X~-ARK-J~~-~ 
Evaluation of the outpatient therapeutic care programme, 
Save the Children UK, North Darfur, Sudan, 2001 I/ 74 35 
Summary of key findings 
Contest of the pro, oramme 
North Darfur experienced a severe drought in 1999 and 2000. This caused widespread 
crop failure, disruption to markets, decrease in the earning power of all families and a 
generalised decline in food security. 
In October 2000, the annual assessment of food needs undertaken by SC-LX and the 
Developnlent & Rehabilitation Committee (DRC) of north Darfur, concluded that 
during 2001 between 17,192 ,and 26,057 MT of relief grain \vould be required, in 
order to prevent loss of life and destitution. The report reconln~ended that this food be 
distributed fioni March 2001, to preempt tlie start of an estended hunger sap and to 
ensure tliat food was available before the planting season in July. 
Despite efforts repeated efforts by SC UK from October 2000 on\\;ards to advocate 
for a response, it was not possible to mobilise donor support for food distribution. It 
had been hoped tliat a general i-ation would be distributed to pre\;ent a further 
deterioration of the food security situation. 
Nutrition surveys carried out in April revealed tlie following rates of malnutrition and 
it became clear that supplementary and therapeutic feeding would be needed to 
prevent fitrther loss of life in the population under 5'. 
Global (< -2 z-scores or oedema) = 23.4% (95%CI 21.8 - 25.0) 
s Severe (< -3 z-scores or oedema) = 2.1 % (95% CI 1.6 - 2.6) 
On the basis of tlie survey results, blanket supplementary feeding was proposed for all 
21 rural councils. Again it was not possible to secure donor support for this. A 
pl-oposal was made for targeted supplementary feeding in the six worst effected rural 
councils and funding was secured from DfID. USAID subsequently indicated that it 
could make USS500,OOO available so it was possible to include a fi~nher 4 rural 
councils in the programme. The rural councils were selected on tlie basis of the 
severity of their situation according to the nutrition survey results (calculated by food 
economy zone) and the Food Econon1y reports'. A general ration distribution of 
15,000MT of grain was also made bet\\.een May and October. 
Once funding was secured, SC UK implemented an outpatient therapeutic feeding 
programme (OTP) with a ready to use therapeutic food (RUTF') which enrolled and 
treated 836 severely n~alnourislied children and a targeted\upplenientary feeding 
programme enrolling approximately 24,000 children and 23,000 pregnant and 
lactating \vomen in 10 rural councils of North Darfur during the period August I 1- 
Decembel- 12 2001. 
Other emergency interventions included: DflD and ECHO funded SC-UK to drill." 
I-ehabilitate 151 shallow wells or hand-pumps. The government of the Netherlands 
funded the provision of fi-ee basic drugs to dispensaries and clinics in 4 of the 12 rural 
councils. USAlD ft~nded ameasles vaccination can~paign. 
Outpatient Tl~erapeutic Programme design and content 
Children were screened in the first instance using MUAC and by checking for 
nutritional oedema. Children 12-59 months with a MUAC <I ljmm and children 6- 
1 1 months wth a MUAC < I l0mm were measured immediately using \veigllt for 
height. Children aged 6-1 1 n~onths with MUAC 110-1 15mm and children aged 12-59 
months with MUAC 115-1 19mm immediately received supplementary food and were 
nieasured using weight for height one week later'. 
Children <70% weight for height or with nutritional oedema were immediately seen 
by the nledical team comprising a medial assistant and team nurse. Children with 
oedema, severe dehydration, no appetite and visibly not eating RUTF when offeredd, 
temperature >39 degrees, increased respiratory rate (> 35 if over 2 years, > 40 if 1 - 1 
years or > 50 if less than 1 year) or any sign of illness were referred in the first 
instance to a hospital (four hospitals were being supported by GOAL to give 
therapeutic care). Where a child could not be taken to the hospital due to [he distance, 
they were referred to a stabilisation centre (3 of these were set up in health centres 
located in areas least accessible to the hospitals). 
