Integrated Community Case Management of Childhood Illness in Ethiopia: Implementation Strength and Quality of Care

Problem statement: Ethiopia has scaled-up integrated community case management of childhood illness (iCCM). This study assessed iCCM implementation strength and quality of care provided by Health Extension Workers (HEWs). Methods: A survey of 150 health posts, 201 HEWs and 257 sick children. Data collection consisted of direct observation of consultations with sick children; caretaker exit interviews; gold standard re-examinations; examinations of commodities; register reviews; and HEW interviews. Paper 1 presents estimates of iCCM implementation strength and quality of care. Paper 2 assesses methods of recruitment of sick children for assessment of quality of care, assesses the validity of register review (RR) and direct observation only (DO) compared to direct observation with re-examination (DO with RE) for assessing quality of care; and assesses the impact of observation on HEW performance. Paper 3 uses multivariate logistic regression to assess associations between quality of care and program interventions. Results: Paper 1: Implementation of iCCM was strong. Most children (64%) were correctly managed. However, just 34% of children with severe illness were correctly managed. Intervention health posts had an average of only 16 sick child consultations in the previous month. Paper 2: Mobilization and recruitment of sick children were feasible and productive methods of obtaining a sample of sick children. Compared to DO with RE, RR and DO produced estimates of quality of care with mostly fair or moderate agreement. The differences between estimates of correct care for observed versus not observed children were small. Paper 3: Performance Review and Clinical Mentoring meetings, follow-up training and number of drugs available were significantly positively associated with quality of care, but supervision, clinical instruction at health centers and availability of supplies were not. Conclusions: The Ethiopia iCCM program has been implemented well and HEWs are providing high quality care. However, low utilization of services will limit the impact of iCCM. Methodological lessons from this study include: 1) sick children can be mobilized or recruited in communities for observation, 2) RR and DO are reasonable, if imperfect, alternatives to DO with RE and 3) observation may not have a large effect on CHW performance