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Community-based Therapeutic Care (CTC) constitutes one of
the most radical innovations in humanitarian practice in a
generation. This meeting provided an opportunity to launch
the HPN Network Paper published on the topic in November 2004,
and to promote debate on the future of the CTC approach.
Ready to Use Therapeutic Food (RUTF) provides the cornerstone
of the CTC approach. André Briend from WHO provided
a comprehensive and provocative account of the history of
RUTF, and of its significance in the shift towards community-based
approaches to severe malnutrition.
Evidence has existed since the 1960s that hospital-based
approaches to the management of severe malnutrition are very
problematic. They tend to be limited in terms of their coverage,
expose patients to a high risk of infection and consume high
levels of scarce healthcare sources.
A major constraint to moving towards community-based approaches
was the fact that the food used, the milk-based F100 formula,
required clinically controlled conditions for safe preparation.
Also, distribution of powdered F100, which resembles infant
formula, may undermine current efforts to promote breastfeeding.
The development of RUTF, has provided a safe alternative to
F100, in the form of a high calorie spread.
While RUTF provided the hard, nutritional input required
to move the treatment of severe malnutrition out into the
community, Dr Briend pointed out that this technical
innovation was not sufficient to reach a large number of children
and to have a public health impact, unless the approach used
to treat severe malnutrition was also changed. In particular,
what was needed was an effective mechanism for identifying
severely malnourished children in the community and to ensure
RUTF distribution at the community level. And it is here that
the CTC approach, developed by Valid International, has come
in.
CTC provides the 'software' that has translated RUTF into
a useable tool for home based care. Steve Collins,
Valid International, described the CTC approach. CTC confronts
the tough operational and ethical challenges facing those
responsible for treating severe malnutrition.
In particular, it tries to square the difficult circle as
to how to maximise the quality of care, whilst also ensuring
high coverage in very poor countries.
It does so first by differentiating between people who are
severely malnourished, but otherwise not ill, and those suffering
from complications. Under the CTC approach, the latter are
referred to inpatient stabilisation centres. The former, however,
are not admitted as in-patients, but are given RUTF which
can be used at home.
Central to the approach is the mobilisation of the communities
to take responsibility for case finding and follow-up of the
acutely malnourished. In a range of contexts CTC programmes
over the past 3 years have clearly demonstrated that, even
in the face of an emergency and coexistent social upheaval,
community structures and resources still exist and represent
an indispensable resource that humanitarian agencies must
work with, if they are to maximise the impact of their interventions.
This approach has been tried and tested in many countries
around the world, with over 10,000 people. The results (detailed
in full in the HPN paper and summarised in Dr Collins' presentation)
are remarkable. The coverage rates attained by these programmes
(typically around 70% even in remote rural communities) are
many times greater than those achieved by centre-based approaches.
In addition, amongst those accessing treatment, mortality
and default rates are lower, while recovery rates are higher,
than standard TFC approaches.
Both speakers outlined the challenges
ahead. WHO will organise in November 2005 a consultation of
experts to review whether and how RUTF and CTC approaches should
become the standard approach to the treatment of severe malnutrition.
Definition of clear guiding principles will be important if
the benefits of CTC recorded in this initial pilot stage are
to be sustained. There is a risk that without rigorous adherence
to internationally agreed protocols, the efficacy of CTC will
be diminished. Donor organisations are likely to have a critical
role to play in ensuring that only experienced and professional
organisations receive their financial support for CTC work.
The discussion following the meeting was wide ranging. There
were different views regarding whether and how the necessary
involvement from communities could be garnered and sustained
in acute emergencies. The need to adopt flexible approaches,
tailored to the needs, cultures and capacities of different
communities and public health systems was also discussed.
This in turn will demand adjusting the profile of staff away
from one dominated by medical personnel, to one that includes
people experienced in social and economic analysis.
The demands of applying CTC in situations of acute emergencies
were also discussed, and specifically the perceived trade-offs
implied between maximising coverage and providing rapid inputs.
As the use of CTC expands, so issues of how to sustain inputs
will need to be addressed.
In part, this is an issue of mainstreaming CTC and the use
of RUTF into the public health system. In Malawi, for example,
the government in now purchasing RUTF through the health budget,
and there are on-going discussions regarding its inclusion
in essential drugs provision.
In summarising the meeting, Frances Mason concluded
that CTC was a major step forward in public health and nutrition.
As an approach it had now gained great credibility, but was
now at a crossroads. Important will be to make sure that in
scaling up the applications of CTC and using it in new contexts,
such as with populations with advanced AIDS, the same rigour
continues to be applied and so its efficacy is sustained.
After 40 years in the making, home-based approaches to severe
malnutrition are at last in sight.