Treatment in the stabilisation centre included: rehydration" where necessary. 
treatment with a systematic autibiotic (amosicyllin) and fansidar, folic acid, vitamin 
A, measles vaccination, feeding with F75 by naso-gastric tube and daily examination 
and monitoring. 
Children were discharged from the stabilisation centre to the OTP when appetite was 
shown to have returned by the successfi~l eating of RUTF for more than one day. 
Children were referred to the hospital if they vomited more than 50% of the feed after 
6 consecutive meals, had a body temperature >39C or had a high respiratory rate or 
failed to resain appetite after 5 days in the stabilisation centre. 
' Xurriser I'lun~py Nut \\.;IS used. 
' Children wcrc idmirred ;rccordins to .\lC.\C crireria nod nor disclmrged from rhc programme. This 
;IIIo\KxI :I greater numlxr oicbildren ro henefir iron2 the progrlmme rhm would haw ken possible \xi& 
rr;d;~rd mcighr for hei~l~r cnrv aod exit criruria. Ibis \\:IS desirdAu +en rl~c Lirnired nrailnble suppon to 
h~uscl,oldz. ' ,\IUt\C cur offs were calculated usins serlsitirity and specificity analysis of \veighr for height and 
MUAC data 011 a sample of 733 children at the tirst distribution's screening session 
'.\hter. ORS :lad susar mere used (using rl~e recommended rccipe) for reh!-drxion as CMV or Rcsonial 
wcrc nor ar:tilal)le ro rhe progrxmme. 
Children admitted into the OTP received a systematic antibiotic (amosycillin). 
chloroquine (according to the Ministry of Health treatment guidelines), folic acid. 
vitamin A, measles vaccination and 14 packets of 0.92g and 500 kcal RCTF per 
week. Children in the OTP were visited daily by the Community Nutrition \Vorker 
(CNW) who checked the child for appetite (sachets of RUTF eaten the previous day). 
diarrhoea history, thirst, dehydration and the presence of a carer and watched the child 
consume RUTF. Children had a full examination weekly by the team nurse or medical 
assistant (health professional category just below a doctor in Sudan) and their weight 
fol- height was recalculated. 
The CNW was also responsible for the identification of severely malnourished infants 
throu~h community screening, instruction in the use of therapeutic foods through 
home visits. the identification (alongside the medical assistant and nurse) and referral 
to inpatient units of severely undernourished children who failed to thrive in the 
outpatient program due to anoresia or co-morbidity, hygiene promotion activities and 
the distribution of soap to mothers of severely undemourished children with skin 
diseases, the promotion of the use of ORS through home \:isits and to act as a 'contact 
point' between the community and other elements (e.g. the clinical team) of the 
outpatient therapeutic program. 
Children were discharged from the OTP to the supplementary feeding pro,gxnnme 
when they had reached 75% weight for height for 4 consecutive weeks. 
In total the programme had 100 distribution points and employed 290 field staff 
including medical assistants and nurses, CNWs, and Team leaders. 
A note about data quality 
A comprehensive monitoring system was put in place to n~onitor the programme 
outcomes as it was a new type of intervention for SCUK. The data system \\.as 
specially designed for the programme but proved to be inadequate and would have to 
be substantially revised for any future programme. One of the reasons may have been 
that the programme had to stall quickly because the rains were forecast which had the 
potential to severely hamper distributions. Specific problems encountered \\.ere 
inconsistencies between daily and weekly reporting forms, some children's outcomes 
not reported at the end of the programme due to the rush to close and the failure of the 
system to track children through OTP and SFP. 
