Volume 94, Issue 3
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645



We conducted a cluster randomized trial of the effects of the integrated community case management of childhood illness (iCCM) strategy on careseeking for and coverage of correct treatment of suspected pneumonia, diarrhea, and malaria, and mortality among children aged 2–59 months in 31 districts of the Oromia region of Ethiopia. We conducted baseline and endline coverage and mortality surveys approximately 2 years apart, and assessed program strength after about 1 year of implementation. Results showed strong iCCM implementation, with iCCM-trained workers providing generally good quality of care. However, few sick children were taken to iCCM providers (average 16 per month). Difference in differences analyses revealed that careseeking for childhood illness was low and similar in both study arms at baseline and endline, and increased only marginally in intervention (22.9–25.7%) and comparison (23.3–29.3%) areas over the study period ( = 0.77). Mortality declined at similar rates in both study arms. Ethiopia's iCCM program did not generate levels of demand and utilization sufficient to achieve significant increases in intervention coverage and a resulting acceleration in reductions in child mortality. This evaluation has allowed Ethiopia to strengthen its strategic approaches to increasing population demand and use of iCCM services.

[open-access] This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Article metrics loading...

The graphs shown below represent data from March 2017
Loading full text...

Full text loading...



  1. Requejo JH, Bryce J, Barros AJD, Berman P, Bhutta Z, Chopra M, Daelmans B, de Francisco A, Lawn JE, Maliqi B, Mason E, Newby H, Presern C, Starrs A, Victora CG, , 2015. Countdown to 2015 and beyond: fulfilling the health agenda for women and children. Lancet 385: 466476.[Crossref] [Google Scholar]
  2. UN Inter-agency Group for Child Mortality Estimation, 2014. Levels and Trends in Child Mortality: 2014 Report. New York, NY: UNICEF. [Google Scholar]
  3. Liu L, Oza S, Hogan D, Perin J, Rudan I, Lawn JE, Cousens S, Mathers C, Black RE, , 2015. Global, regional, and national causes of child mortality in 2000–13, with projections to inform post-2015 priorities: an updated systematic analysis. Lancet 385: 430440.[Crossref] [Google Scholar]
  4. Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, de Onis M, Ezzati M, Grantham-McGregor S, Katz J, Martorell R, Uauy R, the Maternal and Child Nutrition Study Group; , 2013. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet 382: 427452.[Crossref] [Google Scholar]
  5. Bhutta ZA, Das JK, Bahl R, Lawn JE, Salam RA, Paul VK, Sankar MJ, Blencowe H, Rizvi A, Chou VB, Walker N, the Lancet Newborn Interventions Review Group; the Lancet Every Newborn Study Group; , 2014. Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost? Lancet 384: 347370.[Crossref] [Google Scholar]
  6. Jones G, Steketee R, Black R, Bhutta Z, Morris S, the Bellagio Child Survival Study Group; , 2003. How many child deaths can we prevent this year? Lancet 362: 6571.[Crossref] [Google Scholar]
  7. Bryce J, el Arifeen S, Pariyo G, Lanata C, Gwatkin D, Habicht JP, Multi-Country Evaluation of IMCI Study Group; , 2003. Reducing child mortality: can public health deliver? Lancet 362: 159164.[Crossref] [Google Scholar]
  8. Lawn JL, Blencowe H, Oza S, You D, Lee ACC, Waiswa P, Lalli M, Bhutta ZA, Barros AJD, Christian P, Mathers C, Cousens S, the Lancet Every Newborn study group; , 2014. Every newborn: progress, priorities, and potential beyond survival. Lancet 384: 189205.[Crossref] [Google Scholar]
  9. World Health Organization, United Nation Children's Fund, 2012. Integrated Community Case Management (iCCM). Geneva, Switzerland: WHO and UNICEF. [Google Scholar]
  10. Chopra M, Sharkey A, Dalmiya N, Anthony D, Binkin N, on behalf of the UNICEF Equity in Child Survival, Health, and Nutrition Analysis Team; , 2012. Strategies to improve health coverage and narrow the equity gap in child survival, health, and nutrition. Lancet 380: 13311340.[Crossref] [Google Scholar]
  11. Mukanga D, Babirye R, Peterson S, Pariyo GW, Ojiambo G, Tibenderana JK, Nsubuga P, Kallander K, , 2011. Can lay community health workers be trained to use diagnostics to distinguish and treat malaria and pneumonia in children? Lessons from rural Uganda. Trop Med Int Health 16: 12341242.[Crossref] [Google Scholar]
