Scaling up integrated community case management (iCCM) to improve child health in local communities in Ethiopia, presentation at the 2015 American Public Health Association (APHA) conference. The Ethiopia Last 10 Kilometers project is implemented by JSI Research & Training Institute, Inc., and funded by Bill & Melinda Gates Foundation.

1. Common Childhood Illnesses Health-Seeking
Behavior and Treatment Practices after the
implementation of iCCM by HEWs in Ethiopia
JSI Research & Training Institute, Inc./The Last Ten Kilometers
Project Experience
November 10, 2015
Bizuhan Gelaw
CBNC/ICCM Project Coordinator

2. Background
• Ethiopia has taken robust measures
towards achieving MDG 4—i.e., reducing
mortality among children under-five years
of age.
• Ethiopia’s flagship Health Extension
Program (HEP), which is an integral part of
the primary health care unit (PHCU), was
launched in 2004.
• The HEP established one health post and
deployed two female health extension
workers (HEWs) to provide basic
promotive, preventive, and curative health
services for every 5,000 rural community
members.

3. Background
• Because of the demand of curative
service for pneumonia at
community level, in 2010:
– The Federal Ministry of Health
endorsed a policy breakthrough
to the introduction of
community-based pneumonia
treatment by HEWs,
– Which facilitated scaling-up of
the integrated Community Case
Management (iCCM) of common
childhood illnesses.

4. iCCM Overview
Project: JSI Research & Training Institute, Inc./The Last Ten
Kilometers Project has supported the scale-up of iCCM in more
than 200 districts in the four most populous regions between
2011-2014.
Currently consolidating the iCCM support in 167 woredas/
districts in the Community-Based Newborn Care Project
platform.
Funding: UNICEF and USAID

5. From 115 Districts to over 200 Districts
56 iCCM districts
overlap with BMGF
districts

6. Scaling-up Integrated Community Case Management
• L10K has supported the FMOH since 2011 in the design, launch and
implementation of ICCM
• Based on the National Implementation ICCM Plan, L10K supported 201
woredas primarily through:
− Regional /Zonal ToTs, training HEWs, their supervisors, and woreda
focal people in ICCM
− Ensuring availability of supplies and logistics
− Start-up follow-up visits to all HPs with in 4-6 weeks of ICCM
training & regular supportive supervision of HP and HCs
− Performance Review and Clinical Mentoring Meeting and refresher
training
– Generate demand to improve care-seeking
– Training of health workers in IMNCI and ICCM supervisory skill

7. Scaling-up Integrated Community Case Management
By December 2014, L10K had:
• Trained 9,524 HEWs in ICCM
• Launched ICCM in 4,669 health posts
• Trained 1,190 health workers in IMNCI

8. Trends in prevalence (%) of common childhood illnesses
December 2008–January 2009,
December 2010–January 2011, and
December 2014–January 2015
10
23
4
23
7
16
2
13
6
13
2
10
0
5
10
15
20
25
Prevalence of ARI Prevalence of
diarrhea
Prevalence of
blood diarrhea
Prevalence of
fever
Round I Round II Round III

9. ARI and diarrhea care seeking practice (%) in
round II & III household surveys
35
27
44
28
3
68
52 51
34
13
0
10
20
30
40
50
60
70
80
ARI care seeking ARI Rx with
antibiotics
Diarrhea care
seeking
Diarrhea cases Rx
with ORS
Diarrhoe cases Rx
with zinc
2011 2015

10. Findings summary
• Use of health posts for treatment of common
childhood illnesses has been significantly improved
(P-value<0.05), but still needs a supply and demand
side strategy to increase utilization at HP level
• The improvement in care-seeking behaviors for ARI,
diarrhea, and fever can be attributable to the iCCM
strategy the HEP adopted in 2010 and expanded in
2011
• L10K has significantly contributed to iCCM scale-up
in the country

11. Under-five cases seen and treated over 12 months
(data collected from iCCM registers )
365,834sick under-five children
were seen in 4,669health posts
Pneumonia
21%
Diarrhea
30%
Other
49%

12. Quality of iCCM case management by HPs for the three
common childhood illnesses; July 2013 – December 2014
Case
classification
Correct
classification
Correct treatment
(DSD)
Correct follow-up
Pneumonia
# of HPs Percent # of HPs Percent # of HPs Percent
770 85 738 82 716 80
Diarrhea 828 89 683 75 665 73
Malaria 371 95 320 83 324 84
Total 1,969 88 1,741 79 1,705 78

13. Community-Based Newborn Care (CBNC) on iCCM platform
Funded by UNICEF and USAID, L10K began supporting the FMOH in
the design, launch, and scale up of CBNC (since Oct 2013) in the
strong iCCM platform
– L10K is supporting the implementation of CBNC in 17 zones:
• 167 woredas
• 3,992 health posts (7,528 HEWs), and
• 777 health centers

14. – Based on national implementation guidelines, major
activities supported include:
– Building skills of HEWs to provide care including management of
newborn sepsis by Gentamycin injection and Amox DT
– IMNCI &CBNC/iCCM supervisory skill training for HC& WorHO staffs
– Start-up and regular follow up visits to HPs and HCs and PRCCM
– BEmONC and CBNC training for HWs for improved MNH services
– Supporting HEWs to improve demand generation activities though
CBDDM
Community-Based Newborn Care (CBNC) on iCCM platform

15. Percentage of sick young (birth-2 months) infant cases identified:
333 HPs over average of 9 months (total cases = 787)
26%
25%
43%
6%
VSD
LBI
Diarhea
other
46% of very
severe diseases/
neonatal sepsis
treated at health
post level

16. Newborn and Child Health Challenges
 Attrition of HEWs and trained health center staff
 Low service utilization for iCCM, and CBNC
 Cultural barriers especially for seeking newborn care services
 Quality of service
 Health center for IMNCI and other MNCH services (skills and
equip/supply)
 Referral linkages across the PHCU
 Sub-optimal supply chain management-shortage and interruption of supply
of essential commodities
 Zinc short shelf-life
 Ownership and suitability issues - irregularity of supportive supervision by
the government staff

17. Thank you!