CTC in LUSAKA, ZAMBIA: Observations on the Socio- Cultural Context for Community-Based

CTC IN LUSAKA, ZAMBIA: observations on the socio- cultural context for Community-based Therapeutic Care of the severely malnourished

James Lee Social Development Consultant Valid International Ltd.

June 2005

Valid International Ltd. Executive Summary

This report presents findings and recommendations from social investigation to prepare for the introduction of Community-based Therapeutic Care of the malnourished (CTC) in Lusaka District. The aim of the research was to perform a reconnaissance of social and cultural factors that might affect implementation of CTC, and to suggest ways that these might be addressed. The work was carried out over a three week period by the author and an interpreter in and around the Health Centres at Chawama and Kanyama. The main observations and recommendations are summarised below.

The appearance of severe forms of malnutrition in children appears to have strong associations in the popular mind with other, non-clinical issues, including the moral conduct of the parents, witchcraft and jealousy among family or neighbours, and proscriptions concerning breastfeeding during pregnancy. Although the health centres are currently identifying and treating malnutrition using standard community mobilisation methods linked to MCH activities, the use of these methods in an intensified effort to identify and recruit severe cases may prove insufficient, since families of the severely malnourished are unlikely to perceive the problem primarily as a nutritional one.

Nevertheless, severely malnourished children do receive care. There is a wide variety of treatment options outside the health centre which may be accessed by the family of such children, including herbalists, diviners, spirit mediums, faith healers, and a highly developed (and sometimes clandestine) system of ‘modern’ private providers. Engaging these practitioners in the identification and referral of cases is probably a more effective strategy than the general mobilisation that has been employed for CTC elsewhere, since the prevalence of severe malnutrition appears low (May survey).

A second route to the identification of severely malnourished children lies in the CBOs that are active in the community – consisting mainly of community schools and home-based care groups. While the under-5 target group of CTC is not central to the operations of these CBOs, many of them do conduct home visits to the families of their pupils or clients, and are in a good position to refer children for screening and to conduct screening themselves. Some community schools are also soon to introduce early childhood development (ECD) programmes that would give them direct contact with the relevant age group. As the district gains experience with CTC, it may be possible to involve CBOs in the treatment component of CTC as well, since some of the better supported groups employ their own nurses, or are paying allowances to district MCH nurses to attend their clients.

In principle, then, it is possible to envisage the standard nutrition outreach from the health centre being buttressed by direct case-finding (and, in some cases, treatment) through two additional channels:  via paths to treatment (the alternative practitioners)  via community services to siblings or parents of the malnourished (the CBOs).

Valid International Ltd 2 The challenge lies in the practicalities of engaging these potential partners. Ngangas and other alternative practitioners may be hesitant to collaborate with the formal health system for a variety of good reasons (fear of regulation, sensitivity about critiques of their methods as unscientific, or concern about potential loss of income). CBOs, although less difficult to approach, are only partly organized into networks, making it difficult to reach the ones that are unsupported by patrons like the Salvation Army or the major churches.

The obstacles to gaining the cooperation of these two groups of agents are not insurmountable. The individuals and organisations in question are known to the local volunteer agents of the MoH (the NPs, CHPs, and CHWs), and with the help of these agents, could be given a combination of autonomy and guidance which would see them assessing the nutritional status of local children and referring them to the health centre for CTC interventions. The key to this is the simplification of nutritional screening – an area where recent developments offer some new possibilities. By moving to the identification of severe malnutrition based on mid-upper arm circumference (MUAC) and oedema, swollen and wasted children can be identified without resort to more technical weight-for-height calculations. Targeted training in the identification of oedema and in the use of the MUAC tape can be provided to the critical community partners (traditional and private practitioners, community schools, home-based care groups) as well as the established systems of nutrition volunteers and CHWs. The hoped-for result is a network of trained individuals close to the families of the malnourished. These individuals then need only take a MUAC tape from their pocket during a routine visit to/from a family in order to determine whether the child is eligible for therapeutic care.

The report makes the following additional recommendations:  Key messages concerning the CTC strategy and OTP services should be standardized for volunteers, trainers, and others, in order to minimise community mis-reading of their intent. A handbill using local terms for the diseases of swelling and wasting should help to emphasise the target group of swollen and wasted children.  Blanket community mobilisation by NHCs and others, while potentially useful, should not be implemented at the expense of the targeted case-finding efforts through CBOs and alternative practitioners described above.  The future of SFP in Lusaka must be clarified by the major stakeholders, including LDHMT and WFP, before the architecture of CTC can be fully resolved. Provision of HEPS - currently occurring on an erratic basis - should be linked by referral to outreach and OTP where possible.  Mid-upper arm circumference (MUAC) can predict risk of death more accurately than other anthropometric measures, and in addition to its use as an initial screening tool, can be employed as the final admission criterion for therapeutic care (MUAC<110mm), as outlined in the Zambia Draft National Guidelines for Management of severe malnutrition. In some clinics MUAC and oedema identification can replace WHZ measures and this would simplify the referral and admission procedures (reducing the time and staffing required at clinic level) It would also improve acceptance and understanding of CTC in the community, by

Valid International Ltd 3 reducing the risk of “turning away” children referred by one measure (MUAC) but registered using another (WHZ).

 The LDHMT should consider whether volunteers (NPs, CHPs, CHWs) operating out of the health centre could also be given a training role themselves - i.e. used to train and support the strategic case-finding partners (CBOs and alternative practitioners) in MUAC and oedema screening (the alternative is for the District or NGOs to train them directly).  Training of existing volunteers for CTC should bear in mind feelings among volunteers about favouritism (whether real or imagined) and should strive for equity of opportunity to prevent increases in capacity among some from being offset by a reduction of effort among others.  The necessary collaboration between volunteers and alternative practitioners in their communities can be facilitated by the LDHMT, which could establish agreements with the major associations of traditional and other practitioners for their involvement in CTC. Informal discussions with THPAZ suggest that they may welcome this.  An under-acknowledged - but possibly critical - link in the path to treatment of malnourished children is the “counsellor” (bana chimbusa, alangizi) who may be called upon to advise on a course of action for a wasted or swollen child. Although they are not organized into formal groups, these counsellors know each other, and are amenable to meeting and discussion. Volunteers operating out of the health centre know who they are, and should be encouraged to include counsellors systematically as important partners in the identification of severe cases.  It will require considerable effort to pull together community stakeholders, the different arms of the DHMT (MCH, Nutrition, Environmental health), and their compartmentalised staff within the Health Centre. It is important to identify someone at the District level who can take responsibility for ensuring good linkages between these arms of the CTC strategy, as well as for linking CTC effectively with the District’s other Child Health activities. This coordinator’s role would also include monitoring or carrying out recommendations made in this report, or generating discussion about alternatives.

Acknowledgements: I am indebted to the Lusaka District Health Management Team under the direction of Dr. Moses Sinkala, and to Nicky Dent of Valid International for the opportunity to conduct this research. Many other organizations and individuals too numerous to list here shared valuable advice and information in the course of my time in Lusaka, however I wish to thank especially the following: Dr. Seishin Maruyama and Kimiko Igarashi of the JICA PHC Project gave freely of their time and organized a productive discussion on CTC in Zambia; District Nutrition Coordinator Mavis Kalumba, and nutritionists Jean Kasengele of Kanyama HC and Sharon Shebo of Chawama HC helped me to understand current nutrition activities, and were instrumental in arranging for access to the community; Emmanuel Mandalazi of Valid International shared valuable insights from his own enquiries in neighbouring Lusaka compounds; and Alexis Kabanda’s patient interpretation made possible all of my interviews with Nyanja and Bemba speaking informants.

