1. Valid International steve@validinternational.org Community-based Therapeutic Care CTC Steve Collins & Paluku Bahwere Valid International

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

5. Valid International steve@validinternational.org Milk clinically effective but high danger of contamination and therefore cause of diarrhoea

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

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

9. Valid International steve@validinternational.org Coverage, (access & participation) Individual treatment MAXIMISE IMPACT SOCIAL FOCUS CTC CLINICAL FOCUS (TFC) Hard choices

10. Valid International steve@validinternational.org 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. Valid International steve@validinternational.org 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. Valid International steve@validinternational.org 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. Valid International steve@validinternational.org 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. Valid International steve@validinternational.org Classification of malnutrition

15. Valid International steve@validinternational.org Acute malnutrition Severe malnutrition TFC Moderate malnutrition SFP Traditional approach (WHO)

16. Valid International steve@validinternational.org

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

20. Valid International steve@validinternational.org Severely malnourished children who present early are easy to treat and have very high recovery rates

21. Valid International steve@validinternational.org 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. Valid International steve@validinternational.org Further from point of treatment Later presentation More severe cases More complications Harder to treat

23. Valid International steve@validinternational.org The later children present the more difficult they are to treat and the more resources are required and the higher mortality rates

24. Valid International steve@validinternational.org Late presentation Severe and complicated cases Difficult to address Require intensive treatment High mortality Far from point of treatment

25. Valid International steve@validinternational.org Once kwashiorkor present late it is very difficult and very costly to treat and the children suffer from high mortality rates

26. Valid International steve@validinternational.org High program coverage requires access

27. Valid International steve@validinternational.org 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

28. Valid International steve@validinternational.org 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. Valid International steve@validinternational.org Very few resources are required to successfully implement CTC

30. Valid International steve@validinternational.org 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. Valid International steve@validinternational.org Results 11 programmes in Malawi, Ethiopia, N & S Sudan between 2002-2004

32. Valid International steve@validinternational.org Outcome from all patients treated in CTC programs (inpatient & outpatient combined)

33. Valid International steve@validinternational.org Mortality rate 50% lower than centre-based care

34. Valid International steve@validinternational.org

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. Valid International steve@validinternational.org 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. Valid International steve@validinternational.org Capacity 1000Kg / day (3000 cases / month)

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

39. Valid International steve@validinternational.org CTC & HIV

40. Valid International steve@validinternational.org 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. Valid International steve@validinternational.org 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

42. Valid International steve@validinternational.org Cost analysis of CTC programmes Preliminary findings

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

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

45. Valid International steve@validinternational.org 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. Valid International steve@validinternational.orgConsiderations 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. Valid International steve@validinternational.org 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. Valid International steve@validinternational.org 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. Valid International steve@validinternational.org 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. Valid International steve@validinternational.org 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

51. Valid International steve@validinternational.org 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

52. Valid International steve@validinternational.org 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

53. Valid International steve@validinternational.orgSummary 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