with CTC in Mangochi.

Lessons learntThe key lessons learnt in Mangochi are firstly thateffective community mobilisation is central toincreasing service accessibility for patients.Secondly, GMV now know the benefits of catchingthe moderately acutely malnourished cases early forreferral to SF. GMVs need to use simple guidelines,and so admission to SFP is based on MUAC alone,without measuring WH.

3.2 CTC in the DevelopmentContext: the Case of Dowa &Nkhotakota

The first CTC intervention in MalawiWhen a national nutrition emergency was declaredin 2002, an appeal to the UN was made forassistance, and the MoH gave permission to CWWand VALID to come to assist. Dowa district wasidentified as an area of desperate need, and theCTC programme began there in 2002, withNkhotakota following in 2003. Initially, the DHMTwere only passively involved, as CWW tookresponsibility for implementation, communitymobilisation and training of health staff, and it wastheir mobile teams who delivered care to thebeneficiaries.In Dowa, the MoH required all cases of SAM toreceive initial treatment at NRUs, but after about fivemonths, the NRUs became overloaded and the MoHthen adopted a policy of direct admission to OTP.

Increased coverage with more OTPsThe number of NRUs in Dowa district has beenincreased from three to five, and the number of OTPscurrently stands at 19, with a corresponding markedimprovement in coverage. Some ten months afterthe start of the emergency operation, a comparisonwas made between the coverage achieved inMchinji district, which at the time of the survey hadthree NRUs and no OTPs, and that achieved inDowa through CTC. Methods used for assessingcoverage vary, but the figure of 73% coverage inDowa compared with 26–28% in Mchinji provides apowerful indicator of success for CTC.

Figure 5 : Comparison of coverage - Dowa andMchinji (2003)

The coverage in Nkhotakota is similarly muchimproved, with four NRUs and 18 OTPs. Meanwhile,in Lilongwe district CWW and UNICEF inpartnership have extended coverage; the eightNRUs are now complemented by 27 OTPs. InNsanje, there are three NRUs with 12–14 OTPsunderway.

CTC Support TeamThe programmes have since evolved in adevelopmental way, with DHOs now responsible forimplementation. The core unit is the CTC SupportTeam, comprising district health staff. The CTCSupport Team supervises operations; it began withmeetings every two weeks at the health centres toreview activities, and as ownership of theprogramme has grown, these visits are now onlymade monthly. A performance checklist for healthcentres has been designed and every three months itis used to identify the health centre with the mostoutstanding performance; prizes are awarded tomotivate staff (best health centre MK2,500, and bestNRU MK2,500). The CTC Support Team meetsquarterly for review and planning.

Community mobilisationExisting community structures, as well as HSAs andother health staff are continually used formobilisation. The first move is always to alert thechiefs about the programme, telling them thatvolunteers will be sought, and that health staff willbe coming into the village. HSAs continue with IEC,seizing every opportunity at the OTP clinics.Volunteer networks meet monthly, and the districtCTC Support Team meets with them quarterly;volunteers are well trained and knowledgeable.Mother-to-mother networks are effective in outreach;each care-giver whose child has been treated isasked to take responsibility for awareness-raising intheir village. Dowa district is fortunate in havingcommunity nurses to assist with IEC at village level.

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Performance indicatorsThe CTC programmes in Dowa and Nkhotakota aremaintaining Sphere standards now, with the defaultrate improved. However, it remains a challenge tofollow up beneficiaries who have come from otherdistricts.

The following figures show the success rates in Dowadistrict:

Table 4: Performance of NRUs and OTP in Dowa –2003-5

In order to monitor relapses, surveys wereconducted in Dowa on patients one and two yearsafter recovery, by HIV status. It was found that ofHIV-uninfected patients, only 14% relapsed, and ofHIV-infected children 25% relapsed; this mirrorsexperience of CTC programmes in other countries(Table 5).

Table 5: Comparison of performance of CTC inMalawi with other countries

Improved early detection of malnutritionWith its extended coverage, the Dowa experienceexemplifies CTC’s success in increasing earlydetection of malnutrition. Case-finding is aresponsibility shared between community volunteersand the health staff. Diagnosis and treatment aredelivered by trained and qualified staff at the OTPand NRU. An OTP cannot open without thepresence of a MA or nurse; on occasion an HSA willbe faced with a possible case of SAM, and measureshave been taken to train HSAs in how to diagnoseand refer.

Early discharge from the NRUThe length of stay in the NRU is reduced from 42 toabout 7–12 days, with longer stays often attributedto chronic illnesses associated with HIV/AIDS.

OwnershipOwnership of the programme has graduallystrengthened in the CHAM and district healthfacilities, and whereas the communities at first sawthe programme as delivered by “outsiders”, nowthe community completely accepts the approach,with village heads fully in support. The DHO staffhave built on their own capacity, and are moreready to integrate with other programmes.

Using linkages for IECWherever IEC is going on, the CTC programme linksup with it, whether in food security or health. WhenCWW initiated its food security project in Dowa, itdeliberately targeted those families who had beenon the CTC programme. The uptake of ExpandedProgramme of Immunisation (EPI) is enhancedbecause each child is screened when they aretreated for malnutrition. In a similar way, links aremade with the Insecticide Treated Net (ITN) schemeand water and sanitation programmes. Many CTCvolunteers are also engaged in other programmes,e.g. MASAF, and so they tend to be people withbroad knowledge as well as IEC skills. CTC isexploited as a very good entry point for CT andPrevention of Mother-to-Child Transmission (PMTCT).Through IMCI, other medical complications arepicked up and referred for diagnosis and treatment.Since there are so many instances of needy familieswhere the mother has died from HIV/AIDS, leavingthe family at risk of neglect, males as well as femalesneed to be targeted with IEC.

In future, more extension workers from other lineministries will be oriented in CTC. The CTC SupportTeam at district level takes every opportunity tostrengthen working relationships with otherstakeholders, in a constant effort to build up theconstituency of supporters of CTC.

Human Resources capacity issuesGeneral health staffing levels are poor, and there ishigh turnover. Besides, the motivation of volunteersconstantly needs boosting. The DHO lobbiesvigorously for more HSAs, and in an attempt toattract MAs and nurses to leave the towns to cometo work with communities in rural areas, staff housesare well maintained. Opportunities for collaborationwith other districts are sought, in the hope that theywill shortly set up their own CTC programmes.

Scaling up CTC The process of institutionalisation continues in Dowaand Nkhotakota, with logistics and financial issuesgradually being worked out. With the growth ofSWAp, there should be greater likelihood thatresources can be directed to treating SAM children,especially in the times of peak need, as a priority forthe district.

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Contributors: Marko Kerac, VALID / College ofMedicine; additional comments from Dr LeopoldBuhendwa of MSF-Belgium

Moyo House is Malawi’s biggest NRU, with arising annual admission rate of approximately 1,600in 2005–6. The catchment area is both wide(including rural areas that are not easily accessible)and large (due to the densely populated Blantyreurban area).

The admission pattern is highly seasonal with a peakduring the rainy/pre-harvest season betweenDecember and April. In the mid 1990s, doctors atQECH who had spent years working with fatalityrates of 30–35% tried various measures to improveresults. They raised the level of staffing to one nursefor each three children; better care was provided(individual clean bed with blanket and supervisedfeeding every two hours); an experiencedpaediatrician was made constantly available;

systemic infections were evaluated in the laboratoryand a relatively costly antibiotic (ceftriaxoze) wasadministered. In consequence the fatality ratedecreased to about 25%, but it has not beenpossible to lower this rate.The overall prevalence ofHIV is 40–50% of admissions throughout the year;60% of marasmic patients are HIV-infected.