Outpatient Therapeutic Programme outcomes 
Table 1. Key outcome indicators for qualit! of care for the 3 months of 
operations in the OTP 
Average 1 range 
percentage i 1 
Discharged to supplementary feeding progranlnle I SI.4 1 (45-100) i 
Defaulted !10.1 1 (0-36) i 
Died 1 2.9 1 (0-7.7) i 
i 
Transferred (to TFC, hospital or dispensary) i 5.6 i (0-13.4) 
Mortality: 
A mortality rate of 2.9% is very low and well within Sphere standards. However, the 
mortality rate is difficult to interpret because children were discharged to 
supplementary feeding after reaching 75% weight for height and sonie of these 
children niay have subsequently died. Using the Pn~dhon index the crpecfecl 
mortality was calculated based 011 i) the death rates achieved in conventional but well 
run TFCs using internationally recognised protocols, ii) the anthroponietric r' oedenia 
profile of children adniitted into the OTP, iii) the deaths which can be expected in the 
pel-iod froni admission to discharge at 75% weight for height, and iv) using a 
cossection factor to take in account the transfer of children (potentially the most sick) 
to other facilities'. The expected number of deaths was conipared to the obsened 
deatlis in the OTP. Half (51%) of expected deaths of children without oedenla 
(n=714) were actually observed while almost all (92%) those expected occurred for 
children with oederna (n=62). Rates did vary according to location (see ranses in 
Table 1 ). 
Other indicators: 
The average rate of rlej~~rlti~~g was skewed by the high rate of defaulting in one 
location where the largest nomber of children were adniitted (El Faslier to\\n) and 
where up to 34% of children defaulted. This was mainly because the children were 
from pastoralist families \vho only stayed in the town for a few days at a time. 36% 
of children defaulted from another location (Tina) in the pastoral area where only 21 
childsen were adniitted. Discharge rates were therefore also lo\\{ in these two centres. 
With the exception of these two locations, defaulting rates in the other 9 locations 
remained below 14%. Rer~rlmissio~r rates were approximately 1.0% of total 
adniissions. 
11.Ierur le/rg/lr of stq. was estimated at 25 days for wasted children and 35 days for 
oedeniatous children. This data, once again has to be interpreted in the light of the 
discharge criteria of 75% weight for height compared to the usual 85% weight for 
height. 
1b1ecl1,r weight gairr Lvas 6.6g/kg/day for wasted children and l.S@g/day for 
oedeniatous children. 
Children in the stabilisation centres: 
Only 17 children were adniitted to the stabilisation centres, three children in total died 
though two died after discharge to the OTP and are therefore included in the death 
rate in table I. 
- If tc~nsfer cues :Ire not r;kn into ;~ccoonr. momlin rates can appear PC? lo\\- if all cornplicnred .' iugh 
+l, c:ws ;are transferred 
Coverage: 
Rural council 
.A1 sayah 
El fasher nml 
El fasher town 
1 Karnoi 
nates of coverage t 
vlasimum coverage of 
3TP (esc TFC) % 
56 
39 
24 
53 
50 
25 
5s 
10 
30 
20 
OTP location 
15% Contidence 
~otewal 
23-156 
21-81 
12-49 
21-137 
27-104 
10-70 
24- I62 
4-27 
16-62 
8-52 
Table 2 slio\vs the range of estimated coverage rates achieved by ~ral council. The 
I-ates are con~parable to rates achieved in \\.ell-nm TFCs operating in high popularion 
densitites. More childl-en were admitted in locations where prevalence of nialnutrition 
\\as liiglier. Tak~tig into account tlie children admitted into the hospital the presence of 
TFCs did not increase coverage substantially (35% (17-79)). 
Unlborro I I 
There are two possible reasons for the lower than expected coverage rates. First, pan 
of the programme period overlapped with the planting season which affected the rate 
of adiiiissions into the programme and second a miscalculation was made in setting 
the registration targets which may have affected the rate of case finding. 