Valid International Ltd 4

Table of Contents

Executive Summary...... 2 Acknowledgements………………………………..…...………….4 List of Acronyms…………………………………………….….....7

1 INTRODUCTION……………………………………….....9 1.1 Background.………………………………………….....9 1.2 Objectives……………………………………………....9 1.3 Methods and Terms of Reference……………………....9 1.4 Limitations of the Report…………………………...... 10

2 EXISTING SCREENING AND BARRIERS TO PARTICIPATION………………………………………...10 2.1 Means……………………………………………….....10 2.2 Understanding…………………………………………11 2.3 Experience of Clinic Services…………………………11

3 COMMUNITY RESOURCES AND INSTITUTIONS…...12 3.1 Neighbourhood Health Committees…………………...12 3.2 Home Based Care……………………………………...13 3.3 Community Schools…………………………………...13 3.4 Traditional Practitioners……………………………….13 3.5 Private Practitioners……………………………………14 3.6 Elders and Counsellors………………………………...14

4 PROPOSALS FOR OUTREACH………………………….16 4.1 Targeted, not Blanket Mobilisation…………………….16 4.2 Role of MUAC…………………………………………17 4.3 Three Scenarios for Screening and OTP…………….....18

5 FURTHER CONSIDERATIONS AND RECOMMENDATIONS……………………………...... 19 5.1 Links to SFP………………………………………….....19 5.2 Volunteers……………………………………………....20 5.3 Community Distrust………………………………….....20 5.4 CTC Communications…………………………………..21 5.5 Traditional Healers……………………………………...21 5.6 Neighbourhood Health Committees…………………….21

Valid International Ltd 5 5.7 Theatre for Development………………………………..22 5.8 Coordination………………………………………….....23

TABLES AND FIGURES Table 1. Strengths and Weaknesses of Potential Case-finding Agents……………………….…….15 Figure 1. A Strategy for Targeted CTC Case-finding…..…17

APPENDICES 1. Common names for conditions of wasting and swelling in children, and their presumed causes 2. Draft handbill with key CTC messages 3. Draft letter to head of THPAZ from head of DHMT 4. Presentation to JICA and DHMT 5. CTC Summary 6. Possible avenues of future qualitative research

Valid International Ltd 6 LIST OF ACRONYMS

ARV Anti-retrovirals

CBO Community-based Organisation

CHP Community Health Promoter

CHW Community Health Worker

CTC Community-based Therapeutic Care (of the malnourished)

ECD Early Childhood Development

EHT Environmental Health Team

GMP+ Growth-monitoring and Promotion Plus

HEPS High Energy Protein Supplement

HSSP Health Services and Systems Programme

INESOR Institute for Economic and Social Research

LDHMT Lusaka District Health Management Team

MCH Mother and Child Health

MUAC Mid-upper Arm Circumference

NFNC National Food and Nutrition Commission

NGO Non-governmental Organisation

NHC Neighbourhood Health Committee

NP Nutrition Promoter

ORS Oral Rehydration Solution

OTP Outpatient Therapeutic Programme

RUTF Ready to use Therapeutic Food

SFP Supplementary Feeding Programme

TBA Traditional Birth Attendant

THPAZ Traditional Health Practitioners’ Association of Zambia

UNZA University of Zambia

Valid International Ltd 7 UTH University Teaching Hospital (Lusaka)

WHM/WHZ Weight for Height Median / Weight for Height Z-score

WHO World Health Organisation

ZOCS Zambia Open Community Schools

Valid International Ltd 8 1. Introduction 1.1 Background. This report is intended to contribute to discussions taking place within the LDHMT concerning a new strategy for the treatment of severe malnutrition among children. At present, severe paediatric cases are referred to the University Teaching Hospital (UTH), where they are rehabilitated under close observation using a diet of specialized therapeutic milks – usually for at least one month. The new strategy being considered is Community-based Therapeutic Care (CTC). CTC would reduce greatly the time spent by malnourished children at UTH, and in the majority of cases, eliminate it altogether. CTC uses a solid therapeutic food formulated along the same lines as the standard therapeutic milks, but its oily consistency admits no water, allowing it to be administered by the child’s parents in the home - even where there is no refrigeration. This offers several advantages: because CTC does not require the constant presence of the carer on the hospital ward, it reduces the negative impact on the rest of the household; because children make only weekly outpatient visits to the health centre for a check-up, they are not exposed to the same risk of infection as children under the current inpatient hospital regime; and because home therapy removes the barriers created by in-patient capacity and staffing, it allows renewed emphasis to be placed on coverage, with the result that impact in the community is typically well beyond that achieved through traditional therapeutic feeding programmes. In the past four years, over 10,000 cases of severe acute malnutrition have been successfully treated using CTC in several African countries.

1.2 Objectives. Experience has shown that in order to generate the full benefit from the CTC approach, the links between the community and the local health facility monitoring the child’s recovery are crucial. CTC requires effective community-based mechanisms for generating awareness about the new treatment, for identifying candidates for treatment, and for following up the child periodically in the home. The appropriate arrangements for these functions will vary depending on the setting. Two factors are usually important – the local cultural significance of malnutrition (i.e. common interpretations of illnesses of wasting and swelling), and the existing social or institutional arrangements in place for service delivery and knowledge sharing (typically some form of network of community health workers). Observations and recommendations concerning these socio-cultural factors constitute the bulk of this report. 1.

1.2 Methods and ToR. Overall terms of reference for this research were to investigate the social and cultural factors that might affect the success of CTC in Lusaka, and to make recommendations about how these could be best addressed. Research methods consisted primarily of interviews, some open-ended and some structured, with a variety of informants, including: MoH staff involved in nutrition rehabilitation; nutrition and other volunteers attached to the health centres; mothers of children attending growth monitoring sessions; mothers of children admitted to the malnutrition ward of UTH; traditional female counsellors resident in the research sites; and participants in decentralized growth monitoring sessions conducted on an outreach basis from the health centres. Key informant interviews were also conducted

1 For readers unfamiliar with CTC, a summary of CTC nomenclature, principles and practices is attached as Appendix 5. A more complete discussion of CTC, including the evidence base for its success, is contained in HPN Paper no. 48, “Community-based therapeutic care: a new paradigm for selective feeding in nutritional crises”, available from the Valid International Office in Lusaka

Valid International Ltd 9 with staff of UTH, INESOR, NFNC, UNZA, CARE, JICA, CONCERN, HSSP, THPAZ and the LDHMT (MCH, Nutrition, EHT, managers). The research site consisted of the catchment areas of two MoH Health Centres in Kanyama and Chawama compounds. These were selected deliberately from among 5 Lusaka compounds where the LDHMT expects to initiate CTC. Both are large, populous, peri-urban compounds that are home mainly to poor Lusakans. They are also both served by a wide variety of NGO and church organizations in addition to the Health Centres, making the programming environment promising, but also potentially complex. Research was carried out over a three week period, with one week devoted to orientation and initial key informant interviews, and two weeks reserved for observation and interviews in the compounds, in which the author was assisted by an interpreter fluent in Nyanja and Bemba.

1.3 Limitations of Report. This report addresses mainly the socio-cultural environment, and does not constitute a complete “how-to” on CTC implementation (see footnote 1). Given the time allotted, it was necessary to be selective. Emphasis was placed on establishing a picture of the way malnutrition is seen locally, and on considering the implications for CTC strategy. As a product of strictly qualitative methods, the findings presented here cannot claim to be valid across Lusaka, or even in all parts of the two research compounds. This is a composite picture, with elements that will be more true for some locations than for others. Particular caution is urged with the contents of the table in Appendix 1. Data contained therein are the result of a single cycle of focused ethnographic research and are intended to serve only as an illustration of the difference between clinical and local folk interpretations of malnutrition, and their implications for outreach.