The frustration of doctors in this NRU was increasedon discovering that children who had regainedweight and good health in hospital were often dyingafter a while at home. The length of stay required inthe NRU was around 30–40 days and care-giversare unwilling or unable to leave their homes todevote a long period of time to one child. And so alltoo often the central hospital receives cases verylate, and can therefore do little to improve on thecase fatality rate. There is an inpatient mortality rateof around 20% for the complex malnutrition cases,and a 26% mortality overall on follow-up. HIVmakes a significant contribution to these highmortality rates.

4.1 Reviewing the use of RUTF in theNRU

There is increasing confidence in RUTF as analternative to F100 in Phase 2 treatment. Moyo hasbeen evolving this approach since May 2003. Itenables patients who are clinically stable to bedischarged home early to complete nutritionalrehabilitation as outpatients. This in turn makes itpossible for the NRU to treat many more children,especially at peak periods. In Jan–Feb 2006 therewere over 250 admissions. Previously, with anaverage 20-day stay before recovery, 150–200beds would have been needed. With RUTF andreduced stays on the ward, Moyo House manageda maximum of 90 inpatients.

4. Going Beyond NRUs with CTC

Care-givers may have long and difficult journeys to reach the NRU (Blantyre Rural District) (Kerac)

Scenes of Blantyre’s sprawling peri-urbansettlements (Kerac)

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According to existing WHO ‘Ten Steps’/MoHdraft guidelines, routine care in NRUs follows athree-stage approach to feeding:Phase1: F75 130ml/kg/dayTransition phase: F100 130ml/kg/dayPhase 2: F100 ad libatum 200ml/kg/dayPatients are discharged at WH 85% of the median.There are many potential disadvantages in this fullyinpatient-based care of SAM:

• High opportunity costs of attending anNRU

When mothers and health centres know that the stayin the NRU is likely to be long – at least 3 weeks –then the opportunity cost of attending is high.Consequently, mothers may stay at home longer,until their children are sicker. This makes prognosisworse and treatment more difficult if they doeventually arrive at an NRU. Health centres, even ifidentifying early/uncomplicated SAM may fail topersuade mothers to attend an NRU. But withoutCTC/outpatient feeds, these health centres may havelittle to offer.

• Increased risk of nosocomial infections Long stays result in overfilled wards with increasedlikelihood of nosocomial infections. This is aparticular risk in malnourished children, all of whom,irrespective of HIV status, are to a greater or lesserdegree immune compromised. Respiratory diseases,including TB, and diarrhoeal diseases, includingcholera, are a major concern.

Pressure on NRU staffAn overcrowded NRU results in poor staff/patientratios and makes it difficult to care adequately forthe sickest children. There is pressure both onexisting beds and on staff morale.

• Use of RUTFMoyo protocols in 2003–6 initially stabilised

children according to standard WHO protocols andin Phase 2 they were given F100 with Phase 2 milk.However, rather than wait for a nutritional cure onthe ward, children were discharged early, withRUTF, after a median 10 days inpatient stay. Theywould then come back for outpatient follow-up everytwo weeks. From April 2006, with increasingexperience, RUTF is being introduced at TransitionPhase, while the patient is still on the ward, replacingF100 altogether. F75 milk rations are continuedthroughout the stay as the fluid complement to theRUTF.

A disadvantage of the outpatient system is that somepatients fail to travel long distances to attend follow-up. Mothers with children recovering fromkwashiorkor are more likely to default, and they areespecially at risk for lack of follow-up nutritionalsupport. Follow-up care and supplementary feedingare best provided at local level, in OTP at healthcentres.

Various studies have demonstrated the effectivenessof home-based therapy with RUTF for severemalnutrition.

1. Home-based therapy with RUTF. (Manary,Ndekha, Ashorn, Maleta, Briend – Arch Dis Child2004) This study took 282 HIV uninfected SAMchildren under a year old. Three differentregimens were administered in Phase 2:

• RUTF 175 kcal/kg/day• RUTF supp ~ 33% energy RDA• CSB in excess

With the high-calorie RUTF, weight gain was5.1g/kg/day (if WHZ < 3), weight gain was7g/kg/day). 86% of patients in this groupachieved 0 Z-score within 42 days.

2. Home-based therapy with RUTF is of benefit tomalnourished, HIV-infected Malawian children(Ndekha, Manary, Ashorn, Briend – ActaPaediatrica 2005)

This study took 93 HIV seropositive children undera year old. No ARVs were given. The same threeregimens were administered. With the high-calorie RUTF, weight gain was 3.2g/kg/day, and75% reached 100% WH. The median time in theprogramme was 71 days.

3. Home-based treatment of malnourishedMalawian children with locally produced orimported ready-to-use food. (Sandige, Ndekha,Briend, Ashorn, Manary – J PediatrGastroenterol Nutr 2004) This study showed thatthe outcomes for locally produced RUTF were asgood as those for imported RUTF (plumpynut).

4. Comparison of home-based therapy with RUTFwith standard therapy in the treatment of

The average age on admission at Moyo Housewas 24 months (2003-04 survey) (Kerac)

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malnourished Malawian children: a controlled,clinical effectiveness trial (Ciliberto M, Sandige,Ndekha, Ashorn, Briend, Ciliberto H, Manary –Am J Clin Nutr 2005)

This research studied seven NRUs, using astepped-wedge design. Units using F100 to curewere compared with units beginning to go over toRUTF, moving protocols accordingly. Thusstandard MoH care was compared with earlydischarge on to RUTF. The standard entry criteriawere used (WHZ <–3 SD); 1,178 children werestudied. 186 received standard care, and had amedian admission of 22 days; 347 were treatedfor 11 days in the NRU and then discharged withRUTF.Results:

• Weight gain 1.4 x as fast in RUTF group• Less fever cough or diarrhoea • Mortality no different• Twice as likely to reach cure (95%CI 1.7–2.3)• Inpatients twice as likely to relapse or die by 6-

month follow-up• However, weight gain was low in all groups:

2g/kg/d standard, 3.5g/kg/d RUTF.

Unlike other studies that indicate a slowerrecovery period in the community than in theNRU, this study showed a significantly fasterrecovery rate for RUTF and/+ early discharge,with eight weeks’ follow-up. However, sincenone of the children in this study grew well, it isquestionable whether it was a fair study.

5. Supplemental feeding with RUTF in Malawianchildren at risk of malnutrition

(Patel, Sandige, Ndekha, Briend, Ashorn,Manary, J Health Popul Nutr 2005)

There have been no increases in deaths or other

adverse events with RUTF, and weight gain iscomparable. RUTF is clearly operationallyadvantageous; it takes some pressure off staff on theward, since it is easier to prepare. Locally producedRUTF appears as good as imported plumpynut.However, no ‘head to head’ randomised clinicaltrials have been carried out to make a directcomparison between the effectiveness of RUTF andthat of F100 in an NRU setting.

The following outstanding questions need answers:• Given the cost factor, are other RUTFs equally

effective? What evidence will be needed toestablish the equivalence of alternativetherapeutic feeds?

• Can the protocols be further simplified?• Are there certain patient groups that need the

traditional F100 because of complex malnutritionand illness?

RUTF is being tried out at earlier stages; it is beingintroduced with F75 at Transition as well as in Phase2. However, it may not be appropriate formalnutrition with complications. Alternatives togroundnut-based RUTF are also being tested in theunit.

4.2 CTC Scaling-up process at MoyoHouse

The authors of the operational research findingsupdated and described by Dr Kerac are KateSadler (VALID) and Prof Anne Nesbitt (College ofMedicine). Support from World Food Programme(WFP), UNICEF, Action Against Hunger (AAH),Tambala Foods, Blantyre DHMT, MacdonaldNdekha, St Louis Nutrition Project and VALID/CWWwas acknowledged. The study was carried out intwo phases–Phase 1 May–October 2003, andPhase 2 Oct 2003–July 2004.

