National consultation on early research findings of CMAM approach in Malawi

1. Community Therapeutic Care
Seminar Notes
Venue: Malawi Institute of Management
Date: Friday 28
th
June 2004

2. 1. Workshop Objectives
More than half of childhood morbidity and mortality is associated with malnutrition and Malawi
has very high levels of underweight and stunting as well as a consistently high baseline of
acute malnutrition. The Ministry of Health, Concern Worldwide and Valid International believe
that the CTC methodology has the potential to grow into a nationwide approach to addressing
malnutrition in Malawi. To establish the viability of this, it is time that MoH, CHAM and other
partners, NGOs and donors take the programme forward and pilot it in different scenarios.
It is on this background that the dissemination seminar was held with the following objectives:
• To create awareness about CTC programmes among partners
• To disseminate outcomes of the CTC experience in Malawi
• To share lessons learned from the CTC approach in Malawi
• To share experiences on alternative uses of RUTF in Malawi, including as a
complementary food for PLWHA
• To identify the way forward for CTC in Malawi.
Background
The Ministry of Health and Concern Worldwide in partnership with Valid International has
been implementing the CTC approach to treating severely malnourished children in Dowa
district since July 2002 and in March 2004 also in Nkhotakota district. The CTC (Community
Therapeutic Care) approach is based on the following core principles:
• Coverage and Access through numerous small decentralised distribution centres;
• Timeliness in acting before high levels of malnutrition or complicated cases arise;
• Capacity Building through working with existing structures; and
• Sectoral Integration of HIV/AIDS prevention and impact mitigation, hygiene promotion
and food security.
CTC is designed to be an improvement on more traditional approaches of treating severe
malnutrition, such as Therapeutic Feeding Centres (TFCs). TFC treatment of severe
malnutrition keeps the child and its carer (usually the mother) in a nutrition rehabilitation unit
(NRU) for an average of 40 days, where the child receives formula milks and medical care.
These centres require highly specialised resources, skilled staff and expensive imported
therapeutic food. A mother is often reluctant to stay in a centre for this timeperiod, as at home
there are probably siblings and sick relatives to care for and fields to tend. Also, keeping large
numbers of severely malnourished children together in one place promotes cross infection of
diseases, resulting in a slower recovery time or death.
However, not all severely malnourished children require treatment in an NRU and CTC aims
to treat these children in their homes. Trained nurses carry out an assessment of the child’s
health and appetite; if the child has no serious health problems and has appetite, it can be
treated at home using a special nutritional ready-to-use therapeutic food (RUTF). For the
severely malnourished children who are ill and have no appetite, then admission to NRU is
required. These children are given formula milk followed by RUTF as soon as they regain
their appetite. Provided the child has appetite and the medical complications have subsidised
then it can be discharged to home-based care after 7 days, compared to the 40 days in TFC.
All children who receive RUTF return to their local Health Centre every week to receive a
medical check and a one-week ration of RUTF from Ministry of Health staff. The CTC
programme in Dowa is primarily run by HSAs and they play a key role in screening using
MUAC and weight for height, admitting and discharging children, providing health education,

