141st APHA Annual Meeting and Exposition

In This section

279324
Nationwide implementation of integrated community case management of childhood illness in Rwanda: Impact on mortality and health facility utilization

Monday, November 4, 2013

Adam Levine, MD, MPH , Warren Alpert Medical School, Brown University, Providence, RI
Cathy Mugeni , Ministry of Health of Rwanda, Kigali, Rwanda
Richard B. Mark Munyaneza, MD , Ministry of Health of Rwanda, Kigali, Rwanda
Epiphanie Mulindahabi, MPH , Ministry of Health of Rwanda, Kigali, Rwanda
Hannah Cockrell, BA , Development Studies Program, Watson Institute for International Studies, Brown University, Providence, RI
Justin Glavis-Bloom, BA , Warren Alpert Medical School of Brown University, Providence, RI
Cameron T. Nutt , Dartmouth Center for Health Care Delivery Science, Hanover, NH
Claire M. Wagner , Global Health Delivery Partnership, Boston, MA
Corine Karema , Ministry of Health of Rwanda, Kigali, Rwanda
Erick Gaju, BSc , Ministry of Health of Rwanda, Kigali, Rwanda
Alphonse Rukundo, BSc , Ministry of Health of Rwanda, Kigali, Rwanda
Jean Pierre Habimana, BSc , Ministry of Health of Rwanda, Kigali, Rwanda
Fidele Ngabo , Ministry of Health of Rwanda, Kigali, Rwanda
Agnes Binagwaho , Ministry of Health of Rwanda, Kigali, Rwanda
Background: Between 2008-2011, Rwanda introduced Integrated Community Case Management (iCCM) of childhood illness in all 30 districts nationwide. Community health workers in each village were trained and equipped for empirical diagnosis and treatment of diarrhea, malaria, and pneumonia; comprehensive reporting; and referral services.

Methods: Using health facility and community-based vital registry systems, we estimate the change in population-adjusted under-five mortality and health facility utilization in each district by comparing the three month, pre-iCCM baseline period to a seasonally-matched post-iCCM comparison period. We use estimates of baseline trends for under-five mortality and health facility utilization in Rwanda to control for temporal confounding.

Findings: Total under-five monthly mortality rates declined 40% during the one year following iCCM implementation from 0.48 deaths/1000 child-months to 0.29 deaths/1000 child-months, a decrease of 0.19 deaths/1000 child-months (95% CI: 0.10-0.27, p<.001). Health facility utilization also declined from 4.28 contacts/1000 child-months to 3.62 contacts/1000 child-months, a decrease of 0.66 contacts/1000 child-months (95% CI: 0.15-1.17, p=.013). Decreases were significantly greater than would have been expected due to baseline trends in Rwanda for both under-five mortality (p=.002) and health facility utilization (p=.032).

Interpretation: This is the first study to demonstrate significant decreases in both under-five mortality and health facility utilization with implementation of iCCM at a national level. Decreases in total under-five mortality and health facility utilization are significantly greater than would have been expected due to baseline trends in Rwanda and are in line with the results of prior studies conducted at the district level in other low-income countries.

Learning Areas:
Conduct evaluation related to programs, research, and other areas of practice
Provision of health care to the public
Public health or related research

Learning Objectives:
Analyze the impact of community-based health interventions on child mortality and health facility utilization in a resource-limited setting Explain the impact on under-five mortality and health facility utilization in Rwanda following nationwide implementation of Integrated Community Case Management for diarrhea, malaria, and pneumonia

Keywords: Community-Based Health Care, Developing Countries

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I have been the principal investigator on multiple studies involving the assessment and management of diarrhea and pneumonia in children in resource-limited settings, including research conducted in rural Rwanda.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.