INTEGRATED COMMUNITY CASE MANAGEMENT OF CHILDHOOD ILLNESSES IN THE CONTEXT OF FREE PRIMARY HEALTH CARE IN RURAL SIERRA LEONE: EFFECTS ON CARE SEEKING, TREATMENT AND EQUITY
Yansaneh, Aisha Ibrahim
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Problem statement: Integrated community case management (ICCM) of childhood illnesses by community health workers (CHWs) is an endorsed strategy to reduce child mortality in developing countries. The evidence on the effectiveness of ICCM programs in Sub-Saharan Africa is growing; however, evidence on ICCM in the context of free health care is limited. Methods: The study examined: (1) CHW influences on pre-post changes in care seeking and treatment, analyzed using a difference-in-differences (DID) analysis; (2) factors associated with CHW utilization, analyzed using weighted logistic regression; and (3) ICCM effect on equitable coverage of care seeking and treatment by ethnicity and socioeconomic status, analyzed using comparative and DID analysis. Study districts were purposively selected; 2 intervention districts had ICCM by CHWs plus free facility care and 2 comparison districts with free facility care only. A household cluster survey was conducted among caregivers of 5,643 and 5,259 children U5 at baseline (2010) and endline (2012), respectively. Results: ICCM was associated with increased odds in appropriate treatment for pneumonia (OR=2.00, 95%CI: 1.20-3.35) and decreased odds in traditional treatment for diarrhea (OR=0.44, 95%CI: 0.21-0.95) and facility treatments for malaria (OR=0.21, 95%CI: 0.07-0.62). Though no effect on inequalities by wealth, ICCM was associated with increased odds in care seeking (OR=2.98, 95%CI: 1.60-5.54) and appropriate treatment (OR=2.15, 95%CI: 1.12-4.41) and decreased odds in traditional treatments (OR=0.34, 95%CI: 0.14-0.87) among children from ethnic groups other than Mende. ICCM was also associated with increased odds in care seeking (OR=2.17, 95%CI: 1.03-4.57) and appropriate treatment (OR=2.55, 95%CI: 1.24-5.27) among children whose caregivers reported some education and decreased odds in traditional treatment (OR=0.48, 95%CI: 0.23-0.99) among children whose caregivers reported no education. Conclusions: ICCM by CHWs was associated with some increases in appropriate treatment, reduced treatment burden at the facility level, and reduced reliance on traditional treatments. Children from disadvantaged groups also appeared to benefit most from ICCM. The availability of trained and supervised CHWs can be an asset to provision of free healthcare in Sierra Leone.