3. and dispensing RUTF, Likuni Phala and routine drugs to under-five children, pregnant and
lactating women. Children who reach 80% weight-for-height for two consecutive
measurements are discharged from the programme and admitted to the supplementary
feeding programme (SFP)
1
.
The sources of RUTF used in Malawi are local production in a small scale unit, Nambuma
Mission north of Lilongwe, and Tambala Foods in Blantyre. RUTF is nutritionally equivalent to
the F-100 milk powder (WHO) except that RUTF does not require any preparation and is
virtually water free and therefore less likely to be contaminated. It is these properties that
make the home-based treatment possible.
CTC activities can be managed using the existing MoH manpower and structures; Concern’s
experience over the last 10 months in the handing over of CTC activities were encouraging in
some areas and difficult in others. Handing over of technical implementation skills to partners,
i.e. MoH and CHAM staff was very successful but experiences relating to logistic’s
management, supervision and reporting was mixed. More needs to be done in these areas to
ensure sustainability.
2. Presentations
This section outlines the central theme and argument of each of the seminar presentations.
The agenda in annex 2 may serve as a reference point for the extracts while the full
presentations are attached in annex 3
Dr. Steve Collins of Valid International delivered an introduction to CTC, which was defined
as a public health approach to acute malnutrition. CTC maximises impact through prioritising
coverage, access and appropriate level of care. With CTC 85% of cases of severe
malnutrition can be treated in the home, after a few days’ stabilisation treatment at a
stabilisation centre, reserving the traditional and expensive NRU treatment focus on clinical
care for cases with serious complications. CTC’s social focus promotes participation and
behaviour change providing a viable exit strategy for humanitarian programmes. Local
capacity is empowered as the community provides case finding, follow-up and support thus
avoiding the erosion of existing support systems, often caused by external aid. With time CTC
would evolve into a demand driven, sustainable, locally designed and managed programme.
Sustainability is further enhanced through local production of RUTF, which has also been
successfully modified to the special needs of PLWHAs.
Dr. M.C. Joshua outlined the experience of implementing CTC in Dowa District. Since July
2002 the DHO in collaboration with Concern Worldwide has piloted this approach through
existing DHO structures including 3 NRUs used as Stabilisation Centres (SC) and 17 Health
Centres (HC) used as distribution centres and for medical follow-up. Manpower used
comprises HSAs, Nurses, Medical assistants, home craft workers, volunteers, and mothers
who have well defined roles at each level of implementation. In addition to the advantages of
the short admission period, the DHO has found CTC to be very cost effective requiring no
specialised resources or expensive imported therapeutic food and recommends it as the way
forward for treating malnourished children. Problems encountered stemmed mainly from the
inherent understaffing in the health sector especially nurses and MAs at HC level as well as
from logistical constraints.
1
Note that SFP is being significantly scaled down in Malawi from July 2004

4. MacDonald Ndekha and Dr. Mark Manary narrated the results of several studies of treating
malnourished children in home-based therapy using RUTF. The background for these studies
is that over 50% of all children in Malawi are chronically undernourished (stunted) and
malnutrition causes 56% of all under 5 deaths while at the same time prolonged in-patient
treatment with milk-based feedings as recommended by WHO is not effective. Among the
main results were that home therapy is more effective than Phase 2 in-hospital therapy and
that RUTF is superior to a traditional cereal / legume diet. The 2003 study enrolling 1,180
children from 7 NRUs showed recovery rates of 79% for home based therapy using RUTF
compared to 46% for standard therapy while relapse and death rates were at least 40%
lower. In addition, home based therapy, especially using locally produced RUTF, was found to
be a very cost-effective method to treat childhood malnutrition.
Alem Hadera Abay of Concern Worldwide presented the output monitoring data from Dowa
District where admissions, recovery, death, defaulting, referrals, weight gain and length of
stay are collected using tally sheets. In addition, regular nutrition surveys are undertaken to
monitor the progress of the programme. Coverage was estimated at 73% and admissions
were high due to the decentralised mechanisms of service delivery. Mortality rates at all levels
were very low compared to SPHERE standards while recovery rates outside of NRUs were
compromised due to high levels of default during the harvest and post harvest periods. The
impact of the programme saw U5MR declining from 1.57 to 0.46/10,000/day, GAM declining
from 4.5% to 2.6% and SAM declining from 1.1% to 0.7%. It was stressed that management
of acute malnutrition must be integrated into the existing primary health care system to
maintain the declining trend in mortality and malnutrition.
Sister Modesta of Nambuma Rural Hospital shared the experiences of local production of
RUTF, which has been implemented since February 2003. The raw materials have all been
supplied by Concern Worldwide mainly through ECHO and DCI funding with CMV donated by
UNICEF. Production has been done using 2 industrial mixers by local personnel and trained
by Tambala in measuring and mixing of ingredients, as well as care of the equipment,
hygiene, and quality control. This empowerment of local people together with the support to
the local economy and the timely access to RUTF by the nutrition programme were
highlighted as main advantages of local production. The future model for RUTF production at
this scale and the necessary inputs, in terms of capacity building and funding, requires further
researched and discussion.
Andrew Santhe of Tambala Food Products described the company’s experience with
production of RUTF since 2002. Following initial training, the six-person production team
manufactured 40 metric tonnes of RUTF in the first year of operations. Considering potential
demand and production capacity Tambala is negotiating to raise the license agreement with
NUTRISET from 50 to 100 metric tonnes/year. The raw materials for the production of RUTF
are powdered milk, sugar, peanut butter, cooking oil, and a mineral and vitamin complex
(CMV), all of which are locally sourced except for CMV. Aflatoxin contamination of groundnuts
at farm level is the major problem encountered. This could be addressed through training of
smallholder farmers or through making RUTF from alternative ingredients such as sesame
seeds and chickpeas.
Dr. Anne Nesbitt related the experience of using RUTF at Moyo house, the country’s largest
NRU with 1200 admissions a year. To help address high ward mortality rates, low cure rates,
overcrowding and serious outbreaks of diarrhoeal disease, it was agreed with MoH to follow
CTC guidelines for phase 2 treatment. Clinical findings included high levels of severe malaria
and anaemia as well as HIV/AIDS underlining the need to integrate nutritional and clinical
treatment of malnourished children and HIV children for maximum impact. In summary, the
combination of improved inpatient care and RUTF home based care reduced ward mortality

