I have seen this a few times. I once reviewed a CTC program that had decided to run OTP clinics on market days because they felt that caregivers could take advantage of increased transport availability. Some also took advantage of the market to make a little money selling RUTF. I bought some at a very reasonable price (cheaper then the cost to the program distributing it). I suppose I could hunt out the report but I would have to clear it with the implementing agency fro public release. Most implementing agencies go to great lengths to encourage compliance using community-based volunteers, peer mentoring, education sessions at centres &c. This helps to minimise sales (compliance and sales are antithetical). It is good practice to "patrol" markets &c. to check for sales to see if this is a problem. Some programs require caregivers to return used sachets / tubs at each clinic visit as a check on sales.

The sale of RUTF unfortunately is not uncommon. Mark has already highlighted a number of ways to prevent sale/trade of RUTF. In addition to the above, a few years ago in Southern Burundi, we engaged the local police to patrol markets and confiscate RUTF from local traders seen to be re-selling any therapeutic products. They also imposed a fine on traders found to be selling such products and returned to us products removed. This seemed to work, although it was not documented in any official form.

Thanks both for sharing your respective experiences. Hatty, if stocks of RUTF were taken from a store and put on sale, I can see the measure you took is justifiable. However, when mothers take what they are given to the market and get a value for it, I believe we should rather try to understand the mechanism/reasons than punish the behavior. It might be telling us something! Approaches that we know work in emergency setting might not necessarily fit the more developmental context. It might be time for us to think beyond an emergency style service delivery in places that don't warrant one. I will share what I find when I get hold of those reports that I am looking for. Thanks once again!

RUTF is a "medicine", so i totally dont agree with the people who think it is 'ok' for the mother to sell it. When you are suffering from malarial, do you sell half of the dosage prescribed to you because you want to buy something else?. I highly recommend the methods of involving police as mentioned earlier in some places as a means of intervention to prevent RUTF sell. If we tolerate such behaviour of accepting a therapeutic drug to be sold, then we may never see malnutrition eradicated. I suggest more awareness among mothers so that they can appreciate why in the first instance why they have been given RUTF. Seeing a child recorver succesfully from severe malnutrition iam sure is a joy to both mothers and health workers. So where ever we are, let us do what we can to take advantage of what exists in order to reduce and gradually bring to an end the numbers of children dying or suffering from severe malnutrition.

Agreed that it is necessary to try to gain a wider understanding of the problems and associated causes affecting communities with a significant prevalence of malnutrition. However, the objective of the exercise was not to 'punish' mothers for selling RUTF, rather dissuade traders from facilitating the sale of a valuable, medical treatment prescribed to help rehabilitate severely compromised children. In areas where MN is problematic, either cyclically or chronically, in addition to the provision of services predominantly focused on curative care (SCs/OTPs), it is also necessary to try to initiate complimentary activities looking to tackle the underlying/immediate cause(s) of MN. These will usually be multifarious and may well include interventions focused on income generating, income diversification, improved market access etc that may help to tackle the root causes that led these individuals to sell the RUTF in the first instance. Another possiblity (has been observed in some countries), is that RUTF is sometimes sold during the early stages of a programs establishment, when communities have not been properly sensitised as to the objectives of OTP clinics. It's not always that HH's are desperate for cash, but that they percieve the relatively valuable 'food product' (RUTF) to be a luxuary and would rather trade it, where for example, a grater quantity of staple could be bought for the household with funds generated. In such cases, it is often found there is poor recognition of RUTF being a therapeutic product and thus not perceived as a medicine. This can usually be rectified through strong community messaging using both paid and volunteer outreach workers. Obviously, it is recognised that drugs also have a market value, however mothers seem less inclined to sell prescriptive medicine for their children when they understand it is just that, rather than what they might percieve to be a high value simple food product. Good luck in progressing your project to address developmental issues also.