2. Existing Screening and the Barriers to Participation Decentralized growth monitoring of under-fives (GMP+) is taking place with NGO support in the proposed CTC start-up areas already. In principle, this represents a good basis for finding and referring severe cases to OTP (the element of CTC which will treat and monitor the weight gain and recovery of severe cases). However, the number of children currently being admitted to the therapeutic treatment ward of UTH without passing through the MOH’s existing decentralized GMP+ suggests some gaps in participation. It is difficult to speak definitively to the issue of barriers to participation because of the conundrum implied: how can we know who is not coming to existing services? After all, if we knew who they were, they would already be coming. But in general, reasons why a malnourished child might not be presented at clinic can be classed into three, not mutually exclusive groups: 1) reasons relating to means; 2) reasons relating to “understanding” (i.e. thinking of risks and illness in the same way as a modern clinician); and 3) reasons relating to their experience of existing services (e.g. GMP+ or the clinic). Each of these plays a part in Lusaka.

2.1 Means. Poor families may be spending all their time trying to subsist through a variety of time-consuming activities, making it unlikely that they can involve themselves on any routine basis with the GMP+ system. The few income-earning options for a single mother in Lusaka might include petty trade (e.g. selling peanuts by the roadside), doing daily piecework on the peri-urban commercial farms, domestic work for more prosperous families, and prostitution. Reaching these families

Valid International Ltd 10 will require a strategy for case-finding which does not require of them large investments of time.

2.2 Understanding. Interviews conducted in the course of this work suggest that even in urban Lusaka, ideas about swollen and wasted children persist which are markedly different from the ideas of clinically trained health workers. Presumed causes of these extreme forms of malnutrition include:  discord in relations between mother and father (esp. adultery)  disregarding traditional prohibitions against breastfeeding during pregnancy  jealousy and witchcraft from neighbours or in-laws. The important consequence of these beliefs (mapped out in more detail in Appendix 1) is that a swollen or wasted child may not be presented at the clinic or GMP+ - even if supplementary foods and therapy are available there; the presumed cause (and therefore, the treatment) often lies outside the realm of clinical medicine. Even if it is a minority of people who hold such views, it may be a minority that is over- represented among the families of severe cases. The fact that such views are more likely to be held by the older generation of Lusakans does not necessarily reduce their importance, since vulnerable children are now frequently being kept by grandparents in AIDS-affected communities.

2.3 Experience of clinic services. According to both NPs and local mothers, there are a variety of aspects of the GMP+ sessions that limit their utility for identifying severely malnourished children:  At some GMP+ points, the participating mothers appear to be a select group composed of well-fed babies, and well dressed mums – creating a possible intimidation factor for less prosperous families, who lack soap and clean clothes, and who may be reluctant to present to the assembled crowd a baby who is shabbily clothed or in poor physical shape.  Mothers and nutrition volunteers alike say that the sessions can sometimes take 7 hours to run their course, making attendance difficult for mothers whose time is spent trying to scrape together a living with petty trade or other income earning activities.  Growth monitoring in locations that are not linked with effective support (such as the soya supplements provided by the UTH rotating clinic) eventually loses the interest of participating mothers – esp. after the child’s immunization course is completed.  NPs note that mothers whose children have had successive poor results at the weighing sessions are frequently lost to default. (The reason, NPs suggest, is that these mothers feel ashamed at being unable to correct the situation, and some have reported being treated in a hectoring, insensitive way by the MCH nurses or volunteers, behaviour which they resent).  Some mothers fear the effects on their children of amulets and traditional medicines used by their neighbours. These medicines, intended to have a preventive effect on the child in question, are thought to be dangerous if care is not taken to prevent contact with other, unprotected children.  An (admittedly superficial) observation of GMP+ in progress suggests that interpretation of weight results and the counselling offered to mothers is sometimes inconclusive – leaving the mother uncertain as to whether there is a

Valid International Ltd 11 need to go to the clinic, or even whether there is a problem with the child’s growth. These characteristics make GMP+ inconvenient or frustrating for poorer, working mothers without the means to act on nutrition advice, even in cases where the advice is sound and offered in a sensitive, respectful way. It seems clear that despite the improvements to access that decentralized growth monitoring has introduced, it cannot in its current form be expected to provide the sole basis for screening required under a CTC strategy.

3. Community Resources and Institutions: foundations of outreach CTC relies on strong outreach efforts between the health facility administering OTP, and the client community. Outreach builds understanding on both sides: the community needs clear and consistent information about the aims and advantages of the new treatment, the purpose of anthropometric measurements, and the intended target group. Outreach workers, for their part, need to learn the nature of the community in order to satisfy themselves that they are not overlooking pockets of malnourished children. In this respect, the 2 compounds of Kanyama and Chawama enjoy an advantage, in that a reasonably well developed and supported network of community volunteers (NPs, CHPs, CHWs) already exists, and knows intimately the communities of which they are a part. Nevertheless, the problems identified above in section 2 suggest that volunteers will need to work differently if the severe cases are to be brought to light.

Once an initial group of “severes” is identified by case-finding methods, experience shows that the efficacy of RUTF is likely to serve as the best advertisement for the CTC strategy. But at start-up, it will be critical for volunteers to gain the cooperation of a range of other actors in the recruitment of this initial group, so that the “RUTF effect” can be given an opportunity to take hold. The Lusaka environment presents an opportunity to engage with numerous other community forces, some of which are routine partners of the official health system, and some of which are not. There is already a good range of CBO and NGO networks – at least in the initial programme start-up area – which could be utilized for the business of case-finding and case follow-up. There also appears to be a surprising array of therapists available to the residents of Lusaka – many of whom are already involved in the diagnosis and treatment of children who are suffering from severe malnutrition (although it is hard to form an accurate picture of what exactly they are doing). Each generic group has its strengths and weaknesses. The principal challenge (see table 1, below) is that the agents most likely to be in close contact with severe cases are also the ones that will require the most effort to involve.

3.1 Neighbourhood Health Committees (NHCs), are in place in all 5 initial programme compounds. They are intended to serve as the link between the Health Centre and the surrounding community, and have a history of involvement in mobilization for major health campaigns (e.g. cholera, measles, ARVs, environmental health and sanitation). There appears to be considerable variation in the capacity and

Valid International Ltd 12 vitality of the different committees, and one has the sense that where they are active, they are sometimes dominated by a few charismatic individuals. They are meant to have representation at zone level – drawing some of their membership from zonal sub-committees. When motivated, NHCs can undertake to broadcast critical health information using mobile loudspeakers or community theatre. They could be useful for announcing the introduction of CTC, but they may be rather a blunt instrument for actual case identification.

3.2 Home Based Care (HBC) groups are one of the main service providers to the disadvantaged. By virtue of their care of the HIV positive, they are likely to be in contact with households at risk of producing malnourished children. They undertake regular visits to the homes of their clients, making them an ideal way to identify children for OTP screening. Their weaknesses are the patchy nature of their coverage, and the fact that the church affiliation of some groups makes them unwilling to acknowledge the important role of traditional practitioners in the lives of their clients.

3.3 Community Schools are now a well-established element of the education system in Zambia. They generally serve the more disadvantaged households, and many schools in Lusaka have a specific mandate to serve orphans and other children considered at risk. Although their primary school enrolees would be beyond the age for CTC admission, some schools conduct regular visits to the children’s homes, where they would be in a position to identify malnourished siblings. One of the more established networks of community schools in Lusaka (ZOCS) will also be introducing an Early Childhood Development component, which would put them in direct contact with the CTC age group. Weaknesses of community schools have to do with their limited capacity, and with the isolation of many schools from networks of the sort which would make them easily accessible for training or monitoring.