4-28 
The esti~iiates in Table 2 are proble~uatic for several reasons: 
It xvas not possible to estimate coverage with an antliroponietric survey during the 
project period. The numerator is the total number of children admitted (minus 
readmissions and transfers) over the 3-month project period. Coverage should be 
estimated at a single point in time and could therefore be as little as a third of the 
estimated coverage in Table 2. 
There are tlie usual problems in accurate estimates of population figures. These 
figures are based on 20% of the population being being under five years, \\,liereas 
the Bureau of Statistics reconlniends this figure to by 16.6%. Tlic data for the 
pmtoralist areas could utiderestimate tlic real coverage due to overestimation of 
population in these areas. Both of thcsc factors could mcan that the corerage figures 
are underestimated. 
The estimates of malnutrition were based on a survey conducted in April 2001 and 
compared to children admitted into the programme August - December 2001. 
Malnutrition could have increased in tlie run up to the harvest in October i 
November or, as in west Darfur, could have declined. 
Total 32 15-71 
The wider contest of the programme 
Table 3: acute malnutrition before and after the intervention 
Food Economy [ April 2001 I Januar? 2002 i 
Zone / Global acute / Severe acute I Global acute j Severe acute : 
Table 4: Under five mortality rates (3 month8 retrospective survey using 
previous birth technique) 
/ Goz 
i l'ombac 
Pastoralist 
1 Son-wadi 
Pestoralist 
Table 3 sho\vs that rates of global acute n~alnutrition have declined sigificmtly in all 
food economy zones since April 2001, tllougll rates of severe malnutrition have only 
declined significantly in the Goz area. Rates of severe malnutrition remained high in 
January 2002 in tlie Tombac area and in contrast to all other areas (and the April 
sul-vey). 96% of the severe nlalnutrition was oedeniatous. The Tonibac area \vas also 
the only area where severe malnutrition measured by MUAC (<I lOrnn1) gave a 
higher prevalence tlian severe malnutrition measured by weight for height. The 
Tombac area is also tlie area with tlie highest under-five niortality rate. In all other 
zones the under-five mortality rates were acceptable. It is interesting to note that the 
decline in prevalence of global acute malnutrition \\,as least dramatic in the pastoral 
food economy zone suggesting that people dependent on livestock for the li\.elihoods 
are the slowest to recover after a bad year. 
(WHZ) (CI) 1 (\VHZ) (Cl) 
31.3 (27.2-35.5) / 3.0 (1.9-4.7) 
203 (17.1-23.4) 1 2.7(1.5-3.9) 
26.1 (22.4-29.7) / 1.7 (0.7-2.7) 
Conclusions 
(WHZ) (Ci) ! (WHZ) (CI) 1 
8.7 (6.5-10.8) / 0.3 (0-0.6) 
11.8 (9.0-14.7) 3.5 (1.5-5.51 1 
18.5 (14.7-22.3) 1 2.2 (1.2-3.2) 1 
It was hoped that outpatient therapeutic care would offer the follo\ving programmatic 
advantages: 
18.9 (15.6-22.3) 1.1 (0.7-3.2) 9.9 (7.2-12.5) 1 0.7 (0-1.3) I 
- It would avoid having to set up many TFCs which \voold have been beyond the 
capacity of any operating agencies because the large area and scattered population 
would have required the construction, staffing, and equipping of dozens of TFCs 
in order to achieve acceptable levels of coverage and equity of provision. It noold 
therefore allow a decentralised programme \vhicll maximised access, and therefore 
coverage, to be implemented. 
It would avoid having children concentrated in centres risking cross infection and 
being subjected to ill trained medical staff 
It \vould allow the community greater paiticipation in the programme and reduce 
the cost to families of participation in an inpatient programme 
It imp be cheaper than TFCs as tlie technical staff costs and physical 
infrastructure costs of centres would be reduced. 