5. from 30% to 13%, increased cure rates from 45% to 60%, reduced overcrowding and cross
infection and was valued by families and staff alike. Consequently, the Blantyre RUTF
Programme actively seeks funding for continuation and recommends national roll out of RUTF
use in prevention and treatment of malnutrition.
Grace Kaliwo of Medecins Sans Frontieres (MSF) reported on their experience in using
RUTF for nutritional support to TB patients during the first month of treatment, malnourished
hospitalised patients in Thyolo DH, malnourished HIV/AIDS patients in HIV/ART Clinic, and
orphans 6 to 12 months old. The impact of nutritional supplementation through RUTF on
weight gain in TB and hospitalised patients cannot be distinguished from the impact of
medical care and treatment but distinct advantages of RUTF have been identified:
• No cooking is required and RUTF is easy to integrate in meals
• There is no contamination risk of the product
• RUTF is locally known and well accepted – also by children
• It is less heavy than the calorific equivalent of Likuni Phala dry ration
Based on these factors MSF would like to expand the use of RUTF in nutritional support for
malnourished people with HIV/AIDS through Community HBC.
Saul Guerrero of Valid International discussed community mobilisation, which comprises
widespread dissemination of information about the programme to all major stakeholders at
community level and community participation in programme design, implementation, and
handing-over. The stages of community mobilisation were described in detail showing how
the involvement of TAs and Village Headmen resulted in widespread acceptance of CTC as
reflected in sharply increasing admission figures. Community perceptions of CTC include that
it minimises disruption to farming and household activities, reduces marital conflicts and
allows for siblings to continue attending school. There is no prescribed formula for community
mobilisation but early and continued engagement with the community is vital to the success of
CTC and is feasible even during nutritional crises.
Jim Goodman of Concern Worldwide discussed the opportunities and challenges in
integrating food security with CTC.
Paluku Bahwere explored the connections between nutrition and HIV/AIDS care. The vicious
circle of HIV/AIDS, malnutrition and food insecurity is highly evident in Malawi where up to
40% of hospitalised children in NRUs suffer from HIV/AIDS. CTC offers good opportunities to
integrate the treatment of malnutrition with HBC and with it’s focus on strengthening existing
formal and informal structures and avoids crowding out community-based sources of
assistance. CTC can be used as an entry point to HIV/AIDs affected households helping to
avoid stigma and reaching the whole household at an early stage where adults are still able to
implement food security strategies. The RUTF used in CTC helps reduce the workload of
HIV/AIDS affected households and prolong the active live of PLWHAs. This will especially be
true of the new probiotic enhanced RUTF, which is currently being developed.
Kate Sadler of Valid International addressed the issue of handing over implementation of
the CTC programme to local health structures based on Concern’s experience in Dowa