This is a common situation. it is common in all programs where food is distributed including "medical" foods such as RUTF - it is very rarely assessed and I know of only one confidential document where this has been properly assessed (and sharing is very extensive,selling less so). It is partly caused because of the amounts of RUTF that are given by some agencies/protocols. We can easily calculate the amount of energy that a recovering child actually takes from the rate of weight gain. There have been many studies that show that the energy cost of tissue deposition averages 5kcal/g of new tissue - and the energy cost of maintaining weight is about 100kcal/kg/d. Thus, if a child is gaining weight at say 8 g/kg/d then her/his total intake averages 100+5x8 = 140kcal/kg/d. (some of this may come from other foods, family pot etc. so that this is the MAXIMUM amount of the RUTF that the child is actually taking) In actual fact the mean rate of weight gain in many OTP programs is much less than 8g/kg/d. Some as low as 4g/kg/d (indicating an intake of 120kcal/kg/d) or even less! What happens to all the rest of the RUTF (in this example at 80kcal/kg/d and more if some of the child's intake is from other foods). Now most malnourished children when newly admitted have moderate appetites and will not take more than about 100-130kcal/kg/d until their physiological adaptations reverse and they are ready to consume very large amounts of the diet. So what happens when we give 200kcal/kg/d to mother to take home when the child is newly diagnosed? Ideally she does not give other foods to the child so if we take the situation where no other foods are given, and the child is fed and encouraged to take only the RUTF, s/he will become satitated at about 100 to 130 kcal/kg/d during the first week - leading 70-100kcal/kg/d uneaten and unwanted by the malnourished child. What is she to do with this valuable resource? Well usually there is quite extensive sharing within the family (and sometime to neighbouring families) and then some is sold and we find it in the market and get angry and call the police! This is: 1) wasteful and expensive for the program 2) potentially dangerous. If the child, when newly admitted to the program, actually does take that amount it can lead to the "refeeding syndrome" (which can cause death - I can send references to anyone that wants to know more about refeeding syndrome) and refeeding diarrhoea (a different problem not to be confused with refeeding syndrome) 3) in the context of this discussion having fairly large amounts of "left-overs" encourages mothers to share and sell. And indeed the family can become habituated to sharing - then later when the child does regain his/her appetite, the habit of sharing and/or selling is alrady firmly established within the family. 200kcal/kg/d was the MAXIMUM amount that children took in TFCs during the rapid growth phase (after an acute phase AND a transition phase during which the physiological adaptations reversed - those who took all the diet achieved rates of weight gain around 20g/kg/d - a figure that is never achieved in OTP programs). This amount was simply transferred to OTP protocols without testing any other amount or consideration of the implications. Now, it may be that sharing and to a lesser extent selling is inevitable, in which case we should give excess to ensure that the child does indeed get sufficient to recover - but there are really no data on this. In my protocol we have tables that deliver 170kcal/kg/d and the rates of weight gain are the same as when 200kcal/kg/d are given - but there is no documentation about sharing or selling with either of these protocols. The rates of weight gain in OTP in the early, experimental days by ACF when they brought children into residential care for a few days before transfer to OTP averaged around 10g/kg/d (intake 150kcal/kg/d - amount given to patients 170kcal/kg/d), which far exceeds most other program's rates of weight gain. This sort of weight gain can also be achieved with more detailed counselling of the mothers before they go home with the week's ration - but this is uncommon in my experience - but does occasionally happen with well trained teams. The analogy with malaria tablets is not apposite - we do not give a much higher dose of malaria tablets out to patients than are required or can be taken by the patient - and if we do drug monitoring we normally find that the patient has taken the dose prescribed - whereasa with RUTF we give excess and routinely find (from the rate of weight gain) that a large proportion of the "medicine" has not been taken! In theory, we should start with a much smaller amount for the first week of treatment and then increase a bit for the second week and then go to the full amount from then onwards (depending upon the appetite and response of the child) -but this would complicate treatment protocols and I am unsure whether it should be introduced - but it needs to be properly investigated. I have written a draft protocol and constructed tables for giving 135kcal/kg/d for the first week (or so depending upon appetite test) and then 150 for the next week progressing to 170kcal/kg/d thereafter - but this needs to be properly tested before it is written into a generic protocol. If any NGO would like to conduct such a study, I would be happy to work with them. It is also common to find that children are given large amounts of RUTF at the start of a program, and then the supply starts to run out so that after a while the children get a reduced amount (ad hoc and not based upon calculation or tables of what sort of reduction is "acceptable") to "conserve" stocks until the next logistic supply - so some get to much and some to little in practice! This is particularly the case where logistics are problematic (not with well resourced focused INGOs. but often with scaled up services implemented by overstretched MoHs). There is a lot of work to be done on these issues to refine the protocols and advice we give to cartakers - simply getting angry, blaming mothers, designing penalties and inviting the police to intervene does not seem to be the right way to go about things! First we must understand why, do the operational reseach and then refine protocols to address the problem (if it can or should be solved at all). Mike Golden

