On Bathwater, Babies, and Designing Programs for Impact: Evaluations of the Integrated Community Case Management Strategy in Burkina Faso, Ethiopia, and Malawi

The adage “don’t throw the baby out with the bathwater” advises us not to discard the essential along with the unessential, whether due to impatience or frustration. 1 This issue of the journal includes reports on prospective evaluations of the integrated community case management (iCCM) of childhood illness strategy in Burkina Faso, 2 Ethiopia, 3 and Malawi. 4 iCCM seeks to reduce child mortality by making effective treatment of pneumonia, diarrhea, and malaria available from trained health workers at community level. 5 In this commentary, we show results from the three countries, highlighting hard-won lessons about iCCM’s potential to prevent unnecessary deaths among children. The independent iCCM evaluations were designed in 2009– 2010, as a part of the Catalytic Initiative to Save a Million Lives 6 spearheaded by Canada and involving the Bill & Melinda Gates Foundation, the U.K. Department for International Development, the United Nations Children’s Fund, the World Health Organization, the Doris Duke Charitable Foundation, and others. The goal of the Catalytic Initiative was to support and measure the impact of strong, coordinated efforts to deliver high-impact interventions to reduce under-five mortality in low-income, high-burden countries, with a particular focus on providing treatment for childhood pneumonia, diarrhea, and malaria at community level using iCCM. The evaluation in each setting was conducted in collaboration with local research institutions, based on a locally adapted version of the common evaluation framework for maternal, newborn, and child health (MNCH). 7 The evaluation designs were built on impact models reflecting the pathway to child survival. Beginning with policy and program inputs, the pathway moves to project implementation and intermediate outputs such as improved provision of quality services, strengthened health systems, and increased utilization. Continuing to coverage and behavioral outcomes, the pathway culminates in impact of under-five and postneonatal mortality. We focus on mortality among children aged 2–59 months here, because the iCCM strategy did not include guidelines for children under 2 months of age. Detailed methods are described in the individual papers; Table 1 provides a summary. All sites documented program inputs and contextual factors that may have affected program implementation or effectiveness. The evaluation teams shared intermediate and final results with governments and partners as a basis for strengthening iCCM implementation. Selected results across the three countries are shown in Table 2. We reanalyzed some variables to maximize comparability across countries; in some instances, results presented here are not included in the series papers. iCCM was not associated with accelerated mortality declines in children aged 2–59 months during the 2- to 4-year evaluation periods in these three settings. The reasons for this lack of association likely varied across settings, as does the likelihood that these programs may achieve measureable impact after additional years of sustained implementation. In Burkina Faso, iCCM implementation did not reflect current best practice for designing and implementing effective MNCH programs. The program relied on community health worker (CHW) lay volunteers. The initial training was organized as a “cascade” in which representatives from districts were trained and then requested to organize subdistrict-level training sessions to train over 3,000 CHWs in the space of a few months, with minimal support or supervision. The training included written materials even though many of the CHWs