There are good reasons for having OTP on one day. Having it on a specific days makes supervison much easier when on the job training, supervision and general support can be given to staff and volunteers working on the programme. This is particularly useful when OTP is new to a health facility. Another reason for chosing OTP on one day is to put it on a day when the health facility is least busy (ie:not the same day as other busy services that are scheduled on a once a week timetable) which means the OTP can be streamlined to keep waiting times to a minimum. In addition, if there is a significant increase in levels of acute malnutrtion, or an emergency where the health facility needs additional support to manage the case load, then once or twice a week makes it easier for an NGO or MoH mobile team to bring extra staff on OTP days. However, offering OTP everyday as part of all regular health facility activities also works very well for some places both for the staff and for the carers of the SAM children. OTP everyday can help to spread the workload, especially for a clinic run by just one nurse, but can also be beneficial for the carers as it means if they miss a follow up appointment they can come the next day rather than wait a whole week until the next OTP day. It also means that checking MUAC and oedema and immediately treating SAM becomes a daily task which may help nutrition to be seen as an integral part of health more easily. There are certainly pros and cons to both daily or weekly OTP for carers, health workers and supervisors. The decision of what will work most effectively is best judged by the carers, health facility staff and district medical team jointly as they will know how best to manage their workloads. Weekly or daily still make it an integrated service as long as it is viewed as part of the normal PHC activities that are availalble on a continuous basis.

In non-emergency settings the daily screening and treatment of SAM children using CMAM protocols in already established health centres is the way forward to me with each child being on its own follow up schedule like it is done with any other disease. Screening of all <5 children using MUAC or where possible by WHZ should be done routinely as part of IMCI or GMP where functional, medical history and treatment provided should be recorded in the IMCI register, RUTF and systematic and individually required drugs are given out by the dispensary. This has the advantage of mother being able to decide which day and time suits them to come to the health centre, they can combine their 'OTP' visit with their own health check up needs or for any other family member, the case load and with this the work load is equally distributed over the week benefiting health workers and mothers/ children. However there are some challenges with this approach e.g.: keeping an eye on absent/ defaulting children is more difficult, scales and height boards (if used for screening) have to be ready set up at all times, RUTF is a bit bulky for some dispensaries (depends on set up) and it is not possible to conduct nutrition education in group sessions (which is often not done anyway and I have big questions on the quality and impact of this approach). Some of the advantages are: addressing malnutrition is strengthened in the IMCI approach (something often overlooked when there is no treatment on hand, only nutrition education), undernutrition gets the status of a disease dealt with by health workers and not only lower qualified health assistants or community volunteers. Reporting forms currently promoted for OTP need to be replaced by slightly changed IMCI registers, protocols have to be brought in line with the IMCI protocols used in country. However this is possible and has been done in some projects/ countries. And then we should maybe also consider stopping calling it a CMAM programme but instead changing to 'treatment of SAM using CMAM protocols'. This will help to create ownership by government health workers and the MOH, seeing malnutrition as integral part of the primary health care package offered routinely and not considering CMAM as a vertical programme.

I will just highlight a few disadvantages for having OTP in one day; it may reduce the quality of health care service given to each beneficiary if the number of beneficiaries is high in a site, CMAM is likely to be viewed as a separate service from PHC (whilst we are trying to encourage integration), in cases where the condition of a child deteriorates the caregiver hesitates to visit the health centre and only wait for the specific day, and as already highlighted when a beneficiary misses the specific day they have to wait a week to be attended. In case you proceed to choose one day for CMAM, i would encourage that at least the screening and admission of new beneficiaries is done daily like any other service.

From Blessing Mureverwi: I also would discourage the idea of having a separate day for OTP as it does indeed make it look like there is preferential or differential treatment for beneficiaries and may even create stigma.In some contexts it also results in health workers calling for incentives given that it really goes against the idea of integration.

Dear Anonymous 303, As it is already stated by other coleagues, it dependes on the context. i am replying your question in view of Ethiopian context which is In favour of one a day per week. In Ethiopia , the management of CMAM partcularly OTP is decentralized at Health post level. it is entirely managed by health extension workers. in this case, it is difficult for health extension workers to provide daily CMAM services as they do have other household focused health extesion packages (more than 16 packages) that requires frequent home vists. Thanks.

I am curious to know whether having a daily OPT would work in a very weak health system with an almost non existent MoH. for example, if NGO X decided to start up a nutrition program in a remote province of country Y with no other actors, poor health worker to population ratios etc, with a cost recovery system. If then a daily nutrition component was added to health facilities, what would be the effect on the existing health system and would it be able to cope? How would this affect the program? does anyone have experience with CMAM in very weak health systems?

Dear Anonymous 1342, just wondering, is it really feasible to have only OPT in a CMAM program. well, I think this is largely going to depend on your coverage, objective of setting up such and severity of cases you register per day. Some cases just need 24hr attention. How about setting up a SC and setting up tight inclusion criteria to cater for the severe cases.....just thinking aloud. I believe this NGO can find it with in its means to set up a modest system amidst broken health systems. you know they exist every where. Good luck.

sorry maybe i was not very clear, it is a full CMAM programme but i narrowed it down to the OTP because my question was in line with the original question - daily OTP vs once a week OTP. would it be worth starting with once a week OTP then scale up to more days a week while monitoring whether the system will handle? I saw a lessons-learned paper from one of the NGOs which is running CMAM integrated into primary health care and part of what they flagged as a possible problem was rapid scale up worsening an already weak health system.

Hi, this depends on the expected caseload and the status of the health system. As it seems there are no many resources then the best approach is to integrate it fully in the health facility and have the patients treated as any other one with weekly visit day tailored to the constrains of each beneficiary and to the ones of the health center (to avoid that they come on the busiest days). This has proved to work in very poor level health system as in karamoja area of Uganda or north eastern kenya. On the other hand if the attendance expected is very low, then the nurse can decide that it is better having them all at once. What matters is to listen to both the nurses and the benficiaries to know what they would prefer because without listening to the nurse, the risk is that he or she does not adhere and it will fail eventually, and without listening to the beneficiaries the risk is to have high defaulting. So try to find a compromise.

From Huba Chanda: i think in weak health system daily OTP may be the right decesion for strengthening the capacity of MoH staff as well as timely treatment of the cases.