Independent Prospective Evaluation of Integrated Community Case Management and Development and Implementation of a Method for Real-time Mortality Monitoring in the Oromia Region, Ethiopia

STUDY BACKGROUND AND RATIONAL Most low-income countries are making slow progress in addressing childhood mortality - too slow to achieve the fourth Millennium Development Goal by 2015. Countries, donors and development agencies are responding to the situation by redoubling efforts to stimulate and support child survival activities in countries, particularly in Africa. The Catalytic Initiative to Save a Million Lives (CI) is a partnership between donor agencies committed to accelerate progress toward MDGs 4 and 5 through support of scale-up of proven high impact interventions. UNICEF and the Canadian International Development Agency (CIDA), as part of the CI, are undertaking a major initiative to reduce mortality among children less than five years of age in several countries in sub-Saharan Africa, including Ethiopia.

Ethiopia has a high under-five mortality rate, estimated at 123 per 1000 live births by the 2005 Demographic and Health Survey. The country has made a commitment to achieve the MDG 4 target of a two-thirds reduction in mortality by 2015 as reflected through the launching of the national Health Extension Program (HEP) in 2004, with continued support from UNICEF and CI funding. The key program strategy is to train and support approximately 30,000 Health Extension Workers (HEWs) to provide promotive, preventive, and selected curative health care services at the community level. Previously, the HEWs treated diarrhea with ORS and malaria with rapid diagnostic kits and ACTs; pneumonia cases were referred to health centers.

Ethiopia has recently adopted a policy to expand management of pneumonia among children under-five with antibiotics to communities through HEWs. This provides a unique opportunity to accelerate increases in coverage of treatment of pneumonia, which is one of the greatest killers of children under-five in Ethiopia. This expansion, when combined with the existing community management of malaria, diarrhea and severe acute malnutrition, is referred to as integrated community case management (HEP+ICCM) and is largely supported through the Catalytic Initiative by CIDA and UNICEF and will focus on its first stage on five regions of the country: Amhara, Benishangul-Gumaz, Oromia, SNNP and Tigray. The leading strategy of the HEP+ICCM initiative is to increase the capacity of the HEWs to effectively assess, classify, and manage the leading causes of preventable child mortality including pneumonia, malaria, diarrhea, and severe acute malnutrition. In the focus regions, plans have been developed to introduce CCM of childhood pneumonia with cotrimoxazole and diarrhea with ORS and zinc, malaria with ACTs, and malnutrition with therapeutic feeding. The program plans to conduct refresher trainings of HEWs and their supervisors, strengthen supervision, logistical support and the ICCM system overall. The initial implementation will start in August 2010 and to be phased in Oromia region.

The effectiveness of the ICCM varies across specific country contexts and depends on the strength of implementation. It is therefore essential to evaluate the effectiveness of the scale-up strategy to provide a basis for future program improvement and global evidence on effective strategies for accelerating reductions in under-five mortality.

OBJECTIVES The Institute for International Programs at the Johns Hopkins University Bloomberg School of Public Health (IIP-JHU) has been commissioned by CIDA and UNICEF to conduct an independent prospective evaluation of the HEP+ICCM.