Nationwide implementation of integrated community case management of childhood illness in Rwanda.

Corine Karema,Fidele Ngabo,Erick Gaju,Hannah C Cockrell,Adam C Levine,Justin Glavis-Bloom,Richard M Munyaneza,Catherine Mugeni,Cameron T Nutt,Alphonse Rukundo,Agnes Binagwaho,Epiphanie Mulindahabi,Claire M Wagner,Jean Pierre Habimana

doi:10.9745/ghsp-d-14-00080

Abstract

Between 2008 and 2011, Rwanda introduced integrated community case management (iCCM) of childhood illness nationwide. Community health workers in each of Rwanda's nearly 15,000 villages were trained in iCCM and equipped for empirical diagnosis and treatment of pneumonia, diarrhea, and malaria; for malnutrition surveillance; and for comprehensive reporting and referral services. We used data from the Rwanda health management information system (HMIS) to calculate monthly all-cause under-5 mortality rates, health facility use rates, and community-based treatment rates for childhood illness in each district. We then compared a 3-month baseline period prior to iCCM implementation with a seasonally matched comparison period 1 year after iCCM implementation. Finally, we compared the actual changes in all-cause child mortality and health facility use over this time period with the changes that would have been expected based on baseline trends in Rwanda. The number of children receiving community-based treatment for diarrhea and pneumonia increased significantly in the 1-year period after iCCM implementation, from 0.83 cases/1,000 child-months to 3.80 cases/1,000 child-months (P = .01) and 0.25 cases/1,000 child-months to 5.28 cases/1,000 child-months (P<.001), respectively. On average, total under-5 mortality rates declined significantly by 38% (P<.001), and health facility use declined significantly by 15% (P = .006). These decreases were significantly greater than would have been expected based on baseline trends. This is the first study to demonstrate decreases in both child mortality and health facility use after implementing iCCM of childhood illness at a national level. While our study design does not allow for direct attribution of these changes to implementation of iCCM, these results are in line with those of prior studies conducted at the sub-national level in other low-income countries.

Highlights

I n the mid-1990s, the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) launched an Integrated Management of Childhood Illness (IMCI) strategy to reduce child deaths from pneumonia, diarrhea, measles, malaria, and malnutrition.[1]
WHO and UNICEF estimate that timely diagnosis and provision of basic curative services for these diseases could reduce pneumonia deaths by 70%, diarrhea deaths by 70%–90%, and malaria deaths by 40%–60%
The community-based data were derived from monthly community health worker (CHW) reports, which include the number of non-health facility child deaths in each village and the number of children treated for pneumonia, diarrhea, and malaria by CHWs

Summary

Introduction

I n the mid-1990s, the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) launched an Integrated Management of Childhood Illness (IMCI) strategy to reduce child deaths from pneumonia, diarrhea, measles, malaria, and malnutrition.[1] The strategy focused on improving case management skills of health care providers, overall health systems, and family and community health practices. IMCI strategy and stressed the importance of community-based case management to further reduce under-5 mortality.[2] A joint statement by WHO and UNICEF acknowledged that, by providing community-based case management of childhood illnesses, trained community health workers (CHWs) could improve child survival rates.[3]. Community health workers in each of Rwanda’s nearly 15,000 villages were trained in iCCM and equipped for empirical diagnosis and treatment of pneumonia, diarrhea, and malaria; for malnutrition surveillance; and for comprehensive reporting and referral services

Methods

Results

Conclusion