Integrated community case management (iCCM), interim intervention report | GiveWell

# Integrated community case management (iCCM), interim intervention report

This is an interim intervention report. We have spent limited time to form an initial view of this program and, at this point, our views are preliminary. We plan to consider undertaking additional work on this program in the future.

## Summary

• What is the program? Integrated community case management (iCCM) is the provision of treatment for malaria, pneumonia and diarrhea by community health workers (CHWs).
• What is its evidence of effectiveness? We have not found strong evidence demonstrating that iCCM reduces the mortality rate of children under the age of five. We found two randomized controlled trials of iCCM, only one of which found a statistically significant effect.
• How cost-effective is it? Given our questions about the evidence, we have not completed a cost-effectiveness estimate for iCCM. With very optimistic assumptions, we estimate that iCCM would be in the range of cost-effectiveness of our current top charities and other priority programs.
• Does it have room for more funding? The program appears to have room for more funding of approximately $50 million per year. • Bottom line: We would consider additional evidence if we found it, but we do not currently plan to prioritize additional work on this program. Published: November 2016 ## What is the problem? The United Nations Inter-agency Group for Child Mortality Estimation (UN-IGME) estimates that there were approximately 5.9 million deaths of children under five in 2015.1 It attributes approximately 30 per cent of those deaths to diarrhea (8 per cent), malaria (5 per cent) and pneumonia (17 per cent).2 Though uncomplicated presentations of these diseases are relatively simple to treat,3 the WHO estimates that only 39% of children receive correct treatment of diarrhea, only 30% of children with suspected pneumonia receive an antibiotic,4 and only 16% of children with plasmodium falciparum malaria receive correct treatment.5 We have not vetted these estimates. ## What is the program? Integrated community case management (iCCM) describes the provision of treatment for malaria, pneumonia and diarrhea by community health workers (CHWs) to populations with limited access to facility-based health care providers, and especially to children under five.6 iCCM programs train and supply CHWs to diagnose and treat uncomplicated cases of pneumonia with antibiotics, malaria with antimalarial drugs and diarrhea with oral rehydration salts and zinc.7 Implementation elements of CHW programs including recruitment, training, remuneration, and retention strategies for CHWs; supply chain management; communication and social mobilization to ensure access to target populations; and monitoring and evaluation vary across contexts.8 As of 2013, 28 countries in Sub-Saharan Africa supported implementation of iCCM.9 ## Does the program have strong evidence of effectiveness? ### Evidence of iCCM's impact on the mortality rate of children under five There is no strong evidence that iCCM programs decrease the mortality rate of children under five. We rely on Amouzou et al 2014, a systematic review assessing the mortality impact of iCCM programs.10 It identifies two randomized controlled trials (RCTs) testing iCCM against a control group which did not receive iCCM.11 One trial found a significant effect, and one found no statistically significant effect: • In Ghana, a cluster-RCT of an iCCM program implementing treatment for malaria and pneumonia (77 clusters, 8339 children randomized) found a decrease in all-cause mortality in children aged 2-59 months of approximately 44% (95% CI: 0.24, 0.59) at six months (details in footnote).12 Follow-up of the iCCM program in comparison to the control group lasted only six months, due to the stepped-wedge design of the RCT.13 • In Burkina Faso, a cluster RCT of iCCM for fever and pneumonia (38 clusters, 76,000 HHs) found a difference in difference estimate of the mortality rate ratio among children aged 2–59 months of 0.95 (95% CI: 0.57, 1.59), which was not statistically significant.14 This study was reported in Amouzou et al 2014; we have not found a published version of it. ### Other evidence on iCCM We are aware of the following evidence on or related to iCCM, but have not considered it closely: • Randomized controlled trials examining community promotion of treatment for diarrhea, malaria or pneumonia alone, rather than in combination.15 • Quasi-experimental evidence examining, for example, coverage of iCCM treatment and modelled estimates of lives saved.16 • At least one randomized controlled trial showing that CHWs provided with a basket of health goods and operating as micro-entrepreneurs can have significant health impacts.17 However, we consider this intervention to be sufficiently different from iCCM that it is outside the scope of this report. ## How cost-effective is the program? We are not sure how much iCCM costs per child per year. • A cost-effectiveness study of the randomized controlled trial in Ghana described above,18 estimates a cost of$14.20 per child per year.19
• A USAID and Bill & Melinda Gates Foundation-funded costing study of eight existing iCCM programs in Sub-Saharan Africa found iCCM costs of approximately $3.01-$12.43 per child covered per year.20

In our experience, when we eventually identify and recommend a charity implementing a program the cost per person reached is often significantly higher (by a factor of 2 or 3) than it appeared to be based on costing studies or RCTs, alone.