Just a voice to add. Is the sale of RUTF (un)justifiable? I perceive this depends on the set up of the CMAM program i.e iIS COVERAGE COMPREHENSIVE ENOUGH? Like some one said, the sale of RUTF should act as a whistle blower-that there is a gap in the network linking community Out-reach & OTP components, and MAM . Outreach: One would ask, how effective are the Community Outreach Workers to mobilize communities, identify, and refer children with SAM for treatment, trace absentees and defaulters, and follow up on problem cases in the communities (including those who sale RUTF). OTP: Upon admission, are caregivers given basic education (besides inherent care KAPs) on nutrition and linked to the COWs? Are there basic health care package and and supplementary take-home ration, e.g., fortified blended cereal, lipid-based nutrient supplement most commonly given to manage Moderate Acute Malnutrition And perhaps lastly, Are structures in place for essential administration and management activities: the ordering, transportation, and storage of supplies; the referral between CMAM components; the training and supervision of health care providers; and the budgeting, planning, monitoring, and evaluation etc.

Just a voice to add. Is the sale of RUTF (un)justifiable? I perceive this depends on the set up of the CMAM program i.e iIS COVERAGE COMPREHENSIVE ENOUGH? Like some one said, the sale of RUTF should act as a whistle blower-that there is a gap in the network linking community Out-reach & OTP components, and MAM . Outreach: One would ask, how effective are the Community Outreach Workers to mobilize communities, identify, and refer children with SAM for treatment, trace absentees and defaulters, and follow up on problem cases in the communities (including those who sale RUTF). OTP: Upon admission, are caregivers given basic education (besides inherent care KAPs) on nutrition and linked to the COWs? Are there basic health care package and and supplementary take-home ration, e.g., fortified blended cereal, lipid-based nutrient supplement most commonly given to manage Moderate Acute Malnutrition And perhaps lastly, Are structures in place for essential administration and management activities: the ordering, transportation, and storage of supplies; the referral between CMAM components; the training and supervision of health care providers; and the budgeting, planning, monitoring, and evaluation etc.

in some county in sudan in january 2005, an urgency lost alot of RUTF through pilferage, these RUTF ended up in the market for sale and mothers bought it for their children ( malnourished and not malnourished ) at a low cost of 2 dinnars per satchet after hearing and seeing some of its good effects on other children who received it from feeding centres.the result was a reduced prevalence in acute malnutrition and reduced admissions in that county compared to others neighbouring considering that nothing had changed in the food, health and security systems.the problem is they sold an expensive product cheaply since they stole it and didnt know the cost However i think costs allowing , i.e if it can be cheaper ,these RUTF should be sold in markets just like painkillers and should not be medicalised as is the case now.

-An important and needed document to make us question the RUTF/RUSF craze that seems to be unfolding - advocating a measured approach. Well worth a read despite the weakness of a few of the arguments. Sorry for cross postings. http://www.wphna.org/2011_feb_wn3_comm_RUTF.htm micheal

Hi Michael, Thanks for sharing this, I had already seen it. The reason that I was looking for reports that document RUTF sell was to explore a potential for an alternative service delivery approaches beyond and above what we use at the moment. I seem to be getting there! There were quite thoughtful suggestions shared in this forum-which is very encouraging. At the same time there was some suggestion that I thought were counterproductive to our work. I know we all want to use this life saving and expensive product wisely, but I don't agree with punishing the mums for an action that we feel are undesirable just based on our judgment. The whole concept of CTC/CMAM to me was based on an understanding that the community is the centre of the treatment approach and service is tailored to their needs. The notion that they (the community) don't know what is best for them is very dangerous! I believe customer tailored service is the best way forward and will surely bear the best fruit in the long term. Coming to the article, I do understand the authors' reaction and wanting to protect breastfeeding and to some degree trying to protect local food options. But I don't agree that an intervention that has a potential to save lives be stopped just because we are worried. I do strongly agree we do need to regulate the market and we need to standardize the products. Breastfeeding that needs to be protected- is not at all threatened in my opinion- at least for the time being. Tx

From Jamaac Mohamed: To comment the sell of expensive and medical RUTF by the mothers, it may be worth to further explore the reasons why mothers are selling RUTF prescribed to their children? Are there a ignorance, lack of income at home, or there is much more to examine? My comment is to think the negative impact and process of treating malnourished children, by focusing to be integrated and further tailored to other complementary interventions like those addressing( livelihood, WASH and health services ). Thanks

Hi Jamaac, Good point! I think the other side of the game might even be more interesting i.e. knowing why other mothers/caregivers buy the product? what return do they expect when they spent money on the product? How long do they do it for? What age group do they use it for? How much do they spent on it and how does this fit with their usual household spending bill i.e what proportion of their HH spending does it make? and many more Cheers