In reality, the prograninie admitted 836 children which is probably several limes more 
than a therapeutic feeding prograninie could liave achieved within a 5-month period 
(fi-om funding to closure) in North Darft~r. Mortality rates were very lo\\.. probably 
due to a combination of not being presented with tlie risk of poor care and cross 
infection in a TFC and because rates of oedema and coniplicated malnutrition were 
low. Tlic reduced costs to tlie conimunity through a decentralised programme have 
not been evaluated but the overall programme costs (approximately £260 per child) do 
not vary substantially per beneficiary froni costs per child in a TFC Coverage rates 
were not as lii~li as hoped though they were of tlie order achieved in well run TFCs in 
a)-eas of niuch higher population density. Defaulting rates were generally very Ion. 
except in the pastoral areas. 
The future replicability of this programme needs to be considered in tlie light of tlie 
fact that in N Darfur Save tlie Children has 
i) a good knowledge of both tlie macro-economic and micro-economic (i.e. 
household food economies) contest of the intenention setting 
ii) a good knowledge of the geography of the intervention setting 
iii) ready availability of qualified staff and other resources such as offices and 
vehicles 
iv) good relations witli the intervention population 
v) good relations with local government officials at all levels 
vi) good relations with the goveliinient health systems allowing local liealtli staff 
(i.e. medical assistants and nurses) to be seconded to tlie program for both service 
delivery and training of comniunity nutrition workers as well as the use of 
primal-y and secondary level health facilities 
vii) strong leadership and good support from SC (UK) national and international 
offices 
viii) the esistence of a strong community ethic in the intervention population and 
is) the availability of a ready to use therapeutic food (RUTF) acceptable to the 
intervention population 
These factors undoubtedly contributed to the success of the OTP. However, it should 
also be pointed out that North Darfur does not provide an easy operating environment 
and the food security situation was severe. Tlie success of tlie OTP proganime 
suggests that agencies, witli adequate technical support, should make efforts to 
esplore and carefully analyse the options for programming which RUTF presents. 
Future recommendations 
Tlie results of the evaluation froni tlie programme in North Darfur give grounds for 
cautious optimism. The programme \vas implemented witli strong technical support 
in tlie phases of design and early implementation, \\;as thoroughly and independently 
evaluated and the results liave been d~ssetninated. We consider these to be essential 
components of any future work using RUTF or aiming to treat children \\.it11 ser-ere 
malnutrition outside of the TFC or hospital setting. There are also some priority 
areas fol- research and analysis in any future pilots of outpatient care: 
I. More experience on the potential complementary functions of traditional TFCs, 
hospitals, stabilisation centre (as conceived in Darfi~r) and outpatient care. 
Appropriate protocols for each level need to be developed and nlodels for systems 
of referral need to be piloted. 
2. How the needs of children <6 months old and <4kg or with oedenlatous 
malnutrition can be addressed in a programme with an outpatient component. 
3. More carefill analysis of the varying weight gains which children achieve on 
RUTF is required to understand its suitability for different conditions. 
3. The long term prognosis for children receiving outpatient care compared to those 
\vho are discharged from a TFC should be evaluated. 
5. The extent of the reduced cost to communities of a decentralised outpatient 
programme compared to an inpatient programme should be examined. 
6. Whether there is greater opportunity for improved psyc1iosocial stiniulation during 
therapy through an outpatient programme than an inpatient programme should be 
reviewed. 
7. The degree of con~pliance with systematic antibiotic / micronutrient regimens that 
can be sustained in an outpatient programme should be exanlined 
S. Priority should be given to the use of other suitable RUTFs such as BPlOO and to 
the developnient of more scientifically evaluated products with a view to reducing 
prices. Currently the price of Nutriset Plunipy Nut is prohibitive for routine use. 
9 Adequate monitoring systems based on those used for inpatient care should be 
established. 
For more infornlation please colltact Anna Taylor. Nutrition Adviser. Save the Children CK. 
\I.. ., .!,. . . r- ,I\ .w .. xi iik.orc.uJ 
April 2002