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

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.