BackgroundBefore 2003, Moyo House was run as a traditionalNRU with fully inpatient-based treatment formalnourished children. The goal of this operationalresearch project was to evaluate the effect of achange to an outpatient system using RUTF for Phase2/rehabilitation feeding. This is a first and importantstep in the evolution towards a CTC programme.

Aims of the researchThis operational research study had the followingaims:Through introducing RUTF and outpatient Phase 2feeding, to:1. improve ‘cure’ and reduce mortality2. improve Phase 1/inpatient/stabilisation

(following on from regional WHO training inApril 2003)

3. improve Phase 2/outpatient care, using RUTF Moyo House – monitoring in-patientweight gain (Kerac)

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4. evolve the NRU towards a district-wide CTCframework (including integration with otherservices: HIV, TB, palliative care)

These aims were to be achieved with existing levelsof staffing and other resources. A key feature of theresearch was the active follow-up of all defaultersfrom the programme. This was essential to get true,unbiased outcome results.

Nutritional protocolsThe therapeutic feeding strategy for inpatientsbegan traditionally with F75 at Phase 1 and F100 atTransition. Patients began Phase 2 with F100 andonce stable they were discharged with RUTF, andasked to return to the outpatient clinic every twoweeks for check-up and more supplies of RUTF, until“cure” (WH 85% over two consecutive fortnightlyvisits).

Performance indicatorsThe admission profile shows an average age onadmission of 24 months (Table 6).

Table 6: Admission profile at Moyo House by agewith outcomes

An analysis of the admission profile by differenttypes of malnutrition prompted the move towardsextending OTP. Of the 1,082 patients studied, 732(68%) were suffering from kwashiorkor, 222 (21%)were marasmic, and 111 (10%) were suffering frommarasmus and kwashiorkor combined. The WH Z-scores on admission and outcomes, by type ofmalnutrition, are shown in the following table:

Table 7: Admission profile at Moyo House NRUshowing severity of malnutrition and type, withoutcomes

In-patient mortality rates fell. From 2002–3 to2003–4 patients were discharged earlier. Therewere no major disease outbreaks on the ward.However, the overall mortality rate remained high,at 26%. HIV was a significant factor behind this highmortality, especially in marasmic patients. The curerate was 57.7% overall.

Figure 6: Outcomes of Moyo House NRU – overalland by type of malnutrition

CTC and the HIV-infected childHIV has a significant adverse effect on outcomes.Death rate was high in the HIV+ group, many of theinfected children dying under the care of thepalliative care team, either on the ward or afterdischarge home. 30% of the total 282 deaths wereat home – many of these were proven HIV+ve orclinically suspected HIV+ve. Many deaths in the‘ s tatus unknown’ group would also have beenattributable to HIV, since not all patients were tested.Outcomes by HIV status are shown in the tablebelow:

Table 8: Moyo House NRU - outcomes by HIV statusFor proven HIV–ve patients, cure was high anddeath rate was only just above the recommendedSphere standard of <10%.

The limiting factor for HIV testing was lack of test kitsand funding for testing. A separate butcontemporaneous study revealed high (90%)acceptability for teating of SAM children – even ata time when only cotrimoxazole antibioticprophylaxis was available for those found infected.

Recently, testing for HIV has become routine inMoyo House. One reason is to reduce the stigmawhich results from only some patients being selectedfor testing. Acceptability of testing remains high: itgives good news to the care–givers of the HIV-negative children, HIV+ve children can be referred

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to either the ARV clinic, or the cotrimoxazole clinicwhile awaiting ARVs. Monitoring weight-gains inresponse to outpatient feeding helps stage HIV andproritise where on the ARV waiting list childrenshould be.

Study of defaultersDefaulters were defined as those failing to attendtwo consecutive outpatient clinics. These patientswere followed up at home to assess outcomes. Thosewho had died at home were classed as deaths. Ofthe remaining 176 patients, 49% were successfullylocated. There is no reason to suspect that the groupnot found were any different from those found. Ofthose found, 63 (73%) were well and had notreturned to follow-up for this reason. 13 (15%) werefound to be still unwell, and 10 (12%) had died morethan one month after discharge from the ward.

Length of stayMedian length of stay in the Moyo programme wasa total of 37 days. This included approximatelyeleven days inpatient stay. Deaths occurred at amedian of seven days.

Weight gainWeight gains were, like outcomes, dependent onHIV status and nutritional diagnosis:Kwashiorkor ~ 4.8g/kg/dayMarasmus ~ 5.1g/kg/dayHIV-ve/recovered ~ 7.0g/kg/day

SummaryOperational experience from Moyo House showsthat integration of a stringent NRU stabilisationphase within a broad home-based managementprogramme with locally made RUTF is an effectiveand easily implemented alternative to traditionalinpatient feeding with milk.

Overall outcomes from the programme remainsuboptimal, but this is largely due to high HIVprevalence. It is difficult to compare these overall

outcomes with pre-RUTF outcomes since previouslydefaulters were not followed up as in this study.

The locally made RUTF used in Moyo was shown tobe an acceptable food for malnourished childrenboth with and without HIV/AIDS. It is culturallyappropriate and popular with both patients andstaff. Thus, the evolution towards full district CTCprogramming is fully supported by the tertiaryinstitutions. The next moves towards CTC involveincreased harmonisation with other district healthinstitutions, OTPs in health centres, and stronglinkages with SFP.Moyo House can play a significant role in increasingoverall coverage by directing patients to both SFPand OTP.

4.3 OTP Provision Scaling-upThyolo - MSF-Belgium

MSF–Belgium has worked for many years in Thyolodistrict, and pioneered the use of ARVs there. Apillar of MSF’s work in Thyolo has always been thatnutritional support is a vital part of care and supportfor people living with HIV/AIDS. Their emphasis inall programmes is on IEC to communities andindividual care-givers, and to encourage CT.

Situation analysisWith a current population of half a million people,Thyolo has a SAM prevalence of 0.2% of the under-fives, and so on average 230 children should betreated every month. With very limited institutionalprovision (three NRUs and one OTP) only 45% ofthe SAM children were being reached; half of theinpatients had come from over 10km away.

Nutritional support for HIV/AIDS patientsIn Thyolo there is a very high incidence ofHIV/AIDS; 25% of pregnant women test positive,and around 40% of children in Thyolo DistrictHospital’s NRU are HIV-infected. The provision ofARVs is being scaled up and decentralised in orderto reach an estimated 10,000 people, includingyoung children. All children in the NRU and OTP aretested for HIV, and CT is proposed to all care-givers.As yet very few small children are put on HighlyActive Anti-retroviral Therapy (HAART), but the NRUcould be the entry-point, perhaps using growthcriteria, for those in urgent need of HAART. Thescale-up of the nutritional programme, together withother programmes like PMTCT and CBCC, and thedecentralisation of health services in Thyolo district,will have a huge impact on the potential for reachingthe ambitious ARV scale-up plan.

Moyo House – care-givers ready for dischargewith RUTF (Kerac)

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Scaling-up OTP provisionThe scale-up entailed setting up four more OTPs, twoat health centres and two in remote areas.Operating once a week, they are supervised by amobile team of one nurse, one measurer, oneregistrar and a driver. The screening system hasbeen extended, as follows:

• Supplementary Feeding Centres – OTP and SFPactivities are held on the same day at the fiveOTP sites

• Under-five clinics – all SAM children arereferred to the OTP or NRU

• Health centre Out-patient Departments (OPDs)refer SAM children to OTP

• Patients discharged early from NRUs areaccepted

• Community home-based care workers refer allchildren with red or orange MUAC to OTP.

