Background: In 2010, Ethiopia began scaling up the integrated community case management (iCCM) of childhood illness strategy throughout the country allowing health extension workers (HEWs) to treat children in rural health posts. After 2 years of iCCM scale up, utilization of HEWs remains low. Little is known about factors related to the use of health services in this setting. This research aimed to elicit perceptions and experiences of caregivers to better understand reasons for low utilization of iCCM services.Methods: A rapid ethnographic assessment was conducted in eight rural health post catchment areas in two zones: Jimma and West Hararghe. In total, 16 focus group discussions and 78 in-depth interviews were completed with mothers, fathers, HEWs and community health volunteers.Results: In spite of the HEW being a core component of iCCM, we found that the lack of availability of HEWs at the health post was one of the most common barriers to the utilization of iCCM services mentioned by caregivers. Financial and geographic challenges continue to influence caregiver decisions despite extension of free child health services in communities. Acceptability of HEWs was often low due to a perceived lack of sensitivity of HEWs and concerns about medicines given at the health post. Social networks acted both to facilitate and hinder use of HEWs. Many mothers stated a preference for using the health post, but some were unable to do so due to objections or alternative care-seeking preferences of gatekeepers, often mothers-in-law and husbands.Conclusion: Caregivers in Ethiopia face many challenges in using HEWs at the health post, potentially resulting in low demand for iCCM services. Efforts to minimize barriers to care seeking and to improve demand should be incorporated into the iCCM strategy in order to achieve reductions in child mortality and promote equity in access and child health outcomes.

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.

Ethiopia has invested significant resources in integrated community case management (iCCM) of childhood illness. In Oromia Region, iCCM scale-up was phased in, allowing for comparisons between districts providing iCCM and routine services. We assessed the determinants of utilization of health extension workers (HEWs) delivering iCCM services at rural health posts by caregivers of sick, under-five children in a cross-sectional survey. We found low utilization of HEWs with only 9.3% of caregivers of a child sick with diarrhea, fever, and/or pneumonia in the previous 2 weeks taking their child to HEWs in both iCCM and routine areas. There was a higher likelihood of utilization of HEWs in iCCM areas (OR: 1.44; 95% CI: 0.97–2.12; P = 0.07), but this effect disappeared after accounting for confounders. In iCCM areas, maternal education, illness type, and distance were associated with utilization. Perceptions of illness severity and service quality were the primary reasons given for not utilizing the health post. Our findings suggest that though iCCM is reaching some vulnerable populations, there remain significant barriers to use of HEWs delivering iCCM services. Efforts for demand generation and minimization of remaining barriers are urgently needed for the sustained success of the iCCM strategy in Ethiopia.

BackgroundEthiopia has experienced rapid improvements in its healthcare infrastructure, such as through the recent scale up of integrated community case management (iCCM) delivered by community-based health extension workers (HEWs) targeting children under the age of five. Despite notable improvements in child outcomes, the use of HEWs delivering iCCM remains very low. The aim of our study was to explain this phenomenon by examining care-seeking practices and treatment for sick children in two rural districts in the Oromia Region of Ethiopia.MethodsUsing qualitative methods, we explored perceptions of child illness, influences on decision-making processes occurring over the course of a child’s illness and caregiver perceptions of available community-based sources of child illness care. Sixteen focus group discussions (FGDs) and 40 in-depth interviews (IDIs) were held with mothers of children under age five. For additional perspective, 16 IDIs were conducted fathers and 22 IDIs with health extension workers and community health volunteers.ResultsCaregivers often described the act of care-seeking for a sick child as a time of considerable uncertainty. In particular, mothers of sick children described the cultural, social and community-based resources available to minimize this uncertainty as well as constraints and strategies for accessing these resources in order to receive treatment for a sick child. The level of trust and familiarity were the most common dynamics noted as influencing care-seeking strategies; trust in biomedical and government providers was often low.ConclusionsOverall, our research highlights the multiple and dynamic influences on care-seeking for sick children in rural Ethiopia. An understanding of these influences is critical for the success of existing and future health interventions and continued improvement of child health in Ethiopia.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-017-2123-5) contains supplementary material, which is available to authorized users.

No abstract