Community Therapeutic Care

Until recently, the established treatment for children with severe acute malnutrition (SAM) has been at therapeutic feeding centers (TFCs). Rehabilitation can take 30 days. A family member stays with the child, creating camp-like conditions ripe for epidemics, depriving siblings at home of care, and undermining already fragile livelihoods.

 

In 2000, Valid International, a small emergency-response organization, showed that rehabilitating children within the community can be equally effective and can reach more children, more quickly, and at about one-quarter of the cost of TFCs.  

 

Using the Community Therapeutic Care, or CTC approach, emergency workers go to the community to identify the maximum number of malnourished children as quickly as possible. Children with severe acute malnutrition but without medical complications are cared for at home from the start. The 10 or 15 percent who have life-threatening medical complications such as infections and anorexia go to stabilization units for treatment, preferably at local health centers.

 

 

Since 2001 AED has been working with Valid, Concern Worldwide (an Irish relief and development organization), and an array of partners to help mainstream the important innovation of Community Therapeutic Care. Funding has been provided primarily by USAID through the FANTA Project, managed by AED. FANTA has been working with partner NGOs and UN agencies in Ethiopia, Malawi, and Sudan (Darfur and Southern Sudan).

 

AED has provided technical oversight and financial support in order to:  

• Establish the effectiveness of CTC in different country contexts
• Strengthen linksto existing health structures (so the approach can be scaled up)
• Develop protocols and an operations manual
• Develop and test training materials and organize training in several countries
• Investigate usesfor the CTC approach in non-emergency contexts
• Disseminate best practices and tools

The early pilot of the CTC approach carried out in Ethiopia out by Valid and its partner, Concern, focused on just 170 children in a rural district south of Addis Ababa.  To establish effectiveness on a larger scale, AED supported a study measuring the impact and effectiveness of the CTC approach in response to the 2003 Ethiopian famine. Monitoring data after four months showed that CTC could be effective even when dealing with large numbers of children and operating with normal staff resources. The program took place in two districts of South Wollo, a region with a widely dispersed population of 450,000. It reached an estimated 77.5 percent of cases—almost 30 percent higher than the international standard for care. After one year, only 8.5 percent of children had dropped out before completing treatment.

 

In Malawi, AED supported a study in 2003comparing the standard of care for severely malnourished children through traditional treatment in Nutrition Rehabilitation Units (NRUs) with care through outpatient rehabilitation and distribution of locally-produced RUTF. The study found that, in rural areas, children receiving home-based therapy gained more weight and at greater rates than those receiving standard care in the NRUs. They were also less likely to develop fever or cough than children in the NRUs. Mortality among the CTC children was nearly 50 percent of that among those receiving the standard NRU care.

 

In 2004, AED, through FANTA, provided support to Valid to roll-out the CTC approach in Ethiopia and Malawi. Efforts to scale up in both countries have relied on demand creation, NGO capacity building, and strong linkages with national programs.

 

 

The early programs distributed Plumpy’nutâ, a product manufactured in France by the Nutriset company. The cost of producing and transporting Plumpy’nutâ is a problem for many developing countries. Nutriset has set up franchises with various local producers in several countries to produce Plumpy’nutâ locally. 

 

USAID asked the Academy to work with Valid to test the locally-produced RUTF in Malawi and also to develop new formulations various locally-produced formulations for RUTF that do not use either peanuts or imported milk powder. AED and Valid worked with Oxford Brookes University in England to conduct tests on the Malawi RUTF. The university confirmed the product's nutritional content, quality, and safety—allowing local production to be scaled up. They also tested 143 new formulations and identified three different chickpea-sesame based products that meet palatability, nutritional and shelf life criteria.

 

Local manufacture of RUTF in Malawi has reduced the cost of the product and will also allow for valuable links between CTC and local agriculture and micro enterprise projects.

 

 

The CTC approach holds tremendous promise as an entry point for other interventions requiring viable community-based models of care.

 

In Malawi, AED is working with Valid to analyze the clinical records of CTC program beneficiaries to see how effective the program has been in reversing severe malnutrition among both HIV-infected and orphaned children. The study is also looking at the feasibility of adapting CTC as a platform for community-based care of people living with HIV/AIDS.

 

Another study in Malawi is looking at how RUTF can improve the nutrition of both HIV-infected mothers and their infants. Mothers receive locally produced fortified RUTF during lactation. Infants receive RUTF when they are no longer breastfed, usually at six months of age.

 

 

In October 2003, AED and Concern supported an inter-agency workshop in Dublin to share practical experience and lessons learned. AED supported publication of the findings, Community Based Approaches to Managing Severe Malnutrition, by the Emergency Nutrition Network (ENN). In 2005, AED co-sponsored a second state-of-the-art workshop in Washington, DC, focusing on issues of integration, scaling up, and mechanisms to ensure the quality of CTC programming. The proceedings, Operational Challenges of Implementing Community Therapeutic Care, were also published by ENN with AED support.

 

AED has worked with a number of UN agencies to facilitate the development of global protocols for community-based care for implementing agencies and host governments. WHO, UNICEF, WFP and the UN Standing Committee on Nutrition have just issued a joint statement on Community-based Management of Severe Acute Malnutrition. WHO and UNICEF have begun to integrate the CTC approach in their standard facility-based treatment protocols, and, in 2006, the first joint regional WHO/UNICEF training covering both facility- and community-based management of acute malnutrition was held in Tanzania.

 

In 2006, AED, together with partners Valid and Concern released Community-based Therapeutic Care (CTC): A Field Manual. The manual provides essential design, implementation and evaluation protocols for implementing the CTC approach. AED is currently collaborating with Valid and Concern in developing training modules based on the CTC field manual.