The NRU and the OTP complement each other.Criteria for admission to the OTP, or “ambulatoryprogramme”, and to the NRU follow the nationalguidelines, as do the criteria for discharge. Furtherrequirements for transfer from NRU to OTP are asfollows:

• Presence of an OTP nearby• Return of appetite• Significant reduction or absence of oedema• No need for intra-venous (IV) or intra mascular

(IM) treatment• The care-giver accepts the transfer and has a

good understanding of what needs to be donefor the child.

ProtocolsThe protocols also follow the draft nationalguidelines, with the slight difference that a higherdose of amoxicillin (100mg/kg/day) is given inPhase 1 as a routine antibiotic. The patient isexpected to stay a maximum of seven days in Phase1, and receives only F75. If oedema is subsiding andappetite has returned than the patient moves toTransition Phase and changes to F100. In Phase 2,F100 (200ml/kg/day) is given with twice-daily LikuniPhala. The OTP is only for children in Phase 2, andRUTF (plumpynut) is distributed once a week(200kcal/kg/day).

It is preferred that all SAM children start treatment inan NRU, for accurate diagnosis of type ofmalnutrition and possible complications, in order tocheck their HIV status, to stabilise their nutritionalstatus, and to enable them to start HAART when theyare eligible. It would not be possible for an OTP tooffer the kind of intensive care that a child withcomplicated malnutrition, perhaps with kwashiorkor++ or +++, needs.

The effectiveness of the CTC programme dependsabsolutely on IEC being given its requiredimportance. The benefits of the CTC approach inreaching and treating many more malnourishedchildren are clear to see.

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Contributors: Carol Lin, Project Peanut Butter, StLouis Nutrition Project/College of Medicine; StanleyMwase and Alice Nkoroi, CWW; Dr Mark Manary,St Louis Project; Dr James Bunn, Moyo House/College of Medicine; Catherine Mkangama, ChiefNutritionist, MoH; Dr Paluku Bahwere, VALID

What is RUTF?RUTF, also known as Plumpynut or chiponde, is thekey to the success of CTC. It is a mixture of milkpowder, peanut butter, oil, vitamins and mineralsthat is nutritionally equivalent to F100, the standardformula recommended by WHO for Phase 2treatment of severe malnutrition.

The benefits of RUTF are:

• No cooking or preparation required• Low water content prohibits growth of bacteria

even after contamination with dirty hands• Can be stored at ambient temperature for

months without spoiling• Has shown to be acceptable to children and

successfully used in international relief work.

How much does each child need?One child’s needs may be 10–15kg for an averageof 42 days of treatment. For example if averageweight of a child on admission is 8.1kg, increasing

over time to 9kg. For programmatic purposes,calculations are made based on 200kcal/kg/day. Achild taking 150 kcal/kg/day will need a total of10kg, and a child taking 200 kcal/kg/day will needa total of 15kg.

Local productionRUTF is produced locally in Malawi in three places:Nambuma (Dowa district), Lilongwe and Blantyre.The Blantyre production unit is run by PPB, a non-profit Malawian NGO whose sole purpose is toproduce Plumpynut–chiponde for use in governmenthealth centres and by NGOs. PPB has a licensedpartnership with Nutriset, who pioneered RUTF inFrance and have loaned machinery. Productionbegan May 2005 in Blantyre, with 200 tonnes/yearcapacity, and it intends to scale up to 500tonnes/year by July 2006. Quality control ismaintained.

Home–based therapyRUTF has proven success in improving recovery ratesof malnourished children on home-based therapy:home-based therapy greatly increases the reach oftherapeutic programmes for malnourished children,as outpatient clinics do not need to be based in aNRU. It can also be given as supplementary feedingto HIV-positive adults in order to reduce theincidence and the debilitating effects of malnutrition.Through the Global Fund, all 60 clinics offering freeARV treatment are being supplied with importedRUTF. There is a growing demand.

CostWFP and UNICEF have donated such materials asCMVs, milk powder and oil to PPB; USAID hasrecently given large-scale production equipment,which will soon be put to use. RUTF is sold toorganisations for local distribution at aroundUS$3.60 per kg, a figure that includes the rawmaterials and manufacture.

Challenges in scaling up productionOver the current peak season, PPB has beenproducing a tonne a day, by working seven days aweek. In order for scale-up to proceed, variouschallenges have to be overcome:• Supplies of CMVs through UNICEF can take

time, as does the procurement of raw materials;• Duty has to be paid on imported items. If this

duty could be waived, the cost of RUTF could godown to US$3.20 per kg;

The complex interplay between demand,

5. Local Production of RUTF

Standard 260gm pot of RUTF, to be taken asMankhwala (medicine) (PPB)

24

procurement of raw materials (when donations arenot available), payment and production means thatRUTF cannot always be supplied on demand.Several weeks of advance notice are usuallyrequired.

• Ground-nuts are seasonal and are almostimpossible to find in the off-season;

• Dried milk often has to be imported from RSA orZimbabwe, and importation and clearance ofimported goods takes time.

Organisations are constantly seeking cheaper waysto obtain RUTF. Locally-produced RUTF is clearlyadvantageous over the imported product; it ischeaper, and the economic benefits can go to localbusinesses, transporters and farmers.

RUTF and outreachOne of the greatest challenges to CTC is outreach.The cases of SAM can be in remote and inaccessibleplaces, making it not feasible to set up a programmefor a scattered and small number of children.Nationwide coverage can only be achieved if RUTFis incorporated within the EHP. If RUTF were placedon the Essential Drugs List, its availability would beassured to SAM children wherever they are.

Districts wanting to adopt CTC will clearly incurexpenses in the purchase of RUTF. An economicanalysis of the costs and savings of introducing RUTFin all the districts is needed, bearing in mind that

cost-effectiveness is not all; the priority is to bring allSAM children under CTC coverage.

Alternative recipesAlternatives to groundnut-based RUTF needinvestigation, but caution must be exercised.Experiments are being carried out with soya andchickpeas, but it is not simply a matter of replacingone ingredient with another. Nutritional equivalentsmust be found and palatability must be maintained.Children have enjoyed chiponde, a groundnut-basedfood, for generations, and nutritionists can explorehow it may be possible to regenerate it at the villagelevel, for use as a preventive measure.

The question of what mothers add to their ch i ld’sdiet at age six months exercises nutritionists, whomay debate over the relative virtues of Likuni Phala,nsima mixed with dried fish powder or variousrecipes of enriched food in preventing malnutritionfrom setting in. All these foods must help the childaged between the ages of eighteen months to twoyears to fight off and recover quickly from thevarious infections that assail them.

Projections for scale-upIf RUTF is to be provided nationally, then the largeINGOs and the smaller local NGOs could supportRUTF production by contributing to staff training.With the new equipment in use, it will be possible forthe three RUTF producers in Malawi to produce1,000 metric tonnes of RUTF in a year. It can be

PPB production unit in Blantyre

25

estimated that there are around 70,000 SAMchildren needing treatment each year. PPB’scurrent output is one metric tonne per day; VALID inLilongwe is producing two metric tonnes per day.On average the full treatment a SAM child needs is12kg; therefore 800–900 metric tonnes of RUTFwould be required in a year. And so it seems that thecapacity is there to cover the national needs of CTCfor SAM children, with the potential to scale up forprogrammes for HIV-infected adults. The issue is oneof planning (e.g. for a five-year period) andensuring as far as possible the supply of the rawmaterials.

Commercial producers (e.g. Rab Processors) havealready shown that they can step in if the market forRUTF increases. The existing NGO producers andthe MoH need to confer with them regarding clinicaltrials and quality control. RUTF has a strict recipeand is not designed for use as a supplementaryfood; it is a treatment. It may be possible to followthe pattern taken for tablets to treat malaria, which

the government has allowed to be sold in localshops, but great caution needs to be used here,since the clients are sick children and adults in needof proper medical assessment. Furthermore, theprice of RUTF would need to fall to a very fewkwacha for a therapeutic dose in order for it to bewithin the reach commercially of those most likely tobecome malnourished.

