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Community-based Therapeutic CareCommunity-based Therapeutic CareCTCCTC
Steve Collins & Paluku Bahwere
Valid International
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Treats majority (85%) of severe acute
malnutrition at home not in hospitals
Helps people in their villages rather than
them coming to centres
Works through local people
Uses locally produced therapeutic
products
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Aspects of acute malnutritionAspects of acute malnutrition
1. Economic deprivation– Poverty
– High work loads (esp. Women)
2. Social exclusion– Clustered in poorest families
– Malnourished siblings
3. Re-occurring– Chronic vulnerability
4. Individual pathological changes– Reductive adaptation
– Immunosupression
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CLINICAL FOCUS
High cure rates?
High costs to target population
•Low coverage
•High default rate
High risk
•Congregation
Coverage, (access &
participation)
Individual treatment
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Milk clinically effective but high Milk clinically effective but high danger of contamination and danger of contamination and therefore cause of diarrhoeatherefore cause of diarrhoea
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Weight for Height requires many staff Weight for Height requires many staff and is difficult and slow. It cannot be and is difficult and slow. It cannot be performed by community volunteers and performed by community volunteers and it confuses staff used to weight for age it confuses staff used to weight for age
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Keeping children as in patients means Keeping children as in patients means that mothers must stay with them. This that mothers must stay with them. This causes huge opportunity costs to motherscauses huge opportunity costs to mothers
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There are often too many children and too few There are often too many children and too few inpatient beds. This causes over crowding and inpatient beds. This causes over crowding and poor quality treatment with high mortality ratespoor quality treatment with high mortality rates
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Coverage, (access &
participation)
Individual treatment
MAXIMISE IMPACTSOCIAL FOCUS
CTCCLINICAL FOCUS
(TFC)
Hard choices
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RUTF has the same nutritional value s F100 but is much safer and can be used at home by the mothers. Acutely malnourished children grow better on RITF.
RUTF can be made locally out of local crops and is much cheaper than F100
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MUAC much easier to use
Predicts death better than weight for height
Can be used by volunteers
Does not confuse clinic staff used to weight for age
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CTC can operate from clinics with very little additional resources. Operating from local clinics means that people get better access and present earlier when they are easier to treat.
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CTC contains 4 basic elementsCTC contains 4 basic elements
Social mobilisation / participation
Supplementary feeding (SFP)
Outpatient Therapeutic Care (OTP)
Stabilisation Centres (SC)
– Inpatient
– Equivalent to WHO phase 1 TFCs
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Acute malnutrition
Severe malnutritionModerate
malnutrition
TFC SFP
Traditional approach (WHO)Traditional approach (WHO)
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Access and coverage Access and coverage
CTC programmes must be designed to allow people to have good access so that they present early whilst malnutrition is
uncomplicated and easy to treat
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The population close to the point of The population close to the point of treatmenttreatment
centre
Early presentation
Less severe cases
Few complications
Easy to treat
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Severely malnourished children who present early are easy to treat and have very high recovery rates
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Kwashiorkor cases that present early are easy to treat as outpatients. They have very high recovery rates and very low mortality rates when treated in CTC with RUTF
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Further from point of treatmentFurther from point of treatment
Later presentation
More severe cases
More complications
Harder to treat
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The later children present the more difficult they are to treat and the more resources are required and the higher mortality rates
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Late presentation
Severe and complicated cases
Difficult to address
Require intensive treatment
High mortality
Far from point of Far from point of treatmenttreatment
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Once kwashiorkor present late it is very difficult and very costly to treat and the children suffer from high mortality rates
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High program coverage High program coverage requires accessrequires access
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Valid International [email protected]
El Fasher
Mellit
Malha
Tawila & Dar el Saalam
TinaKarnoi &
Um Barow
Koma
Korma
Tina
N Darfur N Darfur 20012001
Hospital TFC
El Sayah
OTP distribution point
100 kms
Stabilisation centre
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Local team
– One expat doctor to support for 3
months
>100 distribution points set up in
under one month
>800 severe cases
24,000 moderate cases
24,000 pregnant and lactating
mothers
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Community volunteers and mothers are the best outreach workers. Once they have seen the CTC programmes working they are motivated to find cases early and follow them up
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ResultsResults
11 programmes in Malawi, Ethiopia, N & S Sudan between 2002-2004
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N Recovered Default Dead Trans Non-rec
7,408 77% 11% 4.7% 5.3% 2.1%
