Effects of the integrated Community Case Management of Childhood Illness Strategy on Child Mortality in Ethiopia: A Cluster Randomized Trial.

Agbessi Amouzou,Nathan P Miller,Yared Mekonnen,Elizabeth Hazel,Mengistu Tafesse,Lawrence H Moulton,Robert E Black,Jennifer Bryce,Bryan Shaw

doi:10.4269/ajtmh.15-0586

Abstract

We conducted a cluster randomized trial of the effects of the integrated community case management of childhood illness (iCCM) strategy on careseeking for and coverage of correct treatment of suspected pneumonia, diarrhea, and malaria, and mortality among children aged 2–59 months in 31 districts of the Oromia region of Ethiopia. We conducted baseline and endline coverage and mortality surveys approximately 2 years apart, and assessed program strength after about 1 year of implementation. Results showed strong iCCM implementation, with iCCM-trained workers providing generally good quality of care. However, few sick children were taken to iCCM providers (average 16 per month). Difference in differences analyses revealed that careseeking for childhood illness was low and similar in both study arms at baseline and endline, and increased only marginally in intervention (22.9–25.7%) and comparison (23.3–29.3%) areas over the study period (P = 0.77). Mortality declined at similar rates in both study arms. Ethiopia's iCCM program did not generate levels of demand and utilization sufficient to achieve significant increases in intervention coverage and a resulting acceleration in reductions in child mortality. This evaluation has allowed Ethiopia to strengthen its strategic approaches to increasing population demand and use of iCCM services.

Highlights

Progress in child survival has been too slow in most lowincome countries to achieve the fourth Millennium Development Goal (MDG4) of reducing mortality among children under five by two-thirds between 1990 and 2015.1,2 Over six million children died in 2013 from preventable causes, largely in low-income countries.[2]
Many countries have adopted a strategy of integrated community case management to tackle the slow and inequitable progress in child survival. iCCM programs train and support community health workers (CHWs) to assess and treat the three major infectious causes of death among children under five: uncomplicated cases of pneumonia with antibiotics, malaria with artemisinin-based combination therapy (ACT), and diarrhea with oral rehydration salts (ORS) and zinc
We report here an evaluation of the iCCM strategy as implemented in Oromia region, Ethiopia, which assessed each step in the impact model outlined above

Summary

Introduction

Progress in child survival has been too slow in most lowincome countries to achieve the fourth Millennium Development Goal (MDG4) of reducing mortality among children under five by two-thirds between 1990 and 2015.1,2 Over six million children died in 2013 from preventable causes, largely in low-income countries.[2] In sub-Saharan Africa, for example, where half of worldwide deaths occurred, neonatal disorders caused a third of these deaths, and pneumonia, diarrhea, and malaria were responsible for 40%.3. Undernutrition is associated with nearly half of the deaths of children under five through its synergistic relationship with infectious diseases.[4] low-cost and proven high-impact preventive and curative interventions exist to reduce neonatal and child deaths rapidly, and can be scaled up to reach high coverage levels through effective delivery strategies. Cases of severe disease seen by these workers are referred to higher

Methods

Results

Conclusion