3.4 Traditional practitioners are a fundamental part of life for many Lusakans - and not only for those recently arrived from more rural areas. The term nganga refers to a wide range of practitioners, including healers with a naturalistic approach (e.g. herbs and roots), but also those who deal with personalistic causes (ancestral spirits, witchcraft, etc.). From the accounts of mothers and health workers, traditional healers are an important resource for families whose children show signs of severe malnutrition (swelling and wasting), and these healers are often consulted long before the family has resort to clinic. They are thus well-positioned to refer children to OTP screenings, or even to do the screening themselves, if their cooperation can be secured. The challenge is that relations between healers on one hand, and the health centre/church/government and other forces of modernity on the other, is characterized by mutual distrust and sometimes antagonism. Even amongst themselves, healers have no uniform position on matters relating to cooperation with the modern health system. There are several umbrella groups for healers with representation in Lusaka. The oldest and largest of these, THPAZ, has expressed informal interest in being involved in CTC; however some healers in the start-up area likely belong to splinter groups which reject THPAZ representation, and there are also practitioners who are unaffiliated to any association, making it difficult to reach them with information or training.

Valid International Ltd 13 3.5 Private practitioners. This “third force”- operating alongside both the health centre and the traditional sector – makes the Lusaka environment different from other CTC settings, where families have usually had only two choices when it comes to therapy for children. As with traditional practitioners, the term “private” covers a wide variety of possible arrangements.2 Informants suggest that private practitioners offer what the health centre offers: they weigh babies on scales, chart their weight and even give “vaccinations” - but without the long queues or the perennial problem of lack of medicines and supplies that characterise health centre treatment. Furthermore, the private facilities, like the ngangas, allow the patient to remain anonymous (one can visit a private practitioner in a neighbouring compound, where one is unknown, but it is not normally possible to be treated at a health centre outside one’s own catchment area. This is particularly important for mothers whose children are in a bad state, and who might feel ashamed to present them at the GMP sessions. The more a sick child is thought to be a reflection on the moral conduct of its parents, the more this anonymity matters. As with ngangas, the principal drawback of using private practitioners for case-finding is the fact that many are unlicensed, and fear contact with the authorities – making them difficult to address en bloc with information or training or proposals concerning their involvement.

3.6 Elders and counsellors. Before a concerned mother decides on a course of action concerning a sick child, she will normally seek the opinions and advice of others – usually within her neighbourhood or extended family group. Reaching these advisors with information concerning CTC could be very effective type of mobilization, since they help to determine whether a mother seeks treatment for a wasted or swollen child at the clinic, the nganga, or from a private practitioner. Several notable things emerge from interviews with families and with elders:

3.6.1 Even a mother who has confidence in the ability of the health centre to cure a malnourished child may be influenced to seek another form of treatment. The reason for this is that children are considered by local custom to be the property of the husband’s lineage, and the consequences for a mother who goes against her mother-in-law’s advice - only to have the child get worse, or even die - would be very serious indeed.

3.6.2 Older women who are referred to as “counsellors” (alangizi in Nyanja, bana chimbusa in Bemba) may be particularly important when it comes to determining the path to treatment for swollen or wasted children, due to traditional beliefs concerning underlying causes of these conditions. Children are in some respects seen as an index of harmony and cooperation between parents. Sexual relations between the two parents, or between one of the parents and an outsider, are thought to introduce health hazards to the child – especially through physical handling by the adults or by breastfeeding. There are a variety of rules, proscriptions and treatments designed to reduce or prevent harm to the child, and many of these are passed on to young women at the point of marriage by elders or counsellors. Even today in Lusaka, there are counsellors with a knowledge of Lozi, Bemba, and Nyanja traditions who are sought out by the parents of a young couple who intend to marry. If after marriage and childbirth their child becomes

2 In a sense, ngangas are private practitioners, too; however, private practitioners are here distinguished from ngangas in that “private” therapies duplicate or are meant to suggest the type of treatment offered at government health centres.

Valid International Ltd 14 sick, and there is an apprehension of moral disturbance in the household, the same counsellors may be sought for advice on treatment. Some alangizi and bana chimbusa are minor healers in their own right – prescribing herbs or roots to be applied to the child, and rituals to be performed by the parents. If CTC mobilization or outreach could be addressed directly to these elders/counsellors, it might have a significant impact on the paths to treatment for the severely malnourished. The challenge is that these women are unaffiliated except where they are also TBAs (in which case a few may be represented by associations like THPAZ). However, the CHWs and NPs know who the counsellors are in their own neighbourhoods, and once contact is established with one counsellor, it is usually possible to meet several, since the great number of inter-tribal marriages means that counsellors from different traditions normally cooperate in relations of mutual respect.

3.6.3 Female elders and counsellors, despite their divergent views on the causes of swelling and wasting, are also quick to recognize the efficacy of some “clinic” treatments. The home preparation of ORS - taught to them by CHWs and MCH nurses – came up in discussion repeatedly as a useful piece of advice which mothers can easily implement and which has demonstrated utility. There is reason to hope that RUTF could also win favour with this influential group, since it helps to minimize the absence of the mother from the home, and like ORS, has a dramatic effect on the sick child. One exploratory discussion with 12 counsellors representing 5 different tribal traditions revealed no obvious barriers to acceptance of RUTF - either its substance or packaging - although there was some concern expressed that people will need a period of adjustment before they become accustomed to MUAC screening.

Table 1. Strengths and Weaknesses of Potential CTC Case-finding Agents

HBC Communit Ngangas Private Counsellors Groups y Schools practitioners Proximity to severe Medium Medium High High High cases Probable interest in High High Low- Low- Medium participating in medium Medium referral Probable ability to High High Medium Medium Medium conduct MUAC screening once trained Accessibility as a High High Medium Low Low group for training

Valid International Ltd 15 4. Proposals for Outreach 4.1 Targeted, Not Blanket Mobilisation. How broad should mobilisation and outreach be? The answer to this question will depend ultimately on the results from the nutrition survey. In Lusaka, the introduction of new health activities and programmes is typically broadcast by NHCs to reach the widest possible audience. However, the kind of mobilisation which is justified, for instance, by cholera (which threatens everyone) may not be justified by the numbers at risk of severe malnutrition. The nutrition survey results are not yet available, but anecdotally, there is evidence that the number of severely malnourished children is relatively small.

An additional consideration is whether a broad mobilization around malnutrition is justified if treatment is to be offered only to the severe cases. There will be some degree of community discontent if people are encouraged to bring forward malnourished children, only to be told that the moderate cases must become worse if they are to be admitted into CTC. Without the introduction of SFP (or the extension to the rest of Lusaka of the soy rations currently being offered through the UTH mobile nutrition clinic) it would be unwise to generate expectations of therapy for the moderately malnourished by employing district-wide mobilisation.

Assuming that supplementary rations remain available only on a patchwork basis, and assuming that the survey results reveal only a modest number of severe cases, the prudent course may be to take a more targeted approach to case-finding and mobilisation, focusing on those agents most likely to see severe cases. If we assume that the standard Health Centre outreach (i.e., growth monitoring sessions, house-to- house visits by NPs/CHPs/CHWs, announcements by the NHC) will play some role in CTC start-up, it is possible to envision this being supported by two other major channels for screening and case-finding, using the agents described above (section 3). Severe cases could also be identified and referred through:

1. other forms of therapy for the sick child – using the various practitioners and counsellors (ngangas, private practitioners, alangizi, bana chimbusa, baprophita)

2. other services to disadvantaged families (principally community schools and home-based care groups) – using services offered to older siblings and/or parents and guardians as a means of identifying malnourished under-fives.

Figure 1 illustrates the proposed case-finding strategy. In this strategy, the health facility remains at the centre, with its standard community programmes and mobilisation forming the backbone of outreach, but volunteers associated with the health centre also work with CBO partners and alternative practitioners (the left and right flanks) to identify malnourished children.