PPB production unit in Blantyre

26

Contributors: The WHO Country Representative, DrMatshidiso Moeti, and Dr Susan Kambale,Programme Officer; Aida Girma, CountryRepresentative for UNICEF; Teresa Banda, of theMinistry of Education, formerly Deputy Director ofClinical Services at the MoH.

Substantial external contributions over a furtherperiod of time are required in order to buildon the progress already made instrengthening the capacity of health systems to

deliver CTC. This investment can lead to a sustainableservice that is both more effective in its outreach andtreatment, and also helps ease the strain on healthfacilities, with their limited technical capacity, staffshortages and very high rates of admission,especially at peak periods.

The shift from dependence on support towards localcontrol and accountability is complex, since thedistricts of Malawi are at different stages ofimplementation. While there are highly active CTCservices delivered in areas of acute need, such asDowa or Machinga, the cases of SAM that arescattered in diverse remote areas of the countrypresent a special challenge. Furthermore, thosecases of urban deprivation, especially in the“hungry season”, that lead to severe nutritionalcrises for certain families must be actively sought andattended to.

6.1 Incorporation of CTC withinWHO Global Guidelines

There is now a wealth of documented experience onCTC, in Malawi and in other countries. With its strongadherence to public health principles, CTC has beenwelcomed in Malawi as a complementary strategy,following WHO guidelines. The NGO partners andMoH staff have recognised the value of CTC andpushed forward with it, in parallel with the currentWHO Guidelines on the Management of the Childwith Severe Malnutrition.

WHO presents the following Guiding Principles ofCTC: 1. Identification of SAM children in the community in

order to provide treatment2. Management of SAM children in the community3. Management of SAM children in the community in

the context of high HIV prevalence

Over time, WHO has become persuaded of the valueof CTC globally, and is now involved in making theirown technical contribution to scaling it up. They arestudying CTC strategies, gathering evidence andconvening such players as CWW in order to build ajoint advisory capacity. WHO staff at regional leveland from headquarters will be invited to participatein the development of policy guidance in Malawi,ensuring the connection with other child healthmeasures, namely IMCI, HIV/AIDs, immunisationand malaria. In this way consultations at headquarters, regionaland at country level will be fed into the formulationof the global guidelines. These guidelines will includethe following criteria for CTC:

• CBM offers a continuum of care.The community health worker’s role is in the earlyidentification of severe malnutrition; inpatient carecan be integrated with therapeutic care at communitylevel. Early discharge is of benefit to the care-giverwith other family responsibilities, however the healthworkers need to ascertain that the homecircumstances are capable of sustaining CTC; if thehome care circumstances are extremely poor, thenthe child will not be discharged.• Feeding the SAM child at community level Where access to appropriate local diet is limited andno nutrient-dense local food is available, nutritionaltreatment consists of a daily ration of 150–220kilocalories per kg per day of RUTF. WHO calls forthe testing locally of family foods to which CMVcould be added, thus making a locally-producedtherapeutic diet.• Current admission and referral criteria

should apply • Nutrition education is a fundamental

requirement of CBM• Links to other services, especially HIV

programmes and IMCI, must be made clear• Monitoring at community level Effective treatment should be based on a weight gainof at least 5g/kg/day in SAM children. Recordsshould be kept on: case fatality rates, defaulting andtreatment failures, length of stay under treatment. • Interim National Guidelines on CTCWHO declared their readiness to work together withthe partners to finalise the National Guidelines onCTC that are at present in draft form, in harmony withthe global guidelines that are under development.

6.2 Integrating CTC into the EssentialHealth Package

WHO recognises the critical importance ofincorporating CBM of SAM within the EHP. Allcomponents of CTC – in-patient care, out-patienttherapeutic care, and community mobilisation andoutreach – are to be integrated into the EHP, atvarious levels. This measure has been approved inMalawi. Effective primary health care needsfunctioning systems at national level (clear healthpolicy and adoption of a strategy to address out-patient treatment of severe malnutrition), district level(district health services with appropriate capacity)and community level. Decentralisation of healthservices is not yet fully established in Malawi, and itis of special concern that costs of CTC should beintegrated into community level planning in thedistricts in a timely way, so that staff training and thesupply of commodities are planned for.

Cost implications of integrating CTC into theEHPThe districts adopting CTC for the first time, andperhaps with little or no NGO support, need to beassured that resources will be found through theSWAp. They should be aware that although the costper recovered child may be high, there are several

6. Strategies for Scaling-up CTC

27

indirect benefits to the health system, such as thecapacity building of staff, the rehabilitation of healthstructures and the improvement of linked servicessuch as EPI.

6.3 PartnershipsThe MoH recognises the critical importance of strongpartnerships in the process of scaling-up CTC to thedistricts. Decentralisation of health services and theSWAp to health care provision form the frameworkwithin which the process is taking place. Thechallenge is to draw together the range of separatebut linked initiatives between various district healthauthorities and NGOs, and gradually make eachCTC programme sustainable under district control. Achallenge to the integration of some CTCprogrammes is the short-term nature of donorfunding; capacity-building at district health serviceand at community level is a gradual process whichwill take many years to complete.

Linkages and coordination with other ministries atdistrict level are of crucial importance in communitymobilisation for the prevention and early detection ofSAM. Key professionals at local level are usually fewin number and over-stretched, and so they need to bepersuaded of the ways in which links can be madebetween CTC as a critically important health initiativeand other community initiatives. In particular, foodsecurity initiatives must tie in with case treatment; thishas been a feature of CWW’s activities in Dowaand Nkhotakota districts from the start.

WHOWhile not in a position to provide major funding,WHO will join advocacy for CTC, supportingresource mobilisation, and leading to the integrationof CTC into health policy and budgets. WHOadvocates with donors for the inclusion on theEssential Drugs List of RUTF as the recommendedtherapeutic food.

UNICEF–Accelerated Child Survival andDevelopmentUNICEF have declared that they are keen for CTC tobe part of this new programme instigated jointly byUNICEF, WHO and the MoH. Eight districts ofMalawi are taking the programme into their DistrictImplementation Plans (DIPs) this year, and it isexpected to roll out to all districts in 2007. UNICEFwants all components of the CTC approach to beincluded in the Accelerated Child Survival andDevelopment initiative.UNICEF will continue to offer technical support andto provide supplies for CTC in response to proposalsfrom the MoH, districts and NGO partners in alldistricts implementing CTC.

6.4 Support Services for CTC – CASand VALID

CASScaling-up CTC will require additional resources,including more staff; existing staff need moretraining. There needs to be more involvement ofmore partners. Protocols must be standardised;proper monitoring and evaluation of the services

provided must be put in place, with performanceindicators that are agreed. Quality control measuresshould be applied and lessons learnt should beproperly documented.

CAS can assist in all these areas. The CAS unit,located in the CWW offices in Lilongwe, currentlycomprises five staff. CAS works in partnership withthe Ministry of Health and VALID, and draws on theirexpertise. CAS offers:

• Training support for health staff (MAs, nurses andHSAs). This support has been given to MSH, Goaland MSF-Belgium;

• Ongoing development of Guidelines, with partnersand through the CTC Steering Committee;

• Development of training materials, written inEnglish and to be translated into local languages;

• Research studies. CAS has identified areas forstudy and will commission and fund them;

• Learning sessions. CAS will bring implementersand partners together in order to shareexperiences, establish best practices and documentthese;

• Documentation of evidence from different areas onthe successes and challenges of CTC.