  12. Yeboah-Antwi K, Pilingana P, Macleod WB, Semrau K, Siazeele K, Kalesha P, Hamainza B, Seidenberg P, Mazimba A, Sabin L, Kamholz K, Thea DM, Hamer DH, , 2010. Community case management of fever due to malaria and pneumonia in children under five in Zambia: a cluster randomized controlled trial. PLoS Med 7: e1000340.[Crossref] [Google Scholar]
  13. Bari A, Sadruddin S, Khan A, Khan IU, Khan A, Lehri IA, Macleod WB, Fox MP, Thea DM, Qazi SA, , 2011. Community case management of severe pneumonia with oral amoxicillin in children aged 2–59 months in Haripur district, Pakistan: a cluster randomised trial. Lancet 378: 17961803.[Crossref] [Google Scholar]
  14. Miller NP, Amouzou A, Hazel E, Victora CG, Black RE, Bryce J, , 2014. Integrated Community Case Management of childhood illness in Ethiopia: implementation strength and quality of care. Am J Trop Med Hyg 91: 424434.[Crossref] [Google Scholar]
  15. Gilroy KE, Callaghan-Koru JA, Cardemil CV, Nsona H, Amouzou A, Mtimuni A, Daelmans B, Mgalula L, Bryce J, CCM-Malawi Quality of Care Working Group; , 2013. Quality of sick child care delivered by health surveillance assistants in Malawi. Health Policy Plan 28: 573585.[Crossref] [Google Scholar]
  16. Bryce J, Victora CG, Habicht JP, Vaughan JP, Black RE, , 2004. The multi-country evaluation of the integrated management of childhood illness strategy: lessons for the evaluation of public health interventions. Am J Public Health 94: 406415.[Crossref] [Google Scholar]
  17. Bryce J, Victora CG, , 2005. Ten methodological lessons from the multi-country evaluation of the Integrated Management of Childhood Illness. Health Policy Plan 20 (Suppl 1): i94i105.[Crossref] [Google Scholar]
  18. Bryce J, Victora CG, Boerma T, Petersa DH, Black RE, , 2011. Evaluating the scale-up for maternal and child survival: a common framework. Int Health 3: 139146.[Crossref] [Google Scholar]
  19. Central Statistical Agency of Ethiopia, ICF International, 2012. Ethiopia Demographic and Health Survey 2011. Addis Ababa, Ethiopia, and Calverton, MD: Central Statistical Agency and ICF International. [Google Scholar]
  20. Central Statistical Agency of Ethiopia, ORC Macro, 2006. Ethiopia Demographic and Health Survey 2005. Addis Ababa, Ethiopia, and Calverton, MD: Central Statistical Agency and ORC Macro. [Google Scholar]
  21. HEPCAPS1 Project Team, 2012. Ethiopia's Health Extension Platform: A Background Paper Prepared for the HEPCAPS1 Project. Ethiopia HEPCAPS1 Series Paper no. 1. Boston, MA and New Haven, CT: Harvard School of Public Health and Yale Global Health Leadership Institute. [Google Scholar]
  22. Ministry of Health, 2010. Health Sector Development Program IV: 2010/11–2014/15. Addis Ababa, Ethiopia: Ministry of Health. [Google Scholar]
  23. Ministry of Health, 2012. Health Sector Development Program IV: Annual Performance Report, 2011/12. Version 1. Addis Ababa, Ethiopia: Ministry of Health. [Google Scholar]
  24. Countdown to 2015, 2008. Tracking Program in Maternal, Newborn and Child Survival: The 2008 Report. New York, NY: UNICEF. [Google Scholar]
  25. Shaw BC, Amouzou A, Miller NP, Surkan PJ, Tafesse M, Bryce J, , 2015. Access to integrated community case management of childhood illnesses services in rural Ethiopia: a qualitative study of the perspectives and experiences of caregivers. Health Policy Plan, 112015, 111. doi:10.1093/heapol/czv115. [Google Scholar]
  26. Legesse H, Degefie T, Hiluf M, Sime K, Tesfaye C, Abebe H, Kebede H, Pearson L, Kassaye A, Taylor M, , 2014. National scale-up of integrated community case management in rural Ethiopia: implementation and early lessons learned. Ethiop Med J 52 (Suppl 3): 1526. [Google Scholar]
  27. Moulton LH, , 2004. Covariate-based constrained randomization of group-randomized trials. Clin Trials 1: 297305.[Crossref] [Google Scholar]
  28. StataCorp, 2013. Stata: Release 13. College Station, TX: StataCorp LP. [Google Scholar]
  29. Tadesse Y, Eniyew A, Mengistu B, Eniyew A, Marsh DR, , 2014. Utilization of integrated community case management services in three regions in Ethiopia after two years of implementation. Ethiop Med J 52 (Suppl 3): 4755. [Google Scholar]
  30. Admasu K, , 2013. The implementation of the Health Development Army: challenges, perspectives and lessons learned with a focus on Tigray's experience. Policy and Practice: Federal Ministry of Health 5: 37. [Google Scholar]

Data & Media loading...

Supplementary PDF

  • Received : 11 Aug 2015
  • Accepted : 29 Sep 2015
  • Published online : 02 Mar 2016

Most Cited This Month

This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error