title: Nationwide implementation of integrated community case management of childhood illness in Rwanda.
abstract: BACKGROUND
  Between 2008 and 2011, Rwanda introduced integrated community case management (iCCM) of childhood illness nationwide. Community health workers in each of Rwanda's nearly 15,000 villages were trained in iCCM and equipped for empirical diagnosis and treatment of pneumonia, diarrhea, and malaria; for malnutrition surveillance; and for comprehensive reporting and referral services.
  
  
  METHODS
  We used data from the Rwanda health management information system (HMIS) to calculate monthly all-cause under-5 mortality rates, health facility use rates, and community-based treatment rates for childhood illness in each district. We then compared a 3-month baseline period prior to iCCM implementation with a seasonally matched comparison period 1 year after iCCM implementation. Finally, we compared the actual changes in all-cause child mortality and health facility use over this time period with the changes that would have been expected based on baseline trends in Rwanda.
  
  
  RESULTS
  The number of children receiving community-based treatment for diarrhea and pneumonia increased significantly in the 1-year period after iCCM implementation, from 0.83 cases/1,000 child-months to 3.80 cases/1,000 child-months (P = .01) and 0.25 cases/1,000 child-months to 5.28 cases/1,000 child-months (P<.001), respectively. On average, total under-5 mortality rates declined significantly by 38% (P<.001), and health facility use declined significantly by 15% (P = .006). These decreases were significantly greater than would have been expected based on baseline trends.
  
  
  CONCLUSIONS
  This is the first study to demonstrate decreases in both child mortality and health facility use after implementing iCCM of childhood illness at a national level. While our study design does not allow for direct attribution of these changes to implementation of iCCM, these results are in line with those of prior studies conducted at the sub-national level in other low-income countries.
authors.affiliation: Rwanda Ministry of Health , Kigali , Rwanda ; Co-first authors.
authors.forename: Catherine
authors.initials: C
authors.lastname: Mugeni
authors.affiliation: The Warren Alpert Medical School of Brown University , Providence, RI , USA ; Co-first authors.
authors.forename: Adam C
authors.initials: AC
authors.lastname: Levine
authors.affiliation: Rwanda Ministry of Health , Kigali , Rwanda.
authors.forename: Richard M
authors.initials: RM
authors.lastname: Munyaneza
authors.affiliation: Rwanda Ministry of Health , Kigali , Rwanda.
authors.forename: Epiphanie
authors.initials: E
authors.lastname: Mulindahabi
authors.affiliation: Brown University, Watson Institute for International Studies, Development Studies Program , Providence, RI , USA.
authors.forename: Hannah C
authors.initials: HC
authors.lastname: Cockrell
authors.affiliation: The Warren Alpert Medical School of Brown University , Providence, RI , USA.
authors.forename: Justin
authors.initials: J
authors.lastname: Glavis-Bloom
authors.affiliation: Dartmouth Center for Health Care Delivery Science , Hanover, NH , USA.
authors.forename: Cameron T
authors.initials: CT
authors.lastname: Nutt
authors.affiliation: Global Health Delivery Partnership , Boston, MA , USA.
authors.forename: Claire M
authors.initials: CM
authors.lastname: Wagner
authors.affiliation: Rwanda Ministry of Health , Kigali , Rwanda.
authors.forename: Erick
authors.initials: E
authors.lastname: Gaju
authors.affiliation: Malaria and other Parasitic Diseases Division, Rwanda Biomedical Center , Kigali , Rwanda.
authors.forename: Alphonse
authors.initials: A
authors.lastname: Rukundo
authors.affiliation: Malaria and other Parasitic Diseases Division, Rwanda Biomedical Center , Kigali , Rwanda.
authors.forename: Jean Pierre
authors.initials: JP
authors.lastname: Habimana
authors.affiliation: Malaria and other Parasitic Diseases Division, Rwanda Biomedical Center , Kigali , Rwanda.
authors.forename: Corine
authors.initials: C
authors.lastname: Karema
authors.affiliation: Rwanda Ministry of Health , Kigali , Rwanda.
authors.forename: Fidele
authors.initials: F
authors.lastname: Ngabo
authors.affiliation: Rwanda Ministry of Health , Kigali , Rwanda ; Harvard Medical School, Department of Global Health and Social Medicine , Boston, MA , USA ; Dartmouth College, Geisel School of Medicine , Hanover, NH , USA.
authors.forename: Agnes
authors.initials: A
authors.lastname: Binagwaho
mesh_terms: D019090:Case Management / Q000458:organization & administration*; D002648:Child; D002662:Child Health Services / Q000458:organization & administration* / Q000706:statistics & numerical data; D046688:Child Mortality; D015362:Child Nutrition Disorders / Q000401:mortality / Q000628:therapy; D002675:Child, Preschool; D019033:Delivery of Health Care, Integrated / Q000458:organization & administration*; D003967:Diarrhea / Q000401:mortality / Q000628:therapy; D005260:Female; D006801:Humans; D007223:Infant; D007226:Infant Mortality; D008288:Malaria / Q000401:mortality / Q000628:therapy; D008297:Male; D011014:Pneumonia / Q000401:mortality / Q000628:therapy; D012432:Rwanda / Q000453:epidemiology