VALIDEstablished in 1999 VALID is a limited companyspecialising in improving the quality andaccountability of humanitarian assistance. With awealth of experience of humanitarian reliefoperations in Darfur, Ethiopia and North and SouthSudan, VALID staff use scientific methods; they haveevaluation expertise and draw upon extensive fieldexperience. VALID has particular expertise inassessing specialised therapeutic feeding services forseverely malnourished children and adults. VALIDhas worked in partnership with CWW, SC-UK, TheCentre for International Child Health, OxfordBrookes University, and Tufts University Boston USA,to develop CTC, with support from WHO, theCanadian government and Torchbox. VALID offerssustained assistance and advice to CWW, in initiatingprojects in Malawi and sustaining them. Dr PalukuBahwere is aVALID expertworking withinCWW Malawi,and supportingone of the threelocal unitsmanu fac tu r ingRUTF.

A satisfied out-patient (Kerac)

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Contributors: Frank Linzie, Deputy DHO Balaka,

As detailed in Ch 3, progress towards thedistrict authorities assuming responsibilityand control for CTC is most advanced inDowa district. Coverage has remained

high and CWW has gradually reduced their level ofsupport to the CTC programme in order to ensuresustainability. Almost all case-finding andmobilisation have been handed over to thecommunity and health authorities.

Since early 2005, Balaka, Salima and Mzimba havebeen supported by MSH, with funding from USAID,to roll out therapeutic feeding with a CTC approach.The progress is steady and fast-moving. Balakadistrict is fully covered now; in February 2006 MSHbegan to support two more districts in the southernregion - Mulanje and Chikwawa.

The experiences of the DHMT in Balaka serve toenlighten DHOs who have not introduced CTC onthe requirements of the approach.

7.1 Case study: CTC Integration intoDHOs – Balaka

Set-up strategyThe Balaka CTC programme is demand-driven, inline with the development approach. The strategyfor setting up the programme began with the NRUs.A close study of their efficiency (orderliness, record-keeping, drugs and equipment) was carried out;staff performance was observed. Patient recordswere analysed with the following indicators:

• Average length of stay• Age of children (nearly all are aged 13–24

months, and most are aged 19–24 months)• Outcomes by weight gain of each child• Deaths, by cause• Areas the children come from.

Partner supportSupport was then enlisted from partners at all levels– from community structures (such as local leaders,Traditional Birth Attendants (TBAs), traditionalhealers), district partners, and all staff in the districthealth facilities.

Referral and links with other health servicesMechanisms have been put in place for betterreferral between community and health facilities. Forreferral to improve, community based child care

groups (CBCC) and other community workers suchas Community Development Assistants (CDAs) needfood and nutrition IEC. Community volunteers havebeen engaged and trained in IEC, identification andreferral. Village Health Committees (VHCs) can beset up to complement the work of the district healthstaff. A particular feature of the Balaka experienceis their chosen objective to integrate family planningservices with nutrition programmes; the majority ofcaretakers are expectant women with at least oneother child.

Links with food security programmesWhen children are discharged from CTC, theirfamily is targeted with farm inputs. Links with foodrelief and food security initiatives could be improvedupon; the DHO advocates for more nutritioneducation in the food security programmes. FAO hasmade a link with MSH in order to promote backyardvegetable gardens, food production and smalllivestock rearing.

Capacity-buildingA predominant feature of MSH-supported projects isthe building of human resource capacity. Balaka hasbenefited from training of trainers in CTC protocolsand guidelines, with the long-term aim of passing onthe knowledge to other districts. Training andsensitisation has been extended to all extensionworkers, especially those from the Departments ofAgriculture & Irrigation and Gender, Child Welfare& Community Services.

Training materialsThe training needs of HSAs and the staff working inOTP clinics is ongoing. CAS can assist with ongoingcapacity-building, and proclaims their readiness tocome in with appropriate assistance. The manualsthat are provided for CTC need to be written in locallanguages as well as in English. A training needsanalysis should be carried out to discover thedifferent levels at which training should be delivered,

7. CTC Integration: The Way Forward

Health staff monitoring progress and distributingRUTF (PPB)

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in order that appropriate training courses aredesigned, with some manuals produced in locallanguages. As soon as the National Guidelines forCTC have been finalised, they will be included inpre-service training for health staff.

Constraints to scaling-upWith low staff numbers, efforts to build staff capacitycan have only limited effect. Weak follow-upremains a challenge, and is especially importantsince some care-givers discharge the patients fromthe programme too early. (As in Dowa, cross-borderadmissions are very difficult to follow up.) There areso many children with malnutrition that is borderlinebetween moderate and severely acute that thehealth facilities wish for more interventions to helpthese children.

Harmonisation with partnersIn Balaka there are several NGOs working in thefield of care for vulnerable children, and there isneed to harmonise different roles and protocols;plans need to be made at district level to bring thesevarious local approaches in line with the InterimNational Guidelines. In order for the best initiativesin CTC to be properly recognised and built on, theyneed to be well-documented. The quality ofdocumentation should be a major concern.

District planningThe next stage is to build CTC into the new DIP. InBalaka, certain elements of CTC are in the 2006 DIP,i.e. capacity-building, supervision and monitoring.At the upcoming Mid-term Review, procurementactivities will be included. CTC programmes can befully introduced into the next DIP cycle in mid-2007,and will then also be included in the AreaImprovement Plans (AIPs).

SustainabilityDistricts like Balaka are achieving success inreaching and treating more SAM children, but theyare unsure of the sustainability of their work. Despitesigns of increasing prevalence of SAM, especially atpeak periods, there are no plans to increase thenumber of NRUs in Balaka district, or indeedelsewhere in the country. Reliance on donor supportthrough direct technical assistance and a variety ofNGO initiatives always raises the issue ofsustainability. CTC does much to assist an over-stretched health system, but the struggle forresources will remain the biggest challenge. Mostimportantly, a guaranteed supply of RUTF isnecessary. Donor support needs to be sought tohelp this process, since large quantities will berequired.

7.2 Planning for the Introduction ofCTC

The majority of districts in Malawi have no or little

CTC programming at present. For many districts theassistance and support of NGOs will not beavailable. The MoH recognises the powerful casefor implementing CTC in improving coverage in thetreatment of severe malnutrition, and modalities arebeing investigated for its uptake in all the districts.DHOs should be confident of introducing the CTCapproach, for the following reasons:

• Major partners (UNICEF, WHO, etc) give theirsupport

• There is a large knowledge base on this means oftreating SAM

• Protocols are in place• The SWAp is in place• Health facilities are already there, to be built on• RUTF is locally available• DHOs are ready to share experiences• “ The time is right” - now that the peak hungry

season is over, health staff can look ahead.

Through the sharing of experiences between DHOswith CTC and those without, the workshop helped togive insight into the careful analysis and planningthat needs to precede the introduction of CTC.

National Plan for Scaling-up CTCThe following guidelines could assist DHMTs withtheir planning. It will become evident that a NationalPlan for Scaling-up CTC would be very valuable toDHMTs, to avoid unnecessary duplication of effort,and to keep the districts updated on developments,e.g. integrating CTC within IMCI. CTC is not intendedto be set up as a parallel programme; it shouldalways be built on to existing health services.

The following list of issues to be addressed couldform the basis for that plan.

1. Survey of nutritional status of the community andanalysis of the existing health care provision

2. Setting up well-defined referral systems;standardising services

3. Establishing monitoring and evaluation andfollow-up systems

4. Integrating CTC within district health plans5. Partnership development6. Integration with other community and health

programmes7. Resource mobilisation (RUTF, human resources,

transport, equipment and materials)8. Capacity building for service providers,

communities and caregivers

1. Survey of nutritional status of thecommunity and analysis of the existinghealth care provision

Refer to the MoH/UNICEF monthly nutrition surveyby district. Study the patient records kept at theNRUs; analyse NRU efficiency and staffperformance (see above, Balaka). Compile the

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reasons that justify introducing CTC – limitedcoverage of NRUs, local areas with chronic orrepeated hunger crises and with associated socialdeprivation, etc.It should be noted that all interventions should betailored to the local capacity to manage and respondto the hunger situation in the worst affectedcommunities. Two areas with similar levels of SAMmight have to receive different responses. And soproper analysis of the capacity of communities andhealth facilities must be carried out at programmeplanning stage for support to be appropriate andeffective.

