Valid International Community-based Therapeutic Care CTC Steve Collins & Paluku Bahwere Valid International

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

Valid International 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

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

Valid International Milk clinically effective but high danger of contamination and therefore cause of diarrhoea

Valid International 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

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

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

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

Valid International 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

Valid International 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

Valid International 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.

Valid International 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

Valid International Classification of malnutrition

Valid International Acute malnutrition Severe malnutrition TFC Moderate malnutrition SFP Traditional approach (WHO)

Valid International

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

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

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

Valid International 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

Valid International Further from point of treatment Later presentation More severe cases More complications Harder to treat

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

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

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

Valid International High program coverage requires access

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

Valid International 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

Valid International Very few resources are required to successfully implement CTC

Valid International 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

Valid International Results 11 programmes in Malawi, Ethiopia, N & S Sudan between

Valid International Outcome from all patients treated in CTC programs (inpatient & outpatient combined)

Valid International Mortality rate 50% lower than centre-based care

Valid International

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)

Valid International 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

Valid International Capacity 1000Kg / day (3000 cases / month)

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

Valid International CTC & HIV

Valid International 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

Valid International A standard element Primary Health Care package Acute malnutrition has been ignored in 1 o 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

Valid International Cost analysis of CTC programmes Preliminary findings

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

Valid International Complications Methodological difficulties –Very new programmes –Accounting systems not yet robust for isolating CTC costs –Higher start-up costs in early CTC programmes

Valid International Preliminary Findings Cost per beneficiary OTP ~ € Cost per beneficiary SFP ~ € Combined cost ~ € Comparable with TFCs –ECHO programmes €

Valid International 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

Valid International 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

Valid International 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

Valid International 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……

Valid International 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

Valid International 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

Valid International 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

Valid International 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