We created a rough cost-effectiveness estimate21 for this program relying on optimistic assumptions. Using these assumptions, iCCM would be in the range of cost-effectiveness of our current top charities and other priority programs. We are not sure about the extent to which each of these assumptions would change, but our guess is that this optimistic cost-effectiveness estimate implies that iCCM would likely not be as cost-effective as our other top charities.22

We are uncertain about the total global room for more funding for iCCM. Rasanathan et al 2014 estimate that there is a funding gap in excess of $50 million per year for iCCM delivery in Sub-Saharan Africa up to 2017.23 This estimate does not seem unreasonable, given 28 countries in Sub-Saharan Africa have implemented iCCM, albeit with widely varying levels of coverage.24 ## Organizations that implement this program We have not attempted to identify all organizations that implement iCCM. Organizations that run this program include: • International Rescue Committee25 • Malaria Consortium26 • USAID's Maternal Child Health Integrated Program27 • Episcopal Relief & Development28 ## Focus of further investigation Below, we list areas we expect to research when we revisit this intervention: • Evidence of effectiveness: • Forthcoming trial results. There is ongoing research measuring appropriate treatment for diarrhea, malaria, and pneumonia following implementation of WHO-recommended iCCM in Mozambique and Uganda.29 • Non-randomized evidence of iCCM's impact, for example, macro trends in child mortality following implementation at scale. • Evidence focused on treatments for malaria, pneumonia and diarrhea provided by community health workers. • Cost-effectiveness: • Costs at scale. A charity implementing iCCM at scale may have substantially lower costs per child covered. Pending further high-quality evidence that iCCM has a significant impact on child mortality, we expect to deprioritize our research into iCCM. This is because our cost-effectiveness analysis estimates that our best guess of iCCM's impact on child mortality would need to be very high (between 32%-208% depending on location) for the program to be cost-competitive with our priority programs.30 ## Our process We reviewed Amouzou et al 2014, the results on Google Scholar for the search terms "integrated community case management" since 2013, the section of the WHO website devoted to iCCM, and some documents provided to us by the International Rescue Committee. ## Sources Document Source Amouzou et al 2014 Source (archive) Amouzou et al 2016 Source (archive) Bari et al 2011 Source (archive) Chinbuah et al 2012 Source (archive) ClinicalTrials.gov - NCT01972321 Source (archive) Collins et al 2014 Source (archive) CPI Inflation Calculator Source (archive) Diaz, Aboubaker and Young 2014 Source (archive) Druetz et al 2013 Source (archive) Episcopal Relief & Development - Malaria (2015) Source (archive) Fact Sheet - Children: Reducing Mortality. World Health Organisation (2016) Source (archive) Fact Sheet - Diarrhoeal Disease. World Health Organization (2016) Source (archive) Fact Sheet - Malaria. World Health Organization (2016) Source (archive) Fact Sheet - Pneumonia. World Health Organization (2016) Source (archive) ICCM CEA Source Integrated Community Case Management at the International Rescue Committee (2015) Unpublished Jamison et al. 2006 Source (archive) Kidane and Morrow 2000 Source (archive) Levels & Trends in Child Mortality Report 2015 - United Nations Inter-agency Group for Child Mortality Estimation Source (archive) Malaria Consortium - iCCM - South Sudan (2016) Source (archive) Mubiru et al 2015 Source (archive) Munos et al 2016 Source (archive) Nonvingon et al 2012 Source (archive) Nyqvist et al 2016 Source (archive) Pneumonia - Overview. Mayo Clinic (2016) Source (archive) Rasanathan et al 2014 Source (archive) UNICEF, the Reproductive, Maternal, Newborn and Child Health (RMNCH) Trust Fund, and The Global Fund's 2014 Joint Statement on a Coordinated Approach to Supporting Integrated Community Case Management Source (archive) USAID's Maternal Child Health Integrated Program - Child Health (2016) Source (archive) WebMD. Malaria: Topic overview Source (archive) World Health Organization - World Malaria Report 2015 Source (archive) World Health Organization. Integrated community case management of malaria (2016) Source (archive) World Health Organization/United Nations Children’s Fund Joint Statement on Integrated Community Case Management (2012) Source (archive) • 1. "According to the latest estimates by WHO and the Maternal and Child Epidemiology Estimation Group of the 5.9 million deaths in children under five that occurred in 2015, about half were caused by infectious diseases and conditions such as pneumonia, diarrhoea, malaria, meningitis, tetanus, HIV and measles," Levels & Trends in Child Mortality Report 2015 - United Nations Inter-agency Group for Child Mortality Estimation, Pg 8. • 2. "According to the latest estimates by WHO and the Maternal and Child Epidemiology Estimation Group of the 5.9 million deaths in children under five that occurred in 2015, about half were caused by infectious diseases