Valid International Ltd 16 Fig 1. A Strategy for Targeted CTC Case-Finding

HEALTH CENTERE

Nutrition Volunteers Nutrition Volunteers Nutrition Volunteers (CHW, NP, CHP)

CBO Partners Usual Channels Alternative Practitioners

Home-based care Growth monitoring Private practitioners Community schools Neighbourhood health committees Traditional healers Churches Mobilisation Counsellors, Elders Alangizi Bana chimbusa

Via parents Via and siblings paths to Malnourished Child therapy

4.2 The Role of MUAC

4.2.1 Screening: The use of the mid-upper arm circumference (MUAC) tape provides a simple, user-friendly means of identifying at-risk children, and moreover, one which is transparent and comprehensible to families and community members. In the poorer compounds of Lusaka, where rumour and suspicion concerning public health interventions are rife, these qualities are likely to prove important. Unlike the height board, scales, calculator and notebooks which limit the mobility of weight-for- height teams, the MUAC tape can be produced from the pocket of a single trained volunteer, either in the privacy of the family home, or in a public setting, whichever he/she deems more appropriate to a given circumstance. Screening for CTC programmes been done on a MUAC basis in several countries, including Malawi, North and South Sudan, and numerous settings in Ethiopia. Experience suggests that with proper training, volunteers can conduct screenings based on a set MUAC cut-off (usually 110mm) and a check for oedema. The challenge lies not in their competence with MUAC, but - as with many community-based programmes - with the sustainability of the efforts of unpaid volunteers. This is significant because the best weight-gain results are achieved when volunteers maintain a degree of contact with the family of a malnourished child after their admission. Fortunately, in the case of Lusaka there is reason to hope that the non-emergency context, with its comparatively low numbers of severely malnourished, provides a significant advantage in that at any given moment, the number of cases requiring weekly follow-up would be relatively few, thus limiting the extra burden on volunteers.

Valid International Ltd 17 4.2.2 Admissions: The use of MUAC as a decentralized community screening tool has occasionally caused complications for CTC implementers when another criterion, typically WHM/WHZ, is used for actual admission. The experience of having a child referred to the health centre on the basis of his MUAC, and then rejected on his WHZ/WHM, can be confusing and disappointing for the family, and has serious implications for participation. While the WHO guidelines do not yet include MUAC as an admission criterion alone, many country guidelines (including Zambia draft National Guidelines) do. Papers comparing MUAC and WHM at a recent international conference on CTC presented evidence that:  MUAC is the best indicator if correspondence with body composition, not mimicking WHM, is considered the gold standard.  admission on MUAC is more selective for risk of mortality than is WHZ/WHM.  the risk of exclusion in CTC programmes using MUAC as admission criteria is less dangerous than the reverse, since those excluded by MUAC are older and less at risk of death than the young children that tend to be excluded by WHM.  children with greater than 70% WHM, but MUAC under 110mm do well in OTP, but not in SFP.  WHO’s presentation on CTC concluded that although WHM is attractive to managers trying to show programme results (since WHM admits the children most likely to prosper under treatment), at the risk of admitting some children who remain longer under treatment, a MUAC criterion does more good by preventing more deaths3. With evidence now pointing to the efficacy of MUAC, CTC in Lusaka should attempt to establish the simplest possible system of filters, relying on MUAC for both screening and admission to OTP, provided inconsistencies with other existing selective feeding initiatives can be minimised.

4.3 Three Scenarios for Implementation of Screening and OTP 4.3.1 Scenario One. In this, the simplest scenario, health centre staff maintain full control of RUTF, and screening on a MUAC basis is done by CHWs, NPs, and CHPs, who are roaming with MUAC tapes at the ready. The screeners make a concerted effort to explain the programme, its target children, and its novel elements (RUTF and MUAC) to as many members of the two groups (local practitioners and CBO partners) as possible. Healers, teachers, caregivers, etc. would be encouraged to send any candidate children to the screeners, who would then refer children who fall below the MUAC cut-off to the health centre for RUTF. If capacity exists, OTP could be extended to the outreach GMP+ points.

4.3.2 Scenario Two. In a more ambitious version of the first strategy, local practitioners, counsellors and CBOs would be trained in the use of the MUAC tape and would do the screening and referrals themselves, supported where necessary by the nutrition volunteers. This has the advantage of empowering a wide range of agents to identify and refer affected children, allowing them some “credit” for the eventual

3 Papers presented at the Interagency Meeting on CTC, Washington, DC, Feb. 2005, are available online at the FANTA website ( http://www.fantaproject.org/ctc/meeting2005.shtml). See especially “MUAC vs. WHM: Screening, Survival, Response”, by Mark Myatt, University College, London, and “Should We Use WfH or MUAC as Admission Criteria in CTC”, by Andre Briend, WHO.

Valid International Ltd 18 recovery of the child. Under this scenario, MUAC tapes would become ubiquitous and no single group would have a monopoly over their use – though the programme would determine admission cut-off points. Provided resources are available for the more inclusive training that is implied, this is probably the most effective way to bring the hidden cases into the light. It relies mainly on the volunteers to know and contact counsellors, healers, and private practitioners in their area, and to either draw them into training sessions supported by the District, or to conduct training on an individual basis over an extended period. Some groundwork would be required by the District – e.g. to secure the “safe passage” of volunteers into the territory of local healers by forging agreements with healers’ associations at a more central level.

4.3.3 Scenario Three. The third scenario would build on either of the first two scenarios, probably at a later phase of implementation. In this expanded version of CTC, the larger CBOs (e.g. Salvation army), the networked community schools, and bigger HBC groups (e.g. the Catholic Church’s) which have nurses on staff could be entrusted after some training with the implementation of OTP, allowing them to offer treatment on-site as well as screening. Other groups which do not employ a nurse, but which pay allowances to MoH nurses to conduct regular under-5 clinics or other services could also provide an opportunity for decentralizing the provision of OTP beyond the health centre..

5. Further Considerations & Recommendations

5.1 Links to SFP. Close links between OTP and SFP are an important feature of CTC in emergency settings, where resources for both are usually readily available. In the Lusaka context, there is no certainty that SFP will be implemented on a District- wide scale alongside OTP. However, dry supplementary rations are being offered to the moderately malnourished in some parts of Lusaka by a variety of agents, including the UTH rotating nutrition clinic, and CBOs. If these initiatives seem likely to be sustained, OTP should be linked to them. Links would exist in two directions:

OTP → SFP. Establishing an additional MUAC cut-off at 120mm or125mm would allow volunteers conducting OTP screening to refer moderate as well as severe cases to the health centre. However this requires a greater staffing or volunteer capacity at health facility level and a risk of more families being turned away if WHM/WHZ only is used for admission.

SFP → OTP. Children referred to SFP by screening will have a MUAC between 110mm and 125mm. But when assessed for WHZ at the clinic, some of these will have a WHZ of less than -3 z-scores. These children should be referred back to OTP to reduce the likelihood of dying.

Other links. The presence of parallel programmes of support has been shown to improve OTP outcomes by reducing intra-household sharing of RUTF. Where CBOs, the Health Centre, or others are offering dry supplementary rations to the vulnerable, these agents should be encouraged to broaden their assistance criteria to include the presence in the household of an OTP child.

Valid International Ltd 19 This may require discussion between the LDHMT and its District social welfare counterparts.

