Community-based Therapeutic Care CTC
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1 Community-based Therapeutic Care CTC Steve Collins 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 High costs to target population Low coverage High default rate High risk Congregation High cure rates?
5 MAXIMISE IMPACT SOCIAL FOCUS CTC CLINICAL FOCUS (TFC) Coverage, (access & participation) Individual treatment Hard choices
6 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
7 Classification of malnutrition
8 Traditional approach (WHO) Acute malnutrition Severe malnutrition TFC Moderate malnutrition SFP
9
10
11 Access and coverage
12 The population close to the point of treatment Early presentation Less severe cases Few complications Easy to treat centre
13 Further from point of treatment Later presentation More severe cases More complications Harder to treat
14 Far from point of treatment Late presentation Severe and complicated cases Difficult to address Require intensive treatment High mortality
15 High program coverage requires access
16 SFP/ OTP SFP/ OTP SFP/ OTP SFP/ OTP SFP/ OTP SFP/ OTP SFP/ OTP SFP/ OTP SFP/ OTP SFP/ OTP SFP/ OTP SFP/ OTP SFP/ OTP SFP/ SFP/ OTP SFP/ OTP SFP/ OTP SFP/ OTP
17 N Darfur 2001 Tina Tina Karnoi & Um Barow Malha Mellit El Sayah Koma Korma El Fasher 100 kms Hospital TFC OTP distribution point Stabilisation centre Tawila & Dar el Saalam
18 Results 11 programmes in Malawi, Ethiopia, N & S Sudan between
19 Outcome from all patients treated in CTC programs (inpatient & outpatient combined) N Recovered Default Dead Trans Non-rec 7,408 77% 11% 4.7% 5.3% 2.1%
20 100% Outcomes from CTC , (n = 7,408), & TFCs (n= 11,287) against SPHERE minimum standards 75% 50% Mortality rate 50% lower than centre-based care 25% 0% recovered died default LTF CTC 77% 5% 11% 7% SPHERE 75% 10% 15% 0% TFC 65% 12% 18% 5%
21 Program Partner Date Coverage (%) N. Sudan SC-UK/MoH N. Sudan SC-UK/MoH 2002 > 60 Malawi MoH/Concern Ethiopia MoH/Concern Ethiopia MoH/SC-US Ethiopia MoH/Care Ethiopia IMC/MoH Malawi MoH S Sudan Concern Ethiopia MoH Darfur Concern
22 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)
23
24 Cost of CTC
25 Ref. The cost of Selective Feeding - Cauldwell,R.& Hallam,A. in Community-based Therapeutic Care (CTC), ENN Special Supplement # 2, Nov 2004
26 Ref. The cost of Selective Feeding - Cauldwell,R.& Hallam,A. in Community-based Therapeutic Care (CTC), ENN Special Supplement # 2, Nov 2004
27 Conclusions Compelling evidence base that CTC works in emergency contexts CTC cost comparable or cheaper than emergency TFCs CTC becoming standard selective feeding intervention in emergencies
28 Future opportunities Local RUTF production Integration with HBC/PMTCT for PLWHA Standard element in primary health care package
29 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
30 CTC & HIV
31 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
32 A standard element in a 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
33 Quality and Standards in CTC
34 Framework for standards and quality Code of practice CTC technical manual Training Core group of agencies with credible CTC expertise Environment for implementation CTC in international & national guidelines Recognition of commitment to quality & standards Donor engagement
35 Summary Public health approach to acute malnutrition Often evolving from emergency response Maximise impact via coverage, access and appropriate level of care Results of 80,000 moderate and 8,000 severe cases very positive High potential for local management Locally made therapeutic foods High potential to provide support to PLWHA Requires action now to ensure standards and quality
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