and conditions such as pneumonia, diarrhoea, malaria, meningitis, tetanus, HIV and measles. The main killers of children under age five in 2015 include pneumonia (17 percent), preterm birth complications (16 percent), neonatal intrapartum-related complications (11 percent), diarrhoea (8 percent), neonatal sepsis (7 percent) and malaria (5 percent)." Levels & Trends in Child Mortality Report 2015 - United Nations Inter-agency Group for Child Mortality Estimation, Pg 8. • 3. • Definition of malaria: "Most malaria infections cause symptoms like the flu, such as a high fever, chills, and muscle pain. Symptoms tend to come and go in cycles. Some types of malaria may cause more serious problems, such as damage to the heart, lungs, kidneys, or brain. These types can be deadly." WebMD. Malaria: Topic overview. • Recommended treatment for malaria: "Early diagnosis and treatment of malaria reduces disease and prevents deaths. It also contributes to reducing malaria transmission. The best available treatment, particularly for P. falciparum malaria, is artemisinin-based combination therapy (ACT). ... WHO recommends that all cases of suspected malaria be confirmed using parasite-based diagnostic testing (either microscopy or rapid diagnostic test) before administering treatment. Results of parasitological confirmation can be available in 30 minutes or less. Treatment, solely on the basis of symptoms should only be considered when a parasitological diagnosis is not possible." Fact Sheet - Malaria. World Health Organization (2016). • Definition of pneumonia: "Pneumonia is an infection that inflames the air sacs in one or both lungs. The air sacs may fill with fluid or pus (purulent material), causing cough with phlegm or pus, fever, chills, and difficulty breathing. A variety of organisms, including bacteria, viruses and fungi, can cause pneumonia." Pneumonia - Overview. Mayo Clinic (2016). • Recommended treatment for pneumonia: "Pneumonia should be treated with antibiotics. The antibiotic of choice is amoxicillin dispersable tablets. Most cases of pneumonia require oral antibiotics, which are often prescribed at a health centre. These cases can also be diagnosed and treated with inexpensive oral antibiotics at the community level by trained community health workers." Fact Sheet - Pneumonia. World Health Organization (2016). • Definition of diarrhea: "Diarrhoea can last several days, and can leave the body without the water and salts that are necessary for survival. Most people who die from diarrhoea actually die from severe dehydration and fluid loss. ... Diarrhoea is defined as the passage of three or more loose or liquid stools per day (or more frequent passage than is normal for the individual). Frequent passing of formed stools is not diarrhoea, nor is the passing of loose, "pasty" stools by breastfed babies." Fact Sheet - Diarrhoeal Disease. World Health Organization (2016). • Recommended treatment for diarrhea: "Key measures to treat diarrhoea include the following: • Rehydration: with oral rehydration salts (ORS) solution. ORS is a mixture of clean water, salt and sugar. It costs a few cents per treatment. ORS is absorbed in the small intestine and replaces the water and electrolytes lost in the faeces. • Zinc supplements: zinc supplements reduce the duration of a diarrhoea episode by 25% and are associated with a 30% reduction in stool volume." Fact Sheet - Diarrhoeal Disease. World Health Organization (2016). • 4. "The number of children dying worldwide continues to decrease, and although this is encouraging, the decrease has been slow, stagnating or even reversing in many countries, particularly in sub-Saharan Africa. Although new preventive interventions, especially pneumococcal conjugate and rotavirus vaccines, will also help reduce mortality, prompt and effective treatment of pneumonia, diarrhea, and malaria remains essential. The delivery of health services is often weakest where the needs are greatest, and low coverage of the most needed interventions results in a significant unmet need for treatment of these major child killers. In developing countries, current treatment levels are unacceptably low: only 39% of children receive correct treatment of diarrhea, only 30% of children with suspected pneumonia receive an antibiotic, and less than 20% of children with fever in sub-Saharan Africa received a finger/heel stick for malaria testing, in 11 of 13 countries with available data in the region." World Health Organization/United Nations Children’s Fund Joint Statement on Integrated Community Case Management (2012), Pg 6. • 5. "The proportion of children in sub-Saharan Africa with P. falciparum malaria receiving an ACT is estimated to have increased since 2000, but access to treatment remains poor. Using (a) household survey data that identified children with a recent fever who had a positive RDT and who received antimalarial treatment; and (b) information on the number of ACT treatments distributed by NMCPs, it is possible to estimate the proportion of children with P. falciparum malaria who received an ACT or other antimalarial medicine. This estimation is only possible in sub-Saharan Africa where there are suffi cient household