6. District over the past ten months. A large number of trained HSAs and government health
workers in the District understand and implement CTC protocols and Health Centre staff is
keen to take more responsibility for the programme. It was stressed that the resulting
programme, run by the DHO, would not look the same as that started by Concern. Rather
than just ‘handing over’, the process should be thought of as support and capacity building of
local health structures for the treatment of severe malnutrition. To ensure sustainability,
programme planning must be integrated into the DHO / DIP; collected data must feed into the
District HIS and programme inputs distributed through the District Medical Stores. In general
the process requires early and close involvement of the DHO and other stakeholders as well
as enhanced capacity building skills of the supporting agency.
3. Discussion
The presentations were discussed in two separate sessions, of which detailed minutes can be
found in Annex 4. The following outlines the overarching issues of these sessions as well as
the way forward as deliberated by MoH and discussed by the forum.
In brief - some questions posed during the seminar
Peter Hailey (UNICEF) referred to Kate Sadler’s (Valid) presentation noting that there was still
a great many things that needed to be worked on, for example: what happens in terms of the
production of plumpy nut, how will this be done, the concept requires a lot of research and
discussion to be done, how will analysis, testing, piloting, be completed?
Dr Muthara, there are a great many questions regarding whether districts can take up the
CTC method, what happens if the inputs dry up, will people see this as a hand out? More
clarity is required. Health services are provided free of charge in Malawi can RUTF be
manufactured and distributed and can this be sustained?
Mac Donald Ndehka, if RUTF is an equivalence of what used to be in place, government
resources, such as F100 could be replaced with RUTF remaining as the primary therapy.
Theresa Banda, MoH. CTC can be linked to other programmes and would be the best way to
prevent malnutrition in the first place. In reply to Dr Muthara’s question, HHs are not expected
to purchase RUTF. If RUTF was used to assist as a supplement to mothers breast feeding
this would be an exception.
Dr. Steve Collins (Valid): RUTF costs. Once it is accepted that malnutrition can be caught
early and prevented, costs reduce a great deal. On the point of cost effectiveness, RUTF
costs $2,100 per m/t, which includes transportation. The cost is double if imported from
France. Half of the RUTF cost is made up using milk powder, the new RUTF variants would
not include milk powder, which would substantially reduce the cost.
Steve highlighted the cost effectiveness of local production, the opportunity costs that acrue,
the holistic integrated approach that CTC offers and the potential effects on local farmers who
could supply ingredients into the production.
Dr Joshua (Dowa, DHO), has the government taken up discussions with Tambala producers
in Tambala. Theresa Banda replied that it was only e-mail exchanges so far with no formal
discussions. The issue still needs addressing.

7. Theresa Banda, at this time NGOs have the ‘know how’ and it is imperative to make sure that
they can assist with / use the wheel that they have invented so far. What are the training
needs, at this stage more information is required from production sites, support is needed to
coalesce CTC into a viable approach and a possible national policy in the future.
Mwanza DHO: SFP programming ending in Mwanza, the district would be happy to pilot CTC.
Dr Ngoma, before making decision’s it is important to look at other programmes. What about
a workforce required for CTC, in all establishments the staffing is simply not there.
Additionally he pointed out that CHAM centres performed a great deal better than the MoH.
Dr.Ngoma pointed out that he is unable to run 2 NRUs and completely unable to spread out to
34 health centres. Great care has to be taken before any decisions are taken.

8. Ànnex 1: List of Participants and their contacts
Name Organization Designation Phone Cell Fax E-Mail Address
Dr R.B. Pendame MOHP PS 1789543 8831636 1788403 shp@dcom.net Box 30377, Lilongwe 4
Dr M O'carrol MOHP
Senior Technical
Advisor 1788645 8839872 1789431
Mr Mwitha
Balaka District
Hospital Clinical Officer 1545344 8339769 1545516 balakadho@sdnp.org.mw Box 138, Balaka
Lazarus Gonani Lilongwe-WFP Programme Officer 1774666 9923482 1775904 lazarus.gonani@wfp.org Box 30571, Lilongwe
Dr. Kapito
Blantyre District
Hospital DHO 1677401 8856892 1672149 atupelekapito@yahoo.com.uk P/Bag 66, Blantyre
Paul Msusa Save US Nutritionist 1594622 8876146 pmmsusa@yahoo.com Box 609, Mangochi
Mr. Zainga
Chikwawa District
Hospital Deputy DHO 1420266 9309807 1420264 chikwawahmis@malawi.net Box 32, Chikwawa
Shelix Munthali
Tambala Food
Products
Production
Manager 1671966 8861976 1671638 tambala@malawi.net Box 500, Blantyre
Mr. Munthali Chiradzulu DHO
01693271/
01693220 9280623 1693271 Box 21, Chiradzulu
Mr. Muthali Chitipa DHO
01382222/
01382252 1382264 Box 95, Chitipa
Dr. Mwakasungula Dedza DHO
01223522/
01223523 8337480 1223523 Box 136, Dedza
Martin Nyangulu Dowa MCH Coordinator 1282222 Box 25, Dowa
Dr. Joshua Dowa DHO 1282208 9912683 1282200 dowa_hmis@malawi.net Box 25, Dowa
Dr V. Msiska Karonga DHO
01362329/
01362706 9246913 1362338 karongadho@sdnp.org.mw P/Bag 1, Karonga