5.2 Volunteers. The volunteers at community level (NPs, CHPs, CHWs) are the key to getting CTC case-finding successfully off the ground. However, some of them are relied upon for a variety of other activities, and there is concern in some quarters that the addition of responsibilities related to CTC may overburden a class of agents who are, after all volunteering their time. The volunteers themselves have hinted in various discussions that they expect to be paid allowances for extra efforts. No definitive solution can be offered here for these concerns, as they are ultimately matters to be decided by the District Health Management Team, based on its rules and available resources; however, there are ways of organising CTC start-up so that the degree of extra effort required of volunteers is minimised. Using the volunteers to train the CBO partners and alternative practitioners in use of MUAC, rather than relying on them to do a blanket house-to-house campaign style mobilisation, would reduce the legwork required. Training them, and then utilizing them as trainers would provide some incentive in the form of allowances. The allowances have the advantage of not being paid indefinitely for ongoing service, but only at the start, during a brief “Awareness Campaign”, to generate effective case-finding. A word of caution is also in order here: the various volunteers at community level are hyper-aware of the differences in support and opportunities that are offered to the different groups of volunteers by the different donors. They look jealously at volunteers who seem to be the clients of active patron agencies; and they argue that if some are being paid (i.e. trained) to perform functions, then, others should be free to reduce their effort. Thus, plans for training in case-finding, MUAC and oedema, follow-up, or other CTC functions, should consider the volunteer cadre in its entirety, or risk a zero-sum situation where training creates less additional capacity than expected. This implies some unanimity or coordination of efforts between the different supporting agencies under the guidance of the LDHMT.

5.3 Community distrust. The compounds where CTC mobilisation and case- finding will be done are characterised by a considerable degree of suspicion – both of neighbours (ill will from neighbours or in-laws is considered a possible cause of illness in both adults and children) and of outsiders (nutrition survey teams performing anthropometric measurements have run up against hostility as pockets of neighbourhoods have accused them of Satanic designs). In this environment, the MUAC-ing of children for CTC could be construed as something sinister, and this is one reason why allowing screening to be done by trusted service providers and figures already known in the community is likely to be important. The volunteers are the critical bridge between OTP and these local service providers (CBOs and alternative practitioners); they have one foot in the modern health system and the other in the community, with its various practices. They are the best people to identify the healers, private practitioners, and others who treat sick children (indeed, when speaking candidly they will admit to utilizing these services themselves), to explain the new programme to them, and to demonstrate the use of the MUAC tape. The volunteers have expressed a willingness to undertake this work on behalf of the programme; however, they are concerned that they themselves may be the object of suspicion when they approach diviners, unlicensed private providers, or other healers not normally contacted by the modern health system. In their view, two things could help them achieve access: some form of identification (a badge or a T-shirt) or some form

Valid International Ltd 20 of announcement (either by radio or by NHC megaphone broadcast) concerning their purpose and presence in the zones. Given the importance of their work to the identification of the target children, these concerns should probably be addressed.

5.4 CTC Communications. CTC messages circulating in the community should be standardised to the greatest extent possible. Developing a simple handbill listing the basic CTC objectives and procedures would serve several purposes: 1) it would help to put a consistent message into an information vacuum that will otherwise be occupied by rumour (Satanism, bloodsucking, etc.); 2) it would give volunteers and others basic facts to refer to when conducting information meetings, screening or outreach; and 3) by using traditional or local disease names and concepts it could help to widen in the mind of the public the range of children who should be screened – overcoming the disconnect between clinical and traditional interpretations of wasting and swelling. Doing this in Lusaka is slightly more complicated than in other CTC settings because of the range of languages and traditions that are present in the start-up compounds (one group discussion conducted at Chawama clinic found seven first languages in a group of just 12 mothers). But creating a simple, standard script in both Bemba and Nyanja would lay a foundation for the programme in the languages that most residents understand. A draft, English version of such a handbill is attached as Appendix 2. This should be translated, and back-translated before being used on a pilot basis to test its effect. The uncertainty concerns the fact that although the document is trying to allay suspicions that CTC is connected with malign forces (by emphasizing that it is a programme offered by the modern health centre), it is nevertheless trying to recruit severely malnourished children by using some of the local names for their condition - names which in some cases do evoke malign intent. Striking the right balance is a matter of guesswork, and the reaction to the first use of the handbill should be closely watched and discussed with the volunteers for possible adjustments.

5.5 Traditional healers. During the course of this research, a brief meeting was held with the Chairman of THPAZ, Dr. R. Vongo, to broach the subject of the participation of healers in screening and referral of the severely malnourished. As a healer himself, and as someone already promoting collaboration between healers and the modern health system in the area of ARVs, he believes there is a good likelihood of gaining the cooperation of healers. The first step would be for a formal letter to be sent to him explaining the intent of the programme, so that he can put it before the Board of THPAZ. If accepted by the Board, there appear to be several other levels of leadership to go through before individual healers operating in the Lusaka area would be informed of the collaboration. It could prove a little drawn-out, but this internal process of dissemination is considered by the volunteers to be another important way to create access to the healers within their zones. The aim is to create the conditions in which local chapters of registered healers could be addressed in a group by volunteers and others (e.g. clinic in-charge, Valid nutrition coordinator, LDHMT members) for the purposes of explaining the innovations to be introduced by CTC, demonstrating the identification of severe cases, and practicing together the use of the MUAC tape. A draft letter of explanation to Dr. Vongo is attached as Appendix 3.

5.6 Neighbourhood Health Committees. NHCs are eager to be involved in the proposed CTC programme, and have a repertoire of mobilization techniques (theatre, public announcements, etc) that they customarily employ. The broadcast strategy of

Valid International Ltd 21 NHCs could be helpful to create a general awareness of CTC. However, if resources for OTP start-up are scarce, the NHC’s broadcast activities should not be allowed to displace plans for training of the non-traditional partners in case-finding and MUAC screening, since this is the key to getting beyond the current limits on participation.

5.7 Theatre for Development. NHC mobilization for other health programmes has employed “Theatre for Development” (TFD) techniques, which use informal street theatre sketches to attract audiences and impart health information. We did not have the opportunity to see NHC theatre troupes performing, and in are in no position to comment on the quality of their work. However, based on experience elsewhere, there are several points which are worth raising concerning the content of dramatic performances intended to generate interest and acceptance of CTC. Didactic theatre often relies on a stereotypical portrayal of two extremes, and then resolves them through the capitulation of one side in favour of the position taken by the other. For instance, development theatre which is intended to promote immunization might show a community health worker struggling with a parent who believes that inoculation will harm his/her child. To create dramatic interest the parent may be given humorous attributes, which sometimes slip into ridicule. One common problem is to create an overly simple opposition between two poles into which numerous attributes are collapsed – e.g. backwardness/tradition/elderly people vs. modernity/educated people/healthy behaviours/young people. Where dramatic pieces are used to impart information about OTP, every effort should be made to avoid casting elderly people and recent rural migrants in an ignorant light, since this may only further marginalize the groups that CTC needs to reach. If possible, the NHC drama troupes should be encouraged to develop story lines which show elders, traditional healers, and clinic staff and parents as equals collaborating to assist children hitherto considered untreatable.

5.8 Coordination. Too little was observed of the operation of nutrition-related services in the health centres to make recommendations in this area with any confidence. However, it is clear from speaking with health centre staff and with mothers that there are numerous routes by which a child may come to the attention of MoH nutrition services – including via VCT, ORT corner, ART, routine MCH visits, GMP+, or admission for other problems. It is clear also that at present the Health Centre nutritionist is not always informed or involved in these cases by her HC colleagues. While CTC is likely to simplify treatment of malnutrition in the medium term, the short term effect may be to introduce a complicating element to a health centre environment which is already unduly fragmented. One important question is whether the Health Centre nutritionist (who is likely to have responsibility for CTC outreach) should also be given responsibility for the overall management (as opposed to clinical administration) of OTP. Ideally this would be so, but it goes against the understood hierarchy within the HC, of which the nutritionists’ current marginalization is a symptom. The DHMT will need to ensure that, whoever is given direct responsibility for management of OTP, the HC nutritionist is closely involved, and that prompt referral from the other HC programmes takes place. Similarly, the various vertical programmes at the District level will also need to dovetail effectively with CTC (for instance, rules concerning the range of medications MCH nurses may take on their MCH outreach visits may need to be altered in order to put the complete range of OTP tools at the disposal of CBOs, or GMP sites). Determining who within

Valid International Ltd 22 the DHMT will have the responsibility for ensuring this District level integration should be a priority.