surveys, but it is also most relevant in this region where childhood malaria represents a substantial proportion of all cases. The proportion of children aged under 5 years, with P. falciparum malaria and who received an ACT, is estimated to have increased from less than 1% through 2005 to 16% in 2014 (range: 12–22%)." World Health Organization - World Malaria Report 2015, Pg 31. • 6. "Integrated Community Case Management (iCCM) is an equity-focused strategy that complements and extends the reach of public health services by providing timely and effective treatment of malaria, pneumonia and diarrhoea to populations with limited access to facility-based health care providers, and especially to children under five. ... As part of iCCM, front-line workers at the community level are trained, supplied and supervised to diagnose and treat children for malaria, pneumonia and diarrhoea, using artemisinin-based combination therapies, oral antibiotics, oral rehydration salts and zinc. All patients are screened for the three diseases and treatment is administered based on the results of the examination and diagnostic testing that includes malaria RDTs, disease history and respiratory rate. The inclusion of pre-referral treatment with rectal artesunate and RDTs is recommended, where feasible." World Health Organization. Integrated community case management of malaria (2016). • 7. "To accelerate progress in reducing child mortality, many countries in sub–Saharan Africa have adopted and scaled–up integrated community case management (iCCM) programs targeting the three major infectious killers of children under–five. The programs train lay community health workers to assess, classify and treat uncomplicated cases of pneumonia with antibiotics, malaria with antimalarial drugs and diarrhea with Oral Rehydration Salts (ORS) and zinc.", Amouzou et al 2014, Pg 1. • 8. See "Table 1 Eight benchmarks for implementation", World Health Organization/United Nations Children’s Fund Joint Statement on Integrated Community Case Management (2012), Pg 8 and see, e.g., Chinbuah et al 2012 (Ghana) and Amouzou et al 2016 (Ethiopia) for different implementation models. • 9. "In 2005 there were only 10 countries in sub-Saharan Africa with policies supporting implementation of iCCM of which 7 included pneumonia treatment [1]. This increased to 28 countries by 2013 that now support implementation of iCCM and this includes pneumonia treatment.", Diaz, Aboubaker and Young 2014, Pg 1 • 10. "We started the review by searching the literature for studies that assessed the mortality impact of integrated community case management programs. We searched PubMed, EMBASE, BIOSIS, Web of Science and Cochrane library to identify relevant studies reported in English, and published at any time until September 2013. ... We then contacted Non-governmental organizations (NGOs) or academic institutions known to have conducted recent evaluations of iCCM programs that included child mortality assessment. Although these studies were not yet published, all data collection had been completed and most were at the data analysis stage or at the report writing stage. We used three criteria for retention of a study for review: (i) the evaluation design must include an intervention area where the iCCM is implemented and a comparison area, (ii) the evaluation must include rigorous assessment of mortality impact through primary data collection using either household survey with full birth or pregnancy history, or population surveillance; and (iii) the researchers must be willing to share their micro–data on mortality to allow data quality assessment of the data sets and reanalysis." Amouzou et al 2014, Pg 3. • 11. "Three of the studies (Burkina Faso, Ethiopia and Ghana) used randomized controlled trial design and the remaining used quasi–experimental design with non–random selection of intervention and comparison areas. ... The Ethiopia study was conducted by researchers from the Johns Hopkins University in two zones covering 31 districts and a population larger than 4.2 million. All 31 districts were randomly assigned to intervention and comparison areas. Although the intervention areas received the enhanced iCCM program, which was initiated in Ethiopia in 2010 and included CCM of all three illnesses (malaria, pneumonia and diarrhea), the comparison areas received the existing CCM of malaria and diarrhea. Thus, in theory, the main difference between the intervention and the comparison areas was the introduction of CCM for pneumonia in the intervention area." Amouzou et al 2014, Pg 4. • 12. Study description: • Location. "The trial was conducted between January 2006 and December 2009 in Dangme-West district in southern Ghana, a district with a population of about 110,000 people." Chinbuah et al 2012, Pg 12. • Methods. "This was a cluster-randomized controlled open trial of an antimalarial versus an antimalarial plus an antibiotic for the treatment of fever among children 2–59 (inclusive) months of age in which the interventions were introduced in a stepped wedge manner. ... In all, 114 clusters of about 100 children under 5 years of age were formed." Chinbuah et al 2012, Pg 12. • Allocation. "All 114 