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Field Article
Figure 4: Quarterly distribution of RUTF to TFP from 2008-
mid 2011, in metric tons. (Source: UNICEF)
metric tons
1800
1600
1400
1200
1000
800
600
400
200
0
4,500
4,000
3,500
3,000
2,500
2,000
1,500
1,000
500
0
2008 2009 2010 2011
Quarter 1 Quarter 2 Quarter 3 Quarter 4
Figure 5: Source and amount (MT) of RUTF for TFP in
Ethiopia (2008-2010)
metric tons
80%
70%
60%
50%
40%
30%
20%
10%
0%
2008 2009 2010
Local RUTF (MT) Offshore RUTF (MT) Local%
Figure 6: Delivery flow chart of RUTF for TFP/CMAM /TFP in
Ethiopia
UNICEF bonded warehouse
RHB Warehouse
ZHD Warehouse
WoHO Warehouse
Health Facilities (health posts,
health centres and hospitals
NGO imported
RUTF
NGO warehouse/
transport assistance
RHB: Regional Health Bureau, ZHD: Zonal Health Department, WoHO:
Woreda Health Office
procurer and distributor of RUTF for most organisations
to facilitate the importation processes. UNICEF
procured and distributed a total of 11,472 metric tons
of RUTF between January 2008 and September 2011 15 .
Small scale local production of RUTF was piloted
from 2004/5 by Concern and Valid Nutrition, using a
small scale local producer and locally produced raw
materials, except for the Dried Skimmed Milk (DSM)
and mineral/vitamin mix which had to be imported.
However, these pilots were unsuccessful as it proved
difficult to ensure the quality of the product using
small-scale producers.
Success factors for local production
In early 2007, larger-scale production was established
following an initial investment from a US-based
philanthropist (donating over 300,000 USD, to be
repaid back to UNICEF through in-kind contribution
by the local manufacturer once the production was up
and running). Through the use of Nutriset’s franchise
network (plumpyfield), a local company HILINA
received the transfer of technology and skills from
Nutriset that enabled local production of RUTF, of a
quality that passed the expected standards of both
Médecins Sans Frontières (MSF) and UNICEF.
While the local producer was gradually scaling-up
production, it was not enough to meet the
needs of the expanded TFP during nutrition
stress years (such as 2008). A large amount
of RUTF still needed to be imported,
although the proportion supplied by local
production is encouraging.
Between January 2008 and June 2011,
approximately 39.3 million USD had been
invested in the procurement of RUTF. This
cost does not include the freight and distribution
expenses. RUTF remains the most
expensive component of the TFP; a cost
analysis is currently being undertaken
(together with the CMAM evaluation),
which is expected to provide more information
of the costing associated with the TFP in
Ethiopia.
Challenges with local production
The local producer continues to procure all
peanuts and oil from the local market, which
positively contributes to the local economy
and livelihoods of farmers. However, sometimes
the quality of the RUTF has been
compromised, with unacceptably high
levels of aflatoxin contamination from poor
handling and storage of peanuts. The local
producer has taken several steps to ensure
that levels of aflatoxin stay within acceptable
recommendations. UNICEF has also
instituted a system of testing each and every
batch of RUTF for contamination. This has
resulted in a two week lead time after
completion of the production until aflatoxin
test results are received from an independent
laboratory in the UK. These efforts by
the producer to improve the quality of the
locally sourced raw materials have been
showing results. Over the past 12 months,
only one batch of RUTF has failed to comply
with acceptable levels of aflatoxin in the
final product.
Distribution systems and structures for
RUTF
The in-country distribution of RUTF uses
various routes to reach the health facilities.
The bulky nature of the RUTF in both
volume and weight that is required to ‘cure’
each severely malnourished child is considerably
larger than the drug supplies usually
needed for routine treatment of other lifethreatening
conditions. As a result,
pre-positioning several months worth of
RUTF supplies has often been beyond the
warehousing capacity of the health system.
Additionally, the seasonal and sometimes
drought-related rapid increases in admissions
to the TFP, intensifies the pressure on
the health service logistic system for ensuring
timely deliveries of large volumes of
RUTF.
The FMoH uses the Pharmaceutical Fund
and Supplies Agency (PFSA) logistic system
for most medicines and supplies used
within the health system. As described,
RUTF is a bulky and heavy product, which
has meant that it is beyond the current
capacity of the PFSA system to handle distribution
and storage. As a result, UNICEF and
partners have been required to deliver the
RUTF through the RHBs and ZHDs, indicated
in Figure 6.
UNICEF has distributed an average of
approximately 2,800 metric tons of RUTF
per year since 2008 to health facilities across
Ethiopia. 16 Mostly it is delivered directly to
the RHB warehouses although in times of
emergency, UNICEF sometimes delivers to
the zonal level or direct to woredas (dotted
lines in Figure 6), to minimise the risk of
damaging stock-outs. Re-supplying of the
RUTF is based on official requests from the
RHBs using the TFP reporting system, with
re-supply levels based on the monthly
reported caseloads.
Major successes of the RUTF supply
and distribution system
The system has enabled rapid expansion of
CMAM capacity to over 7,000 health posts.
It is flexible and able to respond to emergency
needs. Performance is strongly related
to the technical persons implementing the
programme, as they take the lead in requisitioning
and distributing the RUTF. NGOs
can access the RUTF from ZHDs or RHBs
and support its delivery to health post level.
UNICEF acting as the central procurement
channel has considerably eased the burden
on partners for importation and customs
clearance
Major challenges of the RUTF supply
and distribution system
The limited warehousing capacity of the
regional and zonal health offices can sometimes
affect the quantity of RUTF that can be
delivered and stored safely. Late requests
and inadequate forecasting of projected
consumption compromise programming.
Some misuse/ leakage of RUTF by clients
has been reported (selling and sharing),
using for moderately malnourished children
and at times, adults. Some duplication can
occur between partners, e.g. UNICEF, the
Food By Prescription programme (FBP) and
GOAL, creating difficulties for some facilities
to track records of clients versus
commodities. Coordination meetings have
been established to assist with reducing
duplication.
CMAM transition in emergencies and
development
Management of SAM has traditionally been
considered an emergency response, often
implemented by NGOs. In the context of
chronic food insecurity and seasonal hunger,
programmes open based on emergency
thresholds of SAM and GAM rates and then
close as the situation improves, only to
reopen in the next hunger season. The implications
of this traditional emergency focus of
CMAM include irregular and short-lived
funding, inadequate resources for capacity
building of the health system and delays in
the emergency response. These delays have
mostly been linked with the time needed to
identify the affected woredas and conduct
nutrition surveys, in order to justify the poor
situation and hence access emergency funding
from the various donors. This paradigm
has resulted in additional costs of repeatedly
phasing in and phasing out of programmes
for the management of acute malnutrition in
chronically affected woredas. The timeliness
and adequacy of RUTF provision can be
hostage to the declaration of emergency situations
and resulting donor pledges. Hence
there is a need for improved funding mech-
16
This is equivalent to over 217,000 cartons or over 32.5
million sachets per year
19