Valid International Ltd 23  APPENDIX 1. List of names for diseases of wasting and swelling in children, and presumed causes4

Major Signs Name of disease, or concept Presumed Causes Treatments (swelling or wasting) Swelling MIDULO (Nyanja) Adulterous behaviour by one of the parents, Mankwala ya ci boyi (medicine made from AMAKONWESHA (Bemba) followed by handling, feeding, or roots or leaves) is prescribed by basinganga MASATO (Tonga) breastfeeding the child. Also caused when parents fail to observe any of the Injections from private clinic. proscriptions/prescriptions concerning sexual activity between parents in the period immediately after the birth of the child.

Swelling KULOWEWA (Nyanja) Witchcraft has been used to harm the child. Determination of the source of the UKULOOWEKWA (Bemba) Witch can use a variety of mechanisms to witchcraft by spirit medium (mizimu ya achieve his end: harmful medicines can be nganga). placed in the path of the child, where he will crawl or walk on them; child’s food can be poisoned; or witch’s supernatural agents, utumbuma or tukulu, can be sent.

Swelling NJISI (Nyanja) Mother has breastfed child while she is Local herbs as provided by alangizi or MATUFYA (Nyanja) pregnant with another. The pregnancy has basinganga are boiled in pot and the steam spoiled the breastmilk which is causing the used to infuse the affected child, or mixed child who sucks it to become sick, and into child’s porridge. Some charms and swell. This word kunyonkela, which treatment also available from nganga to act describes the mechanism of the illness as preventive against njisi – either from (“baby is sucking”) is often used effect of mother’s own pregnancy or that of interchangeably with the disease name njisi. other nearby women.

4 The Nyanja and Bemba words, concepts and practices summarized in this table are the result of a rapid appraisal, with limited opportunity for cross-checking facts and vocabulary. These observations are thus extremely tentative and are offered only as an illustration of the broad range of traditional ideas and practices which may have implications for the CTC strategy. Several additional reasons for caution: a) this is a composite picture, assembled from discussions with a variety of key informants, so although elements of this picture hold true for many individuals, it is not possible at this stage to say how accurately this aggregated picture truly reflects a group or community outlook b) It is not yet clear how representative this information is of actual practices, and how much is simply a recounting of things which people used to do or believe. .

Valid International Ltd 24 Swelling/Wasting ULUNSE (Bemba) Caused in same way as njisi, above, except Same as njisi that the result is thought by some informants to involve wasting, rather than swelling.

Wasting KALYONDEYONDE (Nyanja) This (kalyondeyonde)appears to refer to Local herbs from alangizi or basinganga. UBULWELI BWAKONDALOKA wasting in general, but lately also to the (“sickness of thinning” Bemba ) particular wasting of children and adults Private clinics for injections. thought to be suffering from HIV/AIDS. Such children are sometimes also referred to as “finished” – e.g. akamwana aka uyu namayo kalipwa (Bemba) “that woman’s child is finished”

Wasting/Swelling NJALA (Nyanja) Child is suffering from hunger caused by “vitamins” and medications at mankwala ya lack of nutritious food, which can result in chizungu clinic both swelling and wasting. Of the disease concepts presented here, Njala best describes the idea of malnutrition as taught by clinic staff and community health workers.

Valid International Ltd 25 APPENDIX 2: Draft handbill with main CTC messages

HELP IS NOW AVAILABLE FOR FAMILIES WITH VERY THIN OR SWOLLEN CHILDREN

The new treatment A new medicine is now available at the health centre for the treatment of children five years and under. Children who are very thin, or who have begun to swell, no longer need to spend a long time in the hospital. A new medicinal food is being offered to the families of such children. The families can use it to rehabilitate the child while he/she continues to live normally with his brothers and sisters in the home.

How to know whether your child needs this medicine To be eligible for this treatment, the child has his arm measured and feet checked. If the arm is too thin, the child visits the health centre, where the measure is repeated and if correct his/her family is provided with a weekly supply of the medicinal food. The arm measurement is done with a tape similar to the cloth tape used by tailors in the marketplace. It is a fast, painless check, which does not involve taking blood or injecting the child. The measurement can be done by many types of person. Different people are being trained in this community in the use of the tape, so that in some cases, the measure can even be done by a person who is known to the child or his family.

If you know a child who is very thin, or whose feet have started to swell, let his parents or guardians know about this new treatment. They can ask in their neighbourhood for the name of a person trained in the arm measurement, or they can go direct to the health centre.

Important points to remember 1. Even very sick children can be helped with this treatment. And since the child remains in the home, the parents or guardians can care for him at the same time as other children. The medicinal food is ONLY for the very thin child and should not be shared.

2. The medicine is mixed into a food made from groundnuts, so children normally have no trouble eating it, and the results are usually very rapid.

3. In different communities the diseases of thin and swollen children go by different names. It is common nowadays to speak of njala, but in some places a child might be said: [for Nyanja version]: to have: njisi (anyonkela) matufya kalyondeyonde midulo kulowewa or kulozedwa

or to be: osila, dayonda

[for Bemba version]: to have ulunse (alyonkela) amakonwesha or ukuloowekwa

Families who suspect these diseases should also ask for the arm measurement or feet to be checked, since their children may also be assisted with the new treatment.

Valid International Ltd 27 APPENDIX 3. Draft Letter to head of Traditional Health Practitioners Association of Zambia (THPAZ) from head of LDHMT

Dr. Rodwell Vongo Executive Director, Traditional Health Practitioners Association of Zambia P.O. Box 37082, Lusaka

Re: Community-based Therapeutic Care for the severely malnourished

Dear Dr. Vongo,

As part of its mandate to improve the quality and accessibility of health services in Lusaka District, the LDHMT is beginning preparations for the introduction of a new strategy for the treatment of the most severe forms of malnutrition in children. Community-based therapeutic care (CTC) is a strategy which is expected to bring treatment for the severely malnourished much closer to the family, making it possible for children and their carers to avoid the long stays at UTH which have customarily been necessary for the treatment of severe, acute malnutrition.

Our objective is to provide a new form of medicinal food (a Ready-to-Use Therapeutic Food, or RUTF) at the health centre level, which the families of eligible children will be able to take home with them. Screening of children for admission into the treatment programme would take place in the community. The main tool for screening is a specially marked tape, which is used to measure the circumference of the upper arm. We would like to provide training in the use of the tape, as well as other ways to identify severe malnutrition, to a variety of practitioners and service providers at community level. With this in place, children suspected of being badly malnourished could be checked on a routine basis by many people, including local practitioners.

We would like to include traditional healers in this training, since they appear to play an important role in the community diagnosis and treatment of diseases of wasting and swelling. I am writing now to extend to THPAZ an invitation to discuss with the LDHMT the forms and degree of collaboration that might be appropriate. At the least, I hope it would be possible to convene the appropriate parts of your Lusaka membership (herbalists, diviners, spiritualists, counsellors) for an orientation to the CTC strategy, the new medicine, and the use of the tape, so that they can undertake screening and referrals when they are presented with swollen or wasted children.

We are confident that the CTC strategy will allow significant advances in the District’s ability to support the recovery of malnourished children, and we look forward to the opportunity to plan for the involvement of your membership in this important endeavour. Please contact me at your earliest convenience.