clusters contributed to the control arm until April 2007, when the 37 clusters with 3,994 children were randomized to receive AAQ, 39 clusters with 4,043 children to receive AAQ+AMX received the intervention and 38 clusters with 4,296 children continued to receive standard care (control arm). The control clusters randomized to either of the two interventions received their intervention 6 months later, resulting in two arms of 55 (AAQ) with 6,121 children and 59 (AAQ+AMX) clusters with 6,212 (Figure 1). Initiation of the intervention was delayed because of costs and logistical challenges causing the three-arm design to last for only 6 months instead of 1 year to allow sufficient time for follow-up of the two-arm design." Chinbuah et al 2012, Pg 15. • Results. "After adjusting for gender, age group, wet and dry seasons, and clustering, there was still a statistically significant reduction in all cause mortality between both intervention arms and the control arm (AAQ: reduction 30%, RR = 0.70, 95% CI = 0.53–0.92, P = 0.011 and AAQ+AMX: reduction 44%, RR = 0.56, 95% CI = 0.41–0.76, P = 0.011). However, the difference in the mortality reduction between the AAQ and AAQ+AMX arms of 21% was not significant (RR = 0.79, 95% CI = 0.56–1.12, P = 0.195) (Tables 3 and 4)" Chinbuah et al 2012, Pg 16. Program description: • Selection. "Briefly, lay persons resident in their various communities were selected through an interactive process based on criteria set by community members during an open community meeting or by their community leaders. Nominated CHWs were informed that their participation would be voluntary and without any financial remuneration." Chinbuah et al 2012, Pg 12. • Training. "A CHW manual, relevant data capture tools such as data capture of the sick child consultation, referral forms, and drug recording forms were designed. Various IEC messages and an IEC video were developed. The CHWs were trained over 3 days using modified Integrated Management of Childhood Illnesses (IMCI) modules and video that had been developed with the Ministry of Health/Ghana Health Service for health workers. Training was conducted by experienced Ghana Health Service national IMCI trainers together with some study team members. Training was held separately for CHWs from different arms and was identical apart from one aspect: CHWs from AAQ+AMX clusters received additional training on how to administer amoxicillin and on how to teach caregivers from those clusters to administer amoxicillin at home." Chinbuah et al 2012, Pg 12. • Drugs. "All drugs were produced in different strengths and color-coded for age. Drugs were provided at no cost to caregivers." Chinbuah et al 2012, Pg 13. • 13. "The control clusters randomized to either of the two interventions received their intervention 6 months later, resulting in two arms of 55 (AAQ) with 6,121 children and 59 (AAQ+AMX) clusters with 6,212 (Figure 1). Initiation of the intervention was delayed because of costs and logistical challenges causing the three-arm design to last for only 6 months instead of 1 year to allow sufficient time for follow- up of the two-arm design." Chinbuah et al 2012, Pg 15. • 14. See "In addition, the Ghana study included only CCM of fever, while the Burkina Faso study included CCM of fever and pneumonia. Both studies used a randomized stepped–wedge approach and ran for approximately three years." and "Table 2. Characteristics of the design of iCCM) evaluation studies," column "Difference in differences estimate of the mortality rate ratio among children age 2–59 months + 95% CI," value "0.95 (0.57–1.59)", Amouzou et al 2014, Pg 4-5. • 15. See, e.g., Kidane and Morrow 2000 (malaria) and Bari et al 2011 (pneumonia). We have not done a comprehensive search for literature of this kind. • 16. See, e.g.: • Mubiru et al 2015: "Between July 2010 and December 2012 a pre-post quasi-experimental study in eight districts with iCCM was conducted; 3 districts without iCCM served as controls. A two-stage household cluster survey at baseline (n = 1036 and 1042) and end line (n = 3890 and 3844) was done in the intervention and comparison groups respectively. Changes in treatment coverage and timeliness were assessed using difference in differences analysis (DID)." Pg 1. • Munos et al 2016: "We conducted a prospective evaluation of the “Rapid Scale-Up” (RSU) program in Burkina Faso, focusing on the integrated community case management (iCCM) component of the program. We used a quasi-experimental design in which nine RSU districts were compared with seven districts without the program. The evaluation included documentation of program implementation, assessments of implementation and quality of care, baseline and endline coverage surveys, and estimation of mortality changes using the Lives Saved Tool. Although the program trained large numbers of community health workers, there were implementation shortcomings related to training, supervision, and drug stockouts. The quality of care provided to sick children was poor, and utilization of community health workers was low. Changes in intervention coverage were comparable in RSU and comparison areas. Estimated under-five mortality declined by 6.2% (from 110 