9. Dr. Tafatatha Kasungu DHO 1253400 8301646 1253630 Box 19, Kasungu
Ms Hanna
Maunde
Machinga District Public
Health Nurse
01542287/
01542205
8328283 1542446 Box 44, Liwonde
Mr EG Phale Mangochi DHO 1594344 8895788 Box 42, Mangochi
Dr. Banda Mchinji DHO 1242310 9511615 1242409 mchinjidho@sdnp.org.mw Box 36, Mchinji
Mr. Lihoma Mulanje Clinical Officer 1466211 1466295 Box 227, Mulanje
Mr. Tamawona Mwanza DHO
01432211/
213/901 8857022 1432349 dhomwanza@malawi.net Box 80, Mwanza
Dr Kangoli Mzimba DHO 1342222
08899441/
09952797 1342238 mzimbadho@sdnp.org.mw Box 131, Mzimba
Dr. Muthali Nkhata bay DHO
01352244/
01352243
09275306/
08336646 1352227 nkhatahosp@sdnp.org.mw Box 4, Nkhata-Bay
Ms Zima Nindi Nkhotakota MCH Coordinator 1292258 8347702 1292363 Box 50, Nkota-Kota
Mr Golombe Nkhotakota MCH Coordinator 1292258 8306621 Box 50, Nkhota-Kota
Mr K. Chikonde Nsanje DHO 1456222 8366038 1456258 nsanjehmis@malawi.net Box 30, Nsanje
Dr. Ng'oma Ntcheu DHO 1235200 8866412 1235459 ntcheuhmis@malawi.net P/Bag 5, Ntcheu
Mr Moffat Phalombe DHO
01480220/
01480288 8842207 1480018 phalombedho@sdnp.org.mw Box 79, Phalombe.
Mr Chavinda Rumphi Participant 1372222 8363726 1372327 Box 225, Rumphi
Ronald Phiri Salima Senior Clinical
Officer
01262277/
01262102
8894311 Salima District Hospital, Box 53,
Salima
Mr Bakali Thyolo DHO
01473419/
01473339 8865125 1473409 thyolo_hmis@maw.net Box 21, Thyolo

10. Dr Gift Banda Zomba DHO
01524588/
01524776 8872117 1524320 uso74@yahoo.co.uk P/Bag 18, Zomba
D Msowoya Alinafe HC Coordinator 9235419 barbas@eomw.net P/Bag 5, Benga
Ms Kalitela Holy Family Matron (RNM)
01480244/
01480072 Box 144, Phalombe
Mr. Kasenga Malamulo Hosp. Project Manager
01470305/
01470105 8366419 1470231 fkasenga@sdnp.org.mw P/Bag 2, Makwasa
Ms E Naphambo Mulambe Hosp. Home Craft Worker 1694225 Box 45, Lunzu.
Sr. Modesta Nambuma HC Sr In-Charge 1286287 9942008 Box 42, Nambuma
Mr Chikhosi Nkhoma Hosp.
Hospital
Administrator 1752799 9264410 1754264 nkhoma@malawi.net Box 48, Nkhoma, LL
Mr. Dimba St. Annes Hosp. Matron
01292366/
01292383 1292335 stannes@malawi.net Box 52, NkotaKota
M. Manfoster St. Gabrieli Hosp. PHC Coordinator 1274213 9279524 P/Bag 1, Namitete, LL
Ms Tchowa St. Luke Hosp. Matron 01539247/
01539264
1539251 St Lukes Hospital, Box 21,
Chilema
Dr. Maluwichi St. Montfort Hosp. Medical Officer 1424280 1424319 Box 68, Nchalo
Dr Anne Nesbit Moyo House
Peter Hailey UNICEF
Head of Section,
ECD 01770788 phailey@unicef.org
Dr M. Manary St Louis Hospital 09205448 mndekha@medcol.mw
Charlot Concern Universal Nutritionist
01223886/
793
Concern Universal, Nutrition
Emergency, Box 217, Dedza
Mrs Nkhata Concern Universal
01223886/
793 09213377
Concern Universal, Nutrition
Emergency, Box 217, Dedza

11. Mrs Regina
Mandele World Vision
Programme
Manager regina_mandele@wvi.org
Tereza Banda MOHP doxcenter@malawi.net Box 30377, LL3