Tuberculosis and Nutrition

Experiences from the Integration of Food and Nutrition in

Care and Treatment Programmes

GBC Workshop on Increasing Corporate Engagement on Tuberculosis

23 February 2010

Cape Town, South Africa

• 100% voluntary funded• Low overhead costs• Mandated to respond

globally to– Emergency aid– Recovery assistance– Chronic hunger reduction

Cost estimates• US$0.25 - Feed a hungry school child per day• US$0.31 – Feed Orphan and/or vulnerable child per day • US$0.66 – to provide nutrition support to an AIDS patient plus family per day

UNAIDS Cosponsors

– UNHCR – UNICEF– WFPWFP – UNDP – UNFPA– UNODC– ILO – UNESCO– WHO – WORLD BANK

WFP’s lead role is dietary and nutritional supportWFP’s lead role is dietary and nutritional support

Background

• Southern Africa has the world's highest HIV infection rates • About one third of PLHIV in the region are co-infected with TB - TB

is the leading cause of death among PLHIV • Severe malnutrition, Body Mass Index (BMI)<16, is associated

with an increased risk of death in the first 4 weeks of TB treatment

• Drug side effects reduce TB treatment compliance• WFP and partners’ support treatment programmes in 14

countries in the region (pre-ART/OI, ART, TB) • Align with national systems for greater ownership and replication

Need to use ongoing programmes as platforms for services model development and national strategic guidance!

WFP Food Assistance ProgrammesWFP Food Assistance Programmes

Care & Treatment

Livelihoods promotion

Social Safety Nets

HIV, AIDS, TB,

Drugs, Malnutrition,

Poverty

“Drugs alone are not enough. Food and nutritional support should be an essential part of the care package for people with HIV/AIDS or tuberculosis”

‘The Lancet’, March 2007

Programme ObjectivesProgramme Objectives

Programmes are designed to achieve one or more (often closely related) objectives, including:

•Nutritional rehabilitation and/or nutrition support to improve individual well-being and treatment success•Social safety nets mechanisms to support treatment adherence and protect the household structure•Livelihood activities to encourage a productive recovery and sustain long-term adherence.

Types of Commodities

Judy Pudlowski, International Medical Corps

• Corn Soya Blend and oil for nutrition rehabilitation

• Cereals, pulses, oil, salt for household

• Other specialized products – RUTF supplied by partner agencies

Quality Assurance

TAG = Technical Advisory Group:• External, independent• Composed of experts in field of nutrition, food

safety, food legislation, consumer acceptability

• Reviews all ‘new’ products offered to WFP and advises WFP on their appropriateness for use in WFP programmes

Operational ChallengesOperational Challenges

• Commodities• Staff capacity• Infrastructure• Supply chain management

Product choices and associated operational considerations are driven by technical and services delivery parameters i.e. protocols

All operational considerations are closely linked to design decisions and vice versa

Operational Challenges: CommoditiesOperational Challenges: Commodities

•Nutritional supplements versus staple commodities (volume, packaging)• Purpose of food reflected in product type - Food as ‘medicine’ or food for social welfare • Number of specialized products for advanced care protocol – elaboration complicates product handling

Specialized nutritional

supplements easier accepted as health

products &facilitation of integration in

health protocols and supply

management

Implication of care protocols for

product choice

Operational Challenges: Staff CapacityOperational Challenges: Staff Capacity

•Integration in job description of doctors, nurses, pharmacists•Requirement for additional staff cadre•Need for integration within curriculum or on-the-job training•Encourage perspective of food as health product•Integration of nutritional care within treatment protocol

Disconnect between nutritional care,

‘prescription’ and commodity handling

discourages full responsibility by

‘medical’ staff

Food and nutrition support perceived as parallel/add-on

service

Operational Challenges: InfrastructureOperational Challenges: Infrastructure

•Staple foods often stored and handled outside the clinic due to bulk (storage volume, spillage), so as specialized nutritional supplements •Requirement for weighing or measuring equipment to determine individual and/or HH entitlements•Location and timing of food distributions do not always match clinic visits (opportunity costs)

‘Distance’ between health trigger and

food support purpose and

handling locationdilutes the health messaging on the

use of food products

Client perception of role of food!

Operational Challenges: Supply Chain Operational Challenges: Supply Chain Management Management

•Integration in medical supply chain (Proportioned supplies by manufacturers/suppliers ) •High cost of supplies to sites with limited clients (high cost/volume)•Explore commercial supply managers, including retailers (cash/voucher)

Integration is the way forward for

national programming

Products need to be adjusted to medical

supply chain parameters

Operational SuggestionsOperational Suggestions

Products for individual nutritional support:•Needs to be provided based on prescription•Should be integrated in routine patient care and case management - clinicians role and responsibility•Need for formalized protocols and training (including NAEC)•Product development (apart from specialized ‘recipe’), shelf life, portions, packaging•Product supply managed within medical supply chain•Procurement through local industries for easier access and sustainability•Quality assurance and oversight - Food standards, national/regional regulation regarding health claims

Operational suggestions, cont.Operational suggestions, cont.

Products for household support:•Distinguish purpose from specialized supplements•Handle food products (staples) outside the health sector infrastructure – civil society, retail •Consider the use of innovative social transfer modalities (cash, vouchers)•Consider linkages to livelihood enhancing activities and existing social welfare schemes •Consider (semi)-conditionality to encourage ‘graduation’

Lessons Learnt

Food and nutrition assistance • Improves nutritional status of patients• Enhances treatment adherence • Decreases treatment default rates, as food acts as an incentive for the

patient to visit the health facility• Increases patients’ access to health services including HIV counseling and

testing• RUTF more effective in severe malnutrition• CSB more appropriate for mild to moderate malnutrition

Thank you