to 103 deaths per 1,000 live births) in the RSU area and 4.2% (from 114 to 109 per 1,000 live births) in the comparison area." Pg 1. • 17. In Uganda, a cluster randomized controlled trial (214 clusters, 8,119 households randomized) of an intervention where community health promoters were trained to offer basic health advice and encouraged to earn income on the sale of health products, decreased the mortality rate of children under five by approximately 27% (0.07, 0.42) over a three-year period. Study details: • Methods. "A cluster-randomized controlled trial, embedded within the scale-up of a new community health delivery program, was undertaken in 214 clusters in 10 districts in Uganda. In the intervention clusters micro entrepreneur-based community health promoters (CHPs) were deployed over a three-year period (2011-2013). On average 38 households were surveyed in each cluster at the end of 2013, for a total sample size of 8,119 households. The primary study outcome was all-cause under-five mortality (U5MR)." Nyqvist et al 2016, Pg 2. • Results. "U5MR was reduced by 27% (adjusted RR 0.73, 95% CI 0.58-0.93). No harm was reported." Nyqvist et al 2016, Pg 2. Program details: • Selection and training. "The CHPs were selected through a competitive process among female community members aged 18 to 45 who applied for the position in each village and who possessed basic writing and math skills. Eligible candidates received 2 weeks of health and business training, covering preventing, diagnosing and treating childhood illness, recognizing danger signs for referral, healthy pregnancy and newborn care, and nutrition. At the end of the training, a skills test was administered to determine who would become an active CHP. Selected CHPs also attended a one-day training each month to review and refresh key health and business topics." Nyqvist et al 2016 Pg 6-7 • Services. "The CHPs tasks were to conduct home visits, educate households on essential health behaviors, provide basic medical advice, referring the more severe cases to the closest health center, and to sell preventive and curative health products. The CHPs were also instructed to visit newborns within the first 48 hours of life and to encourage pregnant women to deliver in a facility or with professional assistance. The product line they had at disposal included prevention goods (e.g. insecticide treated bednets, water purification tablets, and vitamins), curative treatments (e.g., oral rehydration salts, zinc, and ACTs), as well as other health-related commodities (e.g. diapers, detergent, and hand soap) and durables with health benefits (e.g. improved cook stoves, solar lights, and water filters)." Nyqvist et al 2016 Pg 7. • 18. "Objective[:] To assess the cost-effectiveness of two strategies of home management of under-five fevers in Ghana – treatment using antimalarials only (artesunate–amodiaquine – AAQ) and combined treatment using antimalarials and antibiotics (artesunate–amodiaquine plus amoxicillin – AAQ + AMX). Methods[:] We assessed the costs and cost-effectiveness of AAQ and AAQ + AMX compared with a control receiving standard care. Data were collected as part of a cluster randomised controlled trial with a step-wedged design. Approximately, 12 000 children aged 2–59 months in Dangme West District in southern Ghana were covered. Community health workers delivered the interventions. Costs were analysed from societal perspective, using anaemia cases averted, under-five deaths averted and disability- adjusted life years (DALYs) averted as effectiveness measures." Nonvingon et al 2012, Pg 951. • 19. Calculated as follows: • See "Table 2, Total economic costs of (a) AQ study Year 1*arm and (b) AAQ + AMX study arm", "Total (2009 US$), (b) Subtotal - 203 172.75" (see row 9, column 5, combining 4-year costs), Nonvingon et al 2012, Pg 955.
• Multiply by CPI inflation factor of 1.13 (see CPI Inflation Calculator comparing 2009 US$to 2016 US$) for $229,585.21. • Divide by four, then by total number of children (4,043) in the combined treatment using antimalarials and antibiotics arm of the trial, see "Figure 2. Cluster and participant flow after first randomization", Chinbuah et al 2012, Pg 14, for$14.20 per child per year.
• 20.
• "The cost analyses were conducted between 2011 and 2013. The first two studies were conducted of national programs in Malawi and Senegal in 2011 and 2012 as part of the testing of an iCCM costing and financing tool under the United States Agency for International Development (USAID) Translating Research into Action Project, and these countries were selected because they have mature iCCM programs and sufficient data. A third study conducted in Rwanda was excluded because data were not comparable. The second set of five studies was conducted of sub–national programs in Cameroon, Democratic Republic of Congo (DRC), Sierra Leone, South Sudan, and Zambia in 2013 with funding from the Bill and Melinda Gates Foundation (BMGF). These five countries were selected by BMGF to estimate the costs of five iCCM projects funded by another international donor." Collins et al 2014, Pg 2.
• See ICCM CEA, Sheet "Effect sizes for CE threshold in SSA", Cells B18 to H18.
• 21.

