This document summarizes evaluations of integrated community case management (iCCM) programs in Burkina Faso, Ethiopia, and Malawi. It finds that while iCCM implementation strengthened health systems and improved quality of care, overall utilization of iCCM services remained low. Coverage of appropriate treatment for childhood illnesses did not significantly increase in these countries. The evaluations showed progress establishing iCCM services but challenges remained around increasing demand for and access to these services, especially among hard to reach populations. Continued efforts are needed to address all aspects of iCCM from provision to impact in order to fully realize its potential.

1. Evaluations of community health
workers managing childhood illness
Diwakar Mohan
International Institute for Programs
Johns Hopkins Bloomberg School of Public Health

2. Complementary evaluations
Both part of Catalytic Initiative to Save a Million Lives
Aim - Demonstrate achieving rapid gains in coverage for high-impact
interventions (including iCCM) would accelerate declines in child
mortality
• MNCH Rapid Scale-Up in Burkina Faso, Malawi
• Primary grantee – WHO
• Prospective Evaluation of iCCM in Oromia region, Ethiopia
• Primary grantee – UNICEF

3. iCCM implementation
Burkina Faso Ethiopia Malawi
Providers Volunteers (ASBCs);
low literacy; nominal
remuneration
Government cadre (HEWs);
literate; fixed
remuneration
Government cadre (HSAs); literate; fixed
remuneration
Coverage Covering all rural
communities
2 ASCBs per
community
Covering all rural
communities within
project woredas
2 HEW per 5000 population
Targeted “hard to reach” areas
1 HSA: 1000 population
Service provision User fees Free of charge Free of charge
Demand
creation
No deliberate strategy Part of activities but no
standardized approach
Limited community engagement
Dependent on DHO

4. Major implementation challenges
 Recruitment and deployment:
 Illiterate and unpaid volunteers (Burkina Faso)
 HSAs not residing in community and turn over (Malawi)
 CHWs responsible for multiple competing tasks
 Medicines:
 Inadequate forecasting at district level
 Inadequate provision to CHWs
 User-fees (Burkina Faso)
 Supervision and mentorship:
 Irregular , limited case observation
 Supervisors not IMCI trained (Malawi)
 Community engagement: and linkage with health facilities
 Not systematically developed
 Monitoring:
 Incomplete and inconsistent data
 Implementation strength indicators not systematically integrated in HMIS, analysed and used

5. iCCM density
1.3
2.4
1.3
0
0.5
1
1.5
2
2.5
3
iCCMCHWsper1,000under-
fivesEstimated number of iCCM-trained CHWs per 1,000 under-five children
Burkina Faso
2013
Ethiopia
2012
Malawi
2014
% iCCM-CHWs resident in their community?
100% 91% 70%
iCCM strategy
in Malawi is to
deploy to
district-defined
“Hard to Reach
Areas”.

6. iCCM “readiness”
0
20
40
60
80
100
iCCM supervision visits to
CHWs
iCCM supervision/mentoring
with reinforcement of clinical
practice
No stock-outs of essential iCCM
drugs
%ofCHWspracticingiCCM
Burkina Faso Ethiopia Malawi
Proportion of iCCM-active* CHWs reporting that in the three
months before the iCCM implementation strength snapshot:
*In Burkina and Malawi, an iCCM worker who had managed a sick child in the past 3 months; In Ethiopia, a health post where at least one HEW is currently assigned to
provide services to the community, even if the physical health post structure had not been constructed (“functional health post”).

7. iCCM quality of care
0
20
40
60
80
100
Assessed for danger signs Correctly managed for all
iCCM illnesses
Referred if needed
%ofsickchildren
Burkina Faso (2012) Ethiopia (2012) Malawi (2009)
*
Proportion of sick children presenting for care to an iCCM-
trained CHWs who were:
*Reported here only in districts implementing iCCM for pneumonia, for comparability with other countries.

8. Mortality – No change
Ethiopia Malawi

9. Utilization of iCCM - 1
4
16
55
0
10
20
30
40
50
60
MeanNo.ofSickChildrenper
month
Mean number of sick children managed by an iCCM-trained CHW per
month
Burkina Faso
2013
Ethiopia
2012
Malawi
2014

10. Utilization of iCCM – 2
0.23
0.26
0.93
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
Sickchildcontactsperyear
Estimated number of child contacts with an iCCM-trained CHW, per child per year
Burkina Faso
2013
Ethiopia
2012
Malawi
2014

11. iCCM coverage:
Careseeking from any formal providers
0
20
40
60
80
100
Burkina Faso Ethiopia Malawi
%sickchildrentakentoformalprovider
Careseeking for childhood illness from all providers
Burkina Faso Ethiopia Malawi
2010 2013 20132011 2010 2014
iCCM not
associated
with changes
in overall
rates of
careseeking
for childhood
illness.
iCCM intervention
Comparison
.

12. iCCM coverage:
Careseeking from iCCM providers
0
20
40
60
80
100
Burkina Faso Ethiopia Malawi
%sickchildrentakenforcare
Careseeking for childhood illness from CHWs
Burkina Faso Ethiopia Malawi
2010 2013 20132011 2010 2014
Very few
mothers take
their sick child
to an iCCM
provider,
although there
are slight
increases
over time.
iCCM intervention
Comparison

13. iCCM coverage:
Pneumonia treatment with antibiotic
0
20
40
60
80
100
Burkina Faso Ethiopia Malawi
%sickchildrentreated
Treatment (from any source)
Burkina Faso Ethiopia Malawi
2010 2013 20132011 2010 2014
*Reported only in districts implementing iCCM for pneumonia, for comparability with other countries.
*

14. Policy
Impact
Quality
Coverage
Utilization
Provision
iCCM stairway to impact Progress in 3 countries
Burkina Faso Ethiopia Malawi
Synthesis

15. Implications
1. Aim to have all rungs in the iCCM stairway in place
2. iCCM - part of a larger health system continuum of care
3. Rigorous monitoring - Strategic use of data
4. Better understanding needed to address:
 How to increase the use of services (e.g., client perspective,
demand generation)
 Who are the children who are not being reached, and how to
target them
• Regular home visits create better rapport through active and
passive contacts?

16. "If you build it, they will come."
Field of Dreams

17. Thank you