Yours truly,

Dr. Moses Sinkala District Director of Health

Valid International Ltd 28 APPENDIX 4: Presentation to JICA and LDHMT members Slide 1

“Integration” and CTC

presentation to LDHMT and JICA staff Lusaka, May 5, 2005

James Lee Social Development Consultant Valid International

Integration & Lessons learned

• Varieties of integration – Cultural (considering local beliefs) – Sectoral (e.g., nutrition into health) – Temporal (relief into development)

Valid International Ltd 29 Slide 3

Cultural Integration

– Language and beliefs concerning malnutrition (esp. severe forms)

– Range of health care providers, (including traditional)

– Implications for (integrated) outreach strategies and case-finding

CTC can provide a bridge from emergency to development – Sufficient length of support – Clear milestones required – IncentivesLusaka or not – common ideas – Integration starts at project planning • Nutrition as part of public health intervention / IMCI • Staff shortages: motivation/incentives • concerningIncentives for staff, outreach swelling and wasting in children

Food shortage, but also: – Moral conduct of parents - Breastfeeding while pregnant - Jealousy and witchcraft

Lusaka – practitioners who treat swollen or wasted children • Clinic staff and volunteers, but also: – private operatives • Licensed • Unlicensed – Traditional sector • nganga • Alangisi, Bana chimbusa – Faith healers • bapfrofita

Implications for case-finding

Communications and outreach directed to other practitioners

Emphasis on: • identification, referral of severe cases • avoiding confrontation • the promise of new therapy • use of MUAC tape?

350 CTC in Malawi - 2002

200 s r e b m u

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 August 02 distribution round March 03

ADMISSIONS EXITS TOTAL IN PROGRAM

Sectoral Integration - lessons

Nutrition, Health often separated institutionally at policy level…. (risk of dysfunction) ...but at implementation level they often involve the same people (risk of overburdening volunteers)

Implementation with Volunteers

• Requires clarity about expectations • Integration/transition cannot be an afterthought • Screening is easier than follow-up • Broader training useful – e.g. CDD • RUTF generates powerful positive feedback

CTC implementation with volunteers, Lusaka: issues • Level of Effort – No. of cases revealed by survey? – Follow-up to be required? – MUAC admission vs. WfH? • Where best to situate management, guidance of volunteers? • Need to standardize attention/support to volunteers across agencies?

At any given H.C., who is best positioned to…….

mobile MCH Nurse Nutrition- CHW CHP NP clinic ist

Screen and MUAC?

Calculate WfH?

Perform weekly OTP exam?

Counsel carer on use of RUTF?

Follow-up child in the home?

Manage outreach and case follow-up?

Valid International Ltd 34 APPENDIX 5: CTC Summary

Community-based Therapeutic Care (CTC) A new approach to alleviating malnutrition

Abbreviations CTC Community-based Therapeutic Care SFP Supplementary Feeding Programme OTP Outpatient Therapeutic Programme SC Stabilisation Centre TFC Therapeutic Feeding Centre RUTF Ready to Use Therapeutic Food HEPS High Energy Protein Supplement MUAC Middle Upper Arm Circumference (index of acute malnutrition) WFH Weight for Height measurement (index of acute malnutrition) WFA Weight or Age measurement

 Community-based Therapeutic Care (CTC) is a way of managing severe malnutrition in the community and at the health centre level. CTC assists the majority of people suffering from acute malnutrition in their homes, not in inpatient feeding centres.  For the treatment of severe malnutrition, CTC uses Ready to Use Therapeutic Food (RUTF) combined with outpatient drug treatment protocols (antibiotic, antimalarial, micronutrients, deworming) for the treatment of severe malnutrition at home, and referral to inpatient units for those with complications.  The RUTF is a high energy/protein paste, fortified with micronutrients and equivalent nutritionally to formula 100 which is used in hospitals/therapeutic feeding centres during the rehabilitation phase. Due to its oil based nature there is no risk of microbiological contamination as can happen with milks and porridges. It can be eaten directly from the container.

CTC consists of:  Outpatient Therapeutic Programme (OTP). OTP is run at every health facility. In Lusaka it will be included as part of the routine MCH activities. This is where the majority of severely malnourished children are assessed and treated.  Inpatient Facility (hospital, therapeutic feeding centre or stabilization centre) for referral of complicated cases who are not well enough to be treated at home. They are treated as inpatients until their condition is stable enough for them to be discharged home (usually 5-10 days). In Lusaka this is UTH A07.  Outreach Work. The community element must be strong in order to mobilise mothers/carers to bring their child to the clinic for screening. Existing community workers/volunteers (community extension agents, traditional birth

Valid International Ltd 35 attendants, HIV/AIDS educators, Neighbour Health Committees, religious leaders, volunteers etc) are trained to help sensitise the community and to provide the follow up care the severely malnourished children need in order to be treated effectively at home.  Local Food Production: “Ready to Use Therapeutic Food” (RUTF), which is equivalent to F100 is being made locally in Lusaka. This will help sustainability and hopefully keep costs low. If possible:  Supplementary Feeding Programme (SFP). Decentralised centres are run on a fortnightly or weekly basis providing a ration of fortified flour (HEPS in Zambia) to moderately malnourished.  Food Security and Agricultural Projects and Community Health Education are also integrated with CTC wherever possible to provide longer term support to families with malnourished children.

Valid International Ltd 36 APPENDIX 6 Areas for Future Qualitative Research

Areas for future qualitative research. In some respects, the agenda for future research will be governed by the success of the CTC start-up phase. A general plan has been suggested here for case-finding and mobilization to be used in one or more of the 5 start-up compounds. The problems or questions that arise from implementation will suggest further areas for research. For instance, it might be necessary to look in more detail at ways to reach alangisi and bana chimbusa if the volunteers prove unable to make contact with them in a systematic way. The important role played by private practitioners in the urban setting also creates a new challenge for clinic-based CTC. Should mobilization appear to founder on their involvement, it may be useful to investigate who exactly these practitioners are, and how they can be more effectively involved in case-finding. Neither of these problems is likely to be very complex, but the challenge that this programme faces is to solve them with a minimum of extra resources, operating as much as possible within the framework established by the District’s budget and normal operating procedures. To do this, shortcuts identified through qualitative research may prove useful.

Beyond the mechanics of mobilization there are likely to be a number of issues arising from the introduction of RUTF in an environment where the effects of HIV/AIDS are very prevalent. RUTF will be entering a market full of therapies for HIV/AIDS and other ailments. It may be useful to conduct rudimentary research on the therapeutic landscape and to try to anticipate what position within that landscape RUTF is likely to be assigned by consumers /clients, and what consequences this might have. For instance, the dramatic improvements which RUTF makes possible in marasmic children (children who in Lusaka are often referred to as “finished” by HIV/AIDS regardless of their actual HIV status) is unlikely to go unnoticed in the sexually active adult population. There may be scope for qualitative research to examine ways in which the appearance of RUTF might be altered (e.g. certain colours or packaging) to signify RUTF’s status as a medicine for children, thus preventing its diversion to other family members. Applied medical anthropology has faced similar questions of social marketing and cultural perceptions in areas like family planning, and could employ similar methods with regard to RUTF. At the same time, if a ready-to-use supplementary food (RUSF) is to be introduced, the problem is the opposite: how to make the product most attractive to adults? A third area of concern is the relationship between RUTF/RUSF and ARVs. There is evidence out of South Africa that multivitamin therapies are being used (and in some cases being aggressively marketed) not as a complement, but as an alternative to ARVs. Should a similar movement against ARVs take hold in Lusaka, the ready-to-use foods utilized in CTC may come to be seen and used in ways not intended by CTC. Qualitative research could help to establish the risks of this, and to develop information campaigns and modifications to the product that might help to prevent it.