The Effects of an Integrated Community Case Management Strategy on the Appropriate Treatment of Children and Child Mortality in Kono District, Sierra Leone: A Program Evaluation

Abstract

Abstract.Integrated community case management (iCCM) aims to reduce child mortality in areas with poor access to health care. iCCM was implemented in 2009 in Kono district, Sierra Leone, a postconflict area with high under-five mortality rates (U5MRs). We evaluated iCCM’s impact and effects on child health using cluster surveys in 2010 (midterm) and 2013 (endline) to compare indicators on child mortality, coverage of appropriate treatment, timely access to care, quality of care, and recognition of community health workers (CHWs). The sample size was powered to detect a 28% decline in U5MR. Clusters were selected proportional to population size. All households were sampled to measure mortality and systematic random sampling was used to measure coverage in a subset of households. We used program data to evaluate utilization and access; 5,257 (2010) and 3,649 (2013) households were surveyed. U5MR did not change significantly (4.54 [95% confidence interval [CI]: 3.47–5.60] to 3.95 [95% CI: 3.06–4.83] deaths per 1,000 per month (P = 0.4)) though a relative change smaller than 28% could not be detected. CHWs were the first source of care for 52% (2010) and 50.9% (2013) of children. Coverage of appropriate treatment of fever by CHWs or peripheral health units increased from 45.5% [95% CI: 39.2–52.0] to 58.2% [95% CI: 50.5–65.5] (P = 0.01); changes for diarrhea and pneumonia were not significant. The continued reliance on the CHW as the first source of care and improved coverage for the appropriate treatment of fever support iCCM’s role in Kono district.

Health system strengthening—Reflections on its meaning, assessment, and our state of knowledge

“…Existing evidence is suggestive of positive effects on service access and coverage, and health outcomes (focusing principally on infant and child mortality and morbidity, and maternal health) . Successful programmes tend to blend community health worker (CHWs)‐based models with strong referral systems and provision of first‐level care to improve access Service integration interventions usually span multiple building blocks, but primarily at mesolevel or microlevel.…”

“…10,37 Successful programmes tend to blend community health worker (CHWs)-based models with strong referral systems and provision of first-level care to improve access. 38,39 • Service integration interventions usually span multiple building blocks, but primarily at mesolevel or microlevel.…”

Integrated Community Case Management Utilization Status and Associated Factors Among Caretakers of Sick Children Under the Age of 5 Years in West Shewa, Ethiopia

“…There is evidence that ICCM has improved access to appropriate case management, which leads to earlier treatment, fewer severe cases, improved recovery, fewer referrals, and a reduced burden on health service deliveries (4). Similarly, studies have shown that ICCM can increase coverage of appropriate treatment for childhood illnesses among the poor and can lead to substantial reductions in child mortality (7)(8)(9)(10).…”

Using routine health information data for research in low- and middle-income countries: a systematic review

“…However, population-based surveys also have drawbacks, including the fact that they may be costly [26] and are often unable to generate sufficient data at the district or other subnational-levels [27]. In addition, reliance on such data may encourage the use of potentially weak evaluation designs [8] and may make establishing an appropriate baseline challenging when trying to evaluate specific programs [28]. Intermittent cross-sectional population-based surveys themselves also suffer from a number of quality concerns and thus should not be considered the gold standard for estimating service coverage or other population-based estimates [29].…”