Community-based Therapeutic Care CTC

1. Community-based Therapeutic CareCTC Steve Collins & Paluku Bahwere Valid International

2. 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

3. Aspects 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

4. CLINICAL FOCUS Coverage, (access & participation) Individual treatment • High costs to target population • Low coverage • High default rate • High risk • Congregation High cure rates?

5. Milk clinically effective but high danger of contamination and therefore cause of diarrhoea

6. Weight for Height requires many staff and is difficult and slow. It cannot be performed by community volunteers and it confuses staff used to weight for age

7. Keeping children as in patients means that mothers must stay with them. This causes huge opportunity costs to mothers

8. There are often too many children and too few inpatient beds. This causes over crowding and poor quality treatment with high mortality rates

9. CLINICAL FOCUS (TFC) Coverage, (access & participation) Individual treatment MAXIMISE IMPACT SOCIAL FOCUS CTC Hard choices

10. 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

11. 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

12. 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.

13. CTC contains 4 basic elements • Social mobilisation / participation • Supplementary feeding (SFP) • Outpatient Therapeutic Care (OTP) • Stabilisation Centres (SC) • Inpatient • Equivalent to WHO phase 1 TFCs

14. Classification of malnutrition

15. Traditional approach (WHO)

18. 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

19. The population close to the point of treatment Early presentation Less severe cases Few complications Easy to treat centre

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

21. 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

22. Further from point of treatment Later presentation More severe cases More complications Harder to treat

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

24. Late presentation Severe and complicated cases Difficult to address Require intensive treatment High mortality Far from point of treatment

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

26. High program coverage requires access

27. Tina Karnoi & Malha Tina Um Barow Mellit Koma Korma El Fasher Tawila & Dar el Saalam N Darfur 2001 El Sayah 100 kms Hospital TFC OTP distribution point Stabilisation centre

28. 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

29. Very few resources are required to successfully implement CTC

30. 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

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

32. Outcome from all patients treated in CTC programs (inpatient & outpatient combined)

33. Mortality rate 50% lower than centre-based care

35. TFC 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)

36. Local production of Ready to Use Therapeutic Food (RUTF) • Simple to produce in country • Local crops (chickpea, sesame, soya, maize) • Cheaper • Stimulates agricultural production • Cost efficient

37. Capacity 1000Kg / day (3000 cases / month)

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

39. CTC & HIV

40. CTC & 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

41. A standard element Primary Health Care package • Acute malnutrition has been ignored in 1oHC • 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

42. Cost analysis of CTC programmes Preliminary findings

43. Work-to-date • Analysis carried out 2003/04 • Aweil West, South Sudan • Dowa Province, Malawi • Wollo province, Ethiopia • Emergency projects • NGO implemented

44. Complications • Methodological difficulties • Very new programmes • Accounting systems not yet robust for isolating CTC costs • Higher start-up costs in early CTC programmes

45. Preliminary Findings • Cost per beneficiary OTP ~€250-300 • Cost per beneficiary SFP ~ €43-115 • Combined cost ~ €60-150 • Comparable with TFCs • ECHO programmes €288-592

46. Considerations • Costs 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

47. 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 place • Run jointly with local health structures • Investment in future capacity – not one-off cost as with most TFCs

48. Factors that influence cost (2) • Availability of storage • Road infrastructure • Local production • Key area for Valid research • Reduces freight and import charges • Will help local economies • Facilitate exit strategies

49. The future • Further analysis of costs – updating previous work on longer-running programmes • Developing local production • Using more local health infrastructure • Expectation that costs will reduce significantly. Nonetheless……

50. 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