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

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

Abstract

Background: 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.

Methods: 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.

Results: 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.

Conclusions: 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.

Figures

Figure 1.
Figure 1.
Date of Implementation of Integrated Community Case Management by District, Rwanda
Figure 2.
Figure 2.
Seasonal Average Schematic Applied to Community Mortality Data, Rwanda Abbreviation: iCCM, integrated community case management.
Figure 3.
Figure 3.
Total Under-5 Mortality by District, Rwanda Abbreviation: iCCM, integrated community case management.
Figure 4.
Figure 4.
Total Under-5 Health Facility Use by District, Rwanda Abbreviation: iCCM, integrated community case management.
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4168626/bin/328fig5.jpg
A community health worker draws blood from a child for malaria testing.

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