2. Setting up well-defined referral systems;standardising services

Ensure that patients are referred to CTC through thehealth services–integrate CTC within IMCI, GrowthMonitoring Programme (GMP), EPI. Refer care-givers of patients to other programmes –family planning, CT for HIV/AIDS, SFP, food securityand/or farm inputs.Apply the protocols and standardise services - whereNGOs may be operating small-scale CTCprogrammes, obtain agreement to align them so thatthe approach is consistent throughout the district.

3. Establishing monitoring and evaluation andfollow-up systems

Documentation is of vital importance. Protocols laydown requirements for M&E and for follow-up. Allefforts are made for record-keeping to be kept to aminimum, realistic and appropriate to the levels ofstaff concerned. Where volunteers are engaged infollow-up as well as active case-finding and IEC,there is a special need not to over-burden them.

4. Integrating CTC within district health plansIt is of paramount importance that mechanismsshould be set up between the MoH and CHAMinstitutions to ensure that all components of CTC–medical consultations, in-patient care and drugs–are cost-free to patients at all hospitals and clinics.

Although the DIPs for 2006 have already beenprepared, it will be possible at the time of the Mid-term Review to begin to integrate CTC, in a small-scale way. It is hoped that CTC programming will beinstituted nationwide in the 2007 DIPs.

5. Partnership developmentThe CTC programme has been developed throughsustained collaboration between MoH, WHO,UNICEF and key NGOs. The success of the DirectlyObserved Treatment Shortcourse (DOTS) approachto diagnosis, care and treatment of TB is established;CTC is also an outreach programme, and has similaradvantages in terms of increased access to treatment.There is a flow of information from the communitieson the successes and lessons to be learnt, and

modifications to implementation strategies have beenmade accordingly.

Research studiesThe research conducted by VALID and by the Collegeof Medicine serves to validate the move away fromthe management of SAM only through in-patientcare. Nutritionists in Malawi share information andideas for future interventions with their regional andinternational colleagues; this workshop was valuablein giving the opportunity for information on variousaspects of the progress in scaling up CTC to beexchanged.

Partners in implementing CTCKey existing partners in implementing CTC includeWFP’s Targeted Nutrition Programme and SFP; lineministries, especially Agriculture & Irrigation, andGender, Child Welfare & Community Services;Malawi Vulnerability Assessment Committee(MVAC); NGOs in the districts working in health andfood security.

Partners in HIV/AIDS careThe roll-out of ARVs with nutritional support for HIV-infected adults in 60 health facilities across thecountry will have an impact on the scale-up of CTC.Closer partnerships could be developed with thatprogramme, partly because of the common need fora large and sustained supply of RUTF.

6. Integration with other community and healthprogrammes

It is of great importance for the success of CTC thatthe community has a positive outlook on governmenthealth services. Programme uptake is greatlyaffected by attitudes in the community to the healthservice providers; those initiating CTC have to buildpublic confidence. Most communities supporttraditional healers as alternatives or supplements togovernment health structures, and so CTCimplementers work in partnership with thesepractitioners. Traditional healers are well-placed to

Community volunteers, Balaka district (Linzie)

31

refer cases of severe malnutrition, and need to bewell-informed, supported and encouraged to do so.Thus, in a successful CTC programme, traditionalhealers are part of active screening, as is the widercommunity – all should be aware of the signs ofmalnutrition, and have trust that the OTP clinic orhospital will be able to assist the children in need andtheir carers. Sustaining active case-finding and otheroutreach work in the community is a key challenge.Most key health contact points in the community havebeen mentioned already in this report: under-fiveclinics (community level IMCI); health points; VCTclinics; CHAM clinics; GMP; EPI; CBCC; VHCs; HBCprogrammes; traditional healers and TBAs. Teachersand Primary Education Advisers (PEAs) at localprimary schools and Teacher Development Centres(TDCs) need to be educated in the signs ofmalnutrition, in order to pass on their knowledge tochildren and parents, and to act as case-finders in thecommunity. Similarly, the Community DevelopmentAssistants (CDAs) and volunteers running CBCCprogrammes are valuable active case-finders. Theinvolvement and commitment of chiefs and otherlocal leaders are of particular importance in seekingout cases of dire need and/or neglect, in pre-emptingsuch crises in families, and in raising communityawareness of health service provision, the location ofOTPs, etc. Of particular importance to districtplanners is the sensitisation and involvement of AreaDevelopment Committees (ADCs).

7. Resource mobilisation (RUTF, humanresources, transport, equipment andmaterials)

CTC takes advantage of and builds on existing healthstructures, as was shown in Ch 2, where NRU andOTP expenditure in Nsanje district was presented.That analysis showed that the cost per patient stoodat 174 Euros (about US$224), of which capital anddurable equipment cost 28 Euros (US$36), trainingand local capacity-building cost 19 Euros (US$24)and RUTF took by far the largest proportion of theoverall cost–70 Euros or US$90.

Local manufacture of RUTFThe cost of purchase of RUTF per recovered child ishigh, as has also been shown in Ch 5. Perhaps RUTFcan be produced on a commercial basis, withpotential benefits to the local economy. Theprospects for buying larger quantities of locally-grown groundnuts need to be investigated, as well asthe possibilities for stimulating increased groundnutproduction. Farmers, partly through National SmallFarmers Association of Malawi (NASFAM), shouldbe linked with the current production units. Analysisof the best locations for more local production unitsneeds to be undertaken, in terms of minimisingtransport cost while ensuring quality. There wouldneed to be a national quality assurance programme,with laboratories accredited to test and analyse theproduct.

While these options are explored, there is a need forinternational donors to consider long-term supportfor RUTF. At the same time, possibilities forsubsidising certain ingredients should be furtherexplored. With CTC integrated into the EHP, and withRUTF classified as a drug on the Essential Drugs List,responsibility for storage and distribution would fallto MoH, through its decentralised facilities.Communities in a district wishing to initiate CTCimmediately, i.e. in advance of the DIP, may considerapplying to Malawi Social Action Fund (MASAF) forfunding.

8. Capacity building for service providers,communities and care-givers

There is a need for Training Needs Analyses (TNAs)to be carried out by district training teams and lineministries, with the support of CAS. CAS has animportant role to play in conducting such analyses onbehalf of service providers. Where possible, existingtraining teams will be used. Once capacity gaps havebeen identified, training can be designed anddelivered for different levels of literacy andnumeracy. Arrangements for the inclusion of CTC inpre-service training courses are also being supportedby CAS.

Those wishing to mobilise local communities will needa locally-sensitive approach. They will use in-houseexpertise, with NGOs if applicable, and seekanswers to the following questions: - How will this best be done?- Who will be targeted?- How shall we reach them?- What will be their level of involvement?- How will we sustain their commitment?

ConclusionAs the CTC approach becomes institutionalised in the district healthsystem, it is expected that where CTC programmes are beingsupported and supervised by NGOs, the role of the NGOchanges to that of mentor, i.e. the district health services willrequest training and/or specific support as the need arises. In thisway, the NGOs may be able to spread themselves more thinlyacross the country, as mentors rather than project supervisors, thusfacilitating the scaling-up process. Some flexibility will benecessary, as the prevalence of malnutrition and local capacityvary.

