Fighting hunger and malnutrition and their root causes has been central to Concern's work since it was founded in response to the Biafran famine in 1968. We target the basic, underlying conditions that cause malnutrition such as insufficient availability of food, improper food preparation and feeding practices and lack of access to health care and clean water. Concern's livelihoods and health programs aim to address these underlying causes. Our nutrition programs focus on both prevention of malnutrition and treatment of acute malnutrition.
Malnutrition contributes to more than half of the 10 million deaths of children under five every year. (Source: FANTA Project.) Concern's nutrition programs provide life-saving interventions to the most vulnerable communities in emergency and non-emergency contexts. Based on our experience and the evidence to date, Concern has adopted the Community-based Therapeutic Care (CTC) approach to treating acute malnutrition.
WHAT IS CTC?
Until 2002, agencies including Concern responded to emergency levels of malnutrition with Therapeutic Feeding Centers (TFCs). TFCs are large, inpatient centers where care is provided by well-qualified medical staff. Treatment in a TFC requires an average of 30 days of 24-hour inpatient care. These centers are large, and there aren't many of them. Thus, they are often quite far from rural communities. Mothers seeking treatment for their malnourished children had to travel long distances to reach the centers, leaving other family members and their homes and crops untended for weeks at a time.
To address some of the challenges of traditional TFCs, Concern, in partnership with Valid International, pioneered the Community-based Therapeutic Care (CTC) approach to treating acute malnutrition. CTC is an innovative concept that mobilizes communities and supports local health services to rapidly and effectively treat those with acute malnutrition
in their homes. A typical CTC program is comprised of 4 elements:
- community mobilization
- outpatient therapeutic care for uncomplicated cases of acute malnutrition
- inpatient care for those with complicated acute malnutrition
- supplementary feeding for those with moderate malnutrition to prevent them from becoming severely malnourished
Using a CTC approach, uncomplicated cases of acute malnutrition, which are the majority of cases, are provided with weekly medical treatment by community health teams and take-home therapeutic rations. Those diagnosed with complicated acute malnutrition are referred to facilities where they receive inpatient care. Since outpatient treatment can be delivered from a local health post or community gathering point, CTC allows for the decentralization of treatment services. The community has increased access to services and can seek treatment before the cases become complicated. This results in much greater program coverage and impact. Additionally, CTC aims to build relationships with communities so that a foundation is in place for longer-term development work.
Concern piloted the CTC approach in Ethiopia in 2001 with Valid International. Due to the success of the program, Concern developed a three-year research and development program with Valid focusing on developing CTC programs in Ethiopia, Malawi and South Sudan. Given the effectiveness of these programs, Concern has embraced CTC as its preferred methodology for treating acute malnutrition. Concern continues to research and learn from the application of CTC in different contexts.
CONCERN'S CTC PROGRAMS AND ACTIVITIES
Since the pilot in 2001 in Ethiopia, Concern has developed and continues to operate CTC programs in 11 countries: Malawi, Ethiopia, North and South Sudan, Niger, Democratic Republic of Congo, Kenya, Haiti, Nepal, East Timor, Rwanda, Burundi, and Bangladesh. We are currently providing technical support to programs in Somalia.
Overview of some of our programs:
- In both South and North Sudan, Concern is heavily involved in direct implementation of CTC. However, Concern is also playing a lead role in capacity building with the Ministry of Health at a state level and where possible, lat the local level. Additionally, since the peace agreement was signed in South Sudan, Concern has been a lead agency supporting the development of the new South Sudanese policies and strategies for health and nutrition with particular regard to CTC.
- In Malawi and Ethiopia, Concern started out implementing district level CTC projects in response to nutritional emergencies. However, over time, Concern’s activities have shifted from a focus on direct implementation to one of support, national level capacity building, and advocacy. In Ethiopia, along with direct implementation in one area, Concern is working with the Federal Ministry of Health to train and build their capacity to directly implement CTC along with other primary health care services in some areas. Additionally, in both Malawi and Ethiopia, Concern is playing a lead role in advocating for and assisting the Federal Ministry of Health in the process of changing the national protocols and guidelines to include CTC.
- In Niger, we are working with the Ministry of Health towards integrating CTC services into existing health services.
- Concern’s CTC program in Kenya was in response to the 2005 drought and was implemented through local partners. Concern is now working with UNICEF and other stakeholders at national level to design national guidelines and develop a Plan of Action for integrating CTC into existing health services.
TRAINING
The demand for training on CTC is high in many of the countries in which we are working. In Malawi, Ethiopia and South Sudan Concern has been actively engaged with supporting and developing training for not only the Ministries of Health, but also for other NGOs interested in developing CTC programs.
On a global level, Concern and partners Valid International were involved in the first joint UNICEF-WHO training on severe malnutrition in Dar es Salaam, Tanzania in September 2006. Additionally, Concern and Valid have led orientations on CTC to US private voluntary organizations and donors. Concern and Valid, along with UNICEF and funding from Fanta, have developed modules for a practical training on CTC for implementers.
INFLUENCING GLOBAL HEALTH POLICY
Through Concern’s work at a national level in Ethiopia, Malawi and South Sudan it has become evident that there are a few key barriers to changing national policies to support CTC. One of the main barriers is that national governments follow standard WHO treatment protocols and guidelines for the treatment of acute malnutrition. Thus, to change national protocols, global protocols and policies must be tackled first.
With our large evidence base from existing CTC programs, Concern and other actors in international nutrition advocated at a WHO conference in November 2006 to amend their standard protocols to include several CTC program protocols. As a result of the meeting, WHO has agreed to amend their protocols on severe acute malnutrition with several of the recommendations put forth by the international community. In 2007, the World Food Program, the World Health Organization, UNICEF, and the United Nations System Standing Committee on Nutrition endorsed community-based management of severe acute malnutrition as international best practice.
Other global health and nutrition programs and protocols need to be revised and amended accordingly. Concern remains actively engaged in several networks, including the UN Sub-committee on Nutrition, and will participate at several international conferences to continue its global advocacy on CTC.
LINKS
Community-based Therapeutic Care (CTC): A Field Manual
Community-based Approaches to Managing Severe Malnutrition: ENN Report on the Proceedings of an Inter-Agency Workshop
Community-based Management of Severe Acute Malnutrition: A Joint Statement by the World Health Organization, the World Food Program, the United Nations System Standing Committee on Nutrition and the United Nations Childrens Fund, United Nations, May 2007
Community-based Therapeutic Care (CTC), Emergency Nutrition Network (ENN) Special Supplement to Field Exchange Issue 23, 2004
"Management of Severe Acute Malnutrition in Children," Steve Collins, et al, Lancet 2006;368: 1992-2000, October 2006.
“The Sustainability of CTC in Non-emergency Contexts,” Valerie Gatchell (Nutrition Advisor, Concern Worldwide), World Health Organization, November 2006
Valid International
Global Hunger Index