Outcome from all patients treated in Outcome from all patients treated in CTC programsCTC programs
(inpatient & outpatient combined) (inpatient & outpatient combined)
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Outcomes from CTC 2000 - 2003, (n = 7,408), & TFCs 1992-1998 (n= 11,287) against SPHERE minimum standards
0%
25%
50%
75%
100%
CTC 77% 5% 11% 7%
SPHERE 75% 10% 15% 0%
TFC 65% 12% 18% 5%
recovered died default LTF
Mortality rate 50% lower than centre-based care
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Program Partner Date Coverage (%)N. Sudan SC-UK/MoH 2001 30–64N. Sudan SC-UK/MoH 2002 > 60Malawi MoH/Concern 2003 73Ethiopia MoH/Concern 2003 78Ethiopia MoH/SC-US 2003 78Ethiopia MoH/Care 2004 56Ethiopia IMC/MoH 2004 61Malawi MoH 2004 73S Sudan Concern 2004 82Ethiopia MoH 2005 77Darfur Concern 2004 75
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TFC coverage in open situationsTFC coverage in open situations
– 1996 Guinea: 3.4% (Van Damme 1995)
– 2001 N. Sudan: < 20% (nutritional surveys)
– 2002 Malawi (rural) < 10% (nutritional surveys)
– 2003 Malawi (rural) 15% (nutritional surveys)
– 2003 Malawi (urban) 39% (nutritional surveys)
– Darfur 2004 < 5% (nutritional
surveys)
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Local production of Ready to Use Local production of Ready to Use Therapeutic Food (RUTF)Therapeutic Food (RUTF)
Simple to produce in country
Local crops (chickpea, sesame, soya,
maize)
Cheaper
Stimulates agricultural production
Cost efficient
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Valid International [email protected] 1000Kg / day (3000 cases / month)
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Industrial scale production is possible with relatively little investment. Strict quality control procedures must be in place
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CTC & home-based careCTC & home-based care Decentralised support provided in homes
Effective diets & protocols tailored to HIV
Reduced hospitalisation
CTC as entry point for VCT
– Trust
– Reduces Stigma
Nutritional support to allow people to access care
– Ability to get to clinic
– ARVs not suitable for moribund people
Nutritional adjunct to ARV
– Adherence
– Nutritional support & treatment
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A standard element Primary Health A standard element Primary Health Care packageCare package
Acute malnutrition has been ignored in 1o HC
– Lack of affordable or practical treatment options
CTC provides affordable option
– In Wollo Ethiopia & Dowa Malawi CTC becoming central
component in PHC system
• Coverage remains high
• Cure rates remain high
• Fraction of the cost of emergency CTC
Facilitates viable exit strategies
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Cost analysis of CTC Cost analysis of CTC programmesprogrammes
Preliminary findings
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Work-to-dateWork-to-date
Analysis carried out 2003/04
– Aweil West, South Sudan
– Dowa Province, Malawi
– Wollo province, Ethiopia
Emergency projects
NGO implemented
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ComplicationsComplications
Methodological difficulties– Very new programmes– Accounting systems not yet robust for
isolating CTC costs– Higher start-up costs in early CTC
programmes
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Preliminary FindingsPreliminary Findings
Cost per beneficiary OTP ~ €250-300Cost per beneficiary SFP ~ €43-115Combined cost ~ €60-150
Comparable with TFCs– ECHO programmes €288-592
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ConsiderationsConsiderationsCosts adversely affected by NGO not
registered in-country and difficult logistics
Programmes in early stages – start-up
costs proportionally higher
TFC figure does not include high cost to family
– Mother present with child for a month; effect
on siblings; effect on household labour/income
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Factors that influence cost (1)Factors that influence cost (1)Number and density of beneficiaries
– TFCs – essentially fixed cost per beneficiary
– Potentially massive economies of scale• Sensitivity analysis shows that additional
2,000 beneficiaries can halve costs
NGO already in placeRun jointly with local health
structures– Investment in future capacity – not one-
off cost as with most TFCs
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Factors that influence cost (2)Factors that influence cost (2)Availability of storageRoad infrastructureLocal production
– Key area for Valid research– Reduces freight and import charges– Will help local economies– Facilitate exit strategies
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The futureThe future
Further analysis of costs – updating previous work on longer-running programmes
Developing local productionUsing more local health infrastructure
Expectation that costs will reduce significantly. Nonetheless……
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Cost per year of life saved (1)Cost per year of life saved (1)Using OTP cost of €250 per
beneficiary
Assumptions
– 50% of severely malnourished children
would die without assistance
– average age of beneficiary is 2
– life expectancy of 55 years
– 5% mortality, 10% default rates
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Cost per year of life saved (2)Cost per year of life saved (2)
~ €10.00 per life year saved
Compares to:– Emergency cholera: €8 - €15– UK figure for accepting new medical
advance : €45,000
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Cost per year of life saved (3)Cost per year of life saved (3)
Model very robust – even if child goes on to die within five years: €111.5 per life year saved
Still one of the most cost-effective interventions possible
Once local production, established systems - < €5 per life year saved
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SummarySummary Public health approach to acute malnutrition
Maximise impact via coverage, access and appropriate level of
care
Compelling evidence base that CTC works in emergency
contexts
– Results of 80,000 moderate & 8,000 severe cases very
positive
Costs will be much cheaper than TFC
Provides viable exit strategies for emergency programmes
– High potential for local management
– Locally made therapeutic foods
High potential to provide support to PLWHA