Valid International [email protected] Community-based Therapeutic Care CTC Steve Collins & Paluku Bahwere Valid International

Valid International [email protected]

Community-based Therapeutic CareCommunity-based Therapeutic CareCTCCTC

Steve Collins & Paluku Bahwere

Valid International


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


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


CLINICAL FOCUS

High cure rates?

High costs to target population

•Low coverage

•High default rate

High risk

•Congregation

Coverage, (access &

participation)

Individual treatment


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


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


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


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


Coverage, (access &

participation)

Individual treatment

MAXIMISE IMPACTSOCIAL FOCUS

CTCCLINICAL FOCUS

(TFC)

Hard choices


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


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


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.


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


Classification of malnutritionClassification of malnutrition


Acute malnutrition

Severe malnutritionModerate

malnutrition

TFC SFP

Traditional approach (WHO)Traditional approach (WHO)




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


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


Severely malnourished children who present early are easy to treat and have very high recovery rates


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


Further from point of treatmentFurther from point of treatment

Later presentation

More severe cases

More complications

Harder to treat


The later children present the more difficult they are to treat and the more resources are required and the higher mortality rates


Late presentation

Severe and complicated cases

Difficult to address

Require intensive treatment

High mortality

Far from point of Far from point of treatmenttreatment


Once kwashiorkor present late it is very difficult and very costly to treat and the children suffer from high mortality rates


High program coverage High program coverage requires accessrequires access


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


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


Very few resources are required to successfully implement CTC


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


ResultsResults

11 programmes in Malawi, Ethiopia, N & S Sudan between 2002-2004


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)


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


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


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)


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

Valid International [email protected] 1000Kg / day (3000 cases / month)


Industrial scale production is possible with relatively little investment. Strict quality control procedures must be in place


CTC & HIVCTC & HIV


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


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


Cost analysis of CTC Cost analysis of CTC programmesprogrammes

Preliminary findings


Work-to-dateWork-to-date

Analysis carried out 2003/04

– Aweil West, South Sudan

– Dowa Province, Malawi

– Wollo province, Ethiopia

Emergency projects

NGO implemented


ComplicationsComplications

Methodological difficulties– Very new programmes– Accounting systems not yet robust for

isolating CTC costs– Higher start-up costs in early CTC

programmes


Preliminary FindingsPreliminary Findings

Cost per beneficiary OTP ~ €250-300Cost per beneficiary SFP ~ €43-115Combined cost ~ €60-150

Comparable with TFCs– ECHO programmes €288-592


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


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


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


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……


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


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


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


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

Documents

Valid International [email protected] Community-based Therapeutic Care CTC Steve Collins & Paluku Bahwere Valid International