Taking account of these conditionalities (prevalence of malnutritionand local capacity to engage with CTC), it should be possible fora district implementing CTC to achieve the 70% coverage of SAMthat exists in Dowa, largely using existing health serviceinfrastructure.

Documentation of CTC is crucial to its integration in PHC. CTCstatistics, from OTPs as well as from NRUs, need to beincorporated into national health care statistics, i.e. outputmonitoring and HMIS.

RUTF is the main cost in a CTC programme, and local productionmust be expanded to match the scale-up and to increasesustainability. If farmers are encouraged to supply ground-nuts (oralternative, approved crops) as the basis for RUTF, the cost ofRUTF will be counterbalanced by the socio-economic benefits tofarmers and communities at large.

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ANNEX I : Agenda of the CTC Review Workshop

Date: 19 April 2006Venue: Malawi Institute of Management, Lilongwe

Welcome and introductions – Catherine Mkangama, Chief Nutritionist, MoHOpening comments – Shahnewaz Khan, Asst Country Director, CWWOfficial remarks – Dr Matshidiso Moeti, Country Representative, WHO and Dr Dorothy Namate, Director of Health Technical Services, MoH

History of CTC and CTC protocols – Dr. Paluku Bahwere, VALID

CTC Experience: Global impact, challenges, lessons learnt – Alice Nkoroi, CTC Manager for Lilongwe andNsanje, CWW

CTC experience in Dowa and Nkhotakota: Impact and challenges of the CTC experience – SylvesterKathumba, District Nutritionist, Dowa

CTC experience and protocols Moyo House, QECH, Blantyre – Dr Marko Kerac VALID/College of Medicineand Dr James Bunn, Assistant Professor, College of Medicine

MSF-Belgium experience of CTC and HIV/AIDS - Dr Leopold Buhendwa, Programme Rep. Thyolo, MSFBelgium

CTC Emergency experience: M Chiwamba, MCH Coordinator, Mangochi district

CTC experience: Support to district health management – Frank Linzie, Deputy DHO, Balaka district

Local Production of RUTF: Challenges and Sustainability of Project Peanut Butter – Carol Lin, Nutritionist,College of Medicine, PPB

Guidance on policy – Dr Susan Kambale, Programme Officer WHO

CTC Roll-out – The way forward–Facilitator: Dr Eta Banda, CN specialist, MSH

Rolling-out CTC at district level (groupwork) followed by plenary discussion – Catherine Mkangama, ChiefNutritionist, MoH

Closing Remarks – Aida Girma, Country Representative, UNICEF and Dr Matshidiso Moeti, CountryRepresentative, WHO

8. ANNEXES

REFERENCES1. Dr Steve Collins “Community-based therapeutic care. A new paradigm for selective feeding in

nutritional crises”. Commissioned and published by the Humanitarian Practice Network at ODI Nov 2004

2. Manary, Ndekha, Ashorn, Maleta, Briend “Home-based therapy with ready-to-use food” Arch Dis Child2004.

3. Gatchell V, Forsythe V, Thomas P-R, “The sustainability of CTC in non-acute emergency contex t s”Technical Background Paper, Geneva, Nov 05.

On the coverFront : RUTF needs no preparation and is palatable

ANNEX II: Acute Malnutrition Statistics

Acute malnutrition prevalences and figures among children between 6–59 months of age in Rural Malawi, basedon EPI 2006 population projection

These figures are based on WH and oedema results and do not include MUAC. Consequently, they mayunderestimate the number of children eligible to NRU and SFP. Meanwhile children identified by MUAC and notby SAM or MAM represent less than 2

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ANNEX III List of Participants

NAME POSITION ORGANISATION

Dr Dorothy Namate Director Health Technical Services MoH, Capital HillCatherine Mkangama Chief Nutritionist MoH, Capital HillDr Matshidiso Moeti Country Representative WHODr Susan Kambale Programme Officer WHOAida Girma Country Representative UNICEFStanley Chitekwe Head of Nutrition UNICEFTheresa Banda Technical Specialist MoEducation, LilongweTapiwa Ngulube Principal Nutritionist MoH, LilongweJanet Guta Nutritionist MoH, LilongweDr Mark Manary Doctor College of MedicineDr James Bunn Asst Professor College of MedicineDr Marko Kerac Registrar College of Medicine, VALIDCarol Lin Nutritionist Coll of Med, PPBDr Brian Bramson Physician UNC Project, KCHN Nutma Clinician NRU, KCHL Mkutumula Principal Nursing Officer Paeds, KCHAtusaye Mwalwanda Nutritionist CHAMDr M Mwale Programme Manager Adventist Hospital, BlantyrePaluku Bahwere CTC Advisor VALIDIssakha Diop CTC Advisor VALIDShahnewaz Khan Asst Country Director CWWStanley Mwase Progamme Manager CWWAlice Nkoroi CTC Manager, Lilongwe CWW Lilongwe Alice Gandiwa CAS Training Officer CWWRonald Chirwa CTC Advisor CWWJones Moyo CTC Advisor CWW NkhotakotaPeter Agnew Area Programme Manager–NKK CWW NkhotakotaLeo Mugombo Outreach CWW DowaYuwen Chipatala Outreach Supervisor, Lilongwe CWW LilongweGeorge Chasakala CAS, Project Officer CWW LilongweChris Mzembe Area Manager–Dowa CWW LilongweHenry Mpang’ombe Outreach Support Officer CWW LilongwePeter Killick Programme Officer CIDADr Eta Banda CN Specialist MSH Magaret Khonje Nutritionist MSHM Chiwamba MCH Coordinator Mangochi DHOB Banda Nutrition Coordinator MSH BalakaDr Leopold Buhendwa Programme Rep, Thyolo MSF - BelgiumN Magongwa Clinician, Thyolo MSF - BelgiumCecile Salpeteur Nutrition Adviser SC-US, MangochiK Lockwood Programme Manager Catholic Relief ServicesL Chapingasa Actg Project Manager GOALP Fergusson Researcher AAHLaura Fernandez Gavira Programme Coordinator AAH

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NAME POSITION ORGANISATION

Charlotte Walford Nutritionist FHIB Chibambo Program Manager CU, DedzaPeter Jere Consultant CDMFrank Linzie DDHO Balaka DHOMhango DHO BalakaDr Nkhoma DHO BlantyreFred Zainga Ag DHO Chikwawa DHOSSJ Vinkhumbo DHO Chiradzulu DHOT Munthali DHO Chitipa DHC Simchimba CCO Chitipa DHHC Chiumia DHO Dedza DHOViolet Kamfonse Ag DHO DowaSylvester Kathumba Nutritionist Dowa DHOP Munthali DHO KarongaHF Simeza CO KarongaA Mbowe DHO KasunguDr Maida DHO Lilongwe GA Kambwiri DHO Rep Liwonde DHODr Mpunga DHO MachingaDr S Mzumara DHO Mchinji DHODr F Chimbwandira DHO Mulanje DHODr W Tamaona DHO MwanzaNduna Kapawe CCO Mwanza DHP Jere Consultant MzimbaZIG Banda DDHO Mzimba DHODr C Munthali DHO Nkhata BayDZ Makanjira DHO NkhotakotaMM Semba DHO Nsanje DHODr Ngoma DHO NtcheuB Chikuse DNO Ntcheu DHOAlbert Saka Nutritionist NtchisiAnosi Matatno DDHO Ntchisi DHOH Nyasulu DHO NtchisiR Piringu DHO Phalombe DHOB Chavinda DHO Rumphi DHOE Kasela C Sup Salima DHDr A Alide DHO ThyoloGZ Mwanda DHO ThyoloE Mwangala Nurse / midwife Thyolo DHDr Deleza DHO ZombaNN Saiti DDHO Zomba DHO

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