ICCM CEA, Sheet "CEA based on Chinbuah et al 2012".

• 22.

This estimate excludes several important factors:

• This estimate only includes the impact of saving lives. It excludes developmental benefits that we include in our cost-effectiveness estimate for long-lasting insecticide treated nets which prevent malaria. Including this would increase the cost-effectiveness of the program.
• Any decreases in quality of care or coverage in a charity's program from the standard achieved in the randomized controlled trial in Ghana our model is based on. Including a provision for such decreases would reduce the cost-effectiveness of the program.

We assumed a cost per child reached of $14.20 and did not include a "replicability" adjustment for the evidence. More on this concept in our standard cost-effectiveness models. • 23. • "With so much of the funding dependent on external sources, the future of iCCM programmes in sub–Saharan Africa seems fragile. Even after expected Global Fund support of US$ 50–100 million and likely support from ministries and bilateral donors, a gap of more than US$150 million is anticipated for 2015–2017 (Claire Qureshi, personal communication, 9 October 2014)." Rasanathan et al 2014, Pg 2. •$150 million / 3 years [2015-2017] = \$50 million / year.
• 24.

"In sub–Saharan Africa, recent years have seen increasing recognition of iCCM as a core strategy to deliver care to children, particularly those with poor access to health facilities, and reduce child mortality, in the context of the drive to achieve the Millennium Development Goals. Twenty–eight countries in sub–Saharan Africa are now the site of delivery of community case management for each of pneumonia, diarrhoea and malaria, albeit at widely differing levels of coverage between countries", Rasanathan et al 2014, Pg 1.

• 25.
• 26.
• 27.

"MCHIP supports integrated Community Case Management (iCCM) as a “strategy to deliver lifesaving curative interventions for common childhood illnesses… where there is little access to facility-based services."5 At the heart of this approach is the recognition that community health workers (CHWs) are a strong potential workforce in hard-to-reach areas. CHWs are available almost everywhere and, with proper training and support, they can provide lifesaving treatment to children in remote villages. MCHIP supports the introduction and expansion of iCCM at the country level by working hand-in-hand with counterparts at the Ministry of Health. To support countries implementing iCCM programs, MCHIP acts as the Secretariat of the CCM Task Force, helping to strengthen global momentum and coordinate iCCM resources available in support of country level programs." USAID's Maternal Child Health Integrated Program - Child Health (2016).

• 28.

"In order to care for the holistic health needs of remote communities, NetsforLife® has successfully implemented the integrated Community Case Management (iCCM) methodology in several pilot countries to reduce sickness and death from diarrhea, pneumonia and malaria (together, these three account for half of child deaths in many countries)." Episcopal Relief & Development - Malaria (2015).

• 29.
• 30.

See ICCM CEA, "Effect sizes for CE threshold in SSA" Sheet, Cells B33:H33.