In 2010, 7.6 million children died before the age of five,1 two-thirds unnecessarily.2 A concise list of evidence-based, life-saving interventions guides health policy makers, planners, and program implementers to decrease child mortality in low and middle income countries.2,3 Adding to the list, through discovery science, is challenging and exciting. Bringing existing interventions to families who need them, through delivery science, is at the same time more challenging, perhaps a bit less exciting, but more life-saving. The greatest gains to be made in intervention coverage across the continuum of care are for newly introduced interventions, as expected, and for existing curative interventions.4 Similarly, modeling exercises have repeatedly shown that the greatest reductions in mortality for children less than five years of age are to be achieved through increasing the coverage of treatment interventions for the three major causes of childhood mortality: pneumonia, malaria, and diarrhea.5 Because millions live at or beyond the periphery of the health system, there is a need to improve access to care for common childhood infectious diseases by bringing treatment closer to the community, especially in rural settings where distance, cost, and limited availability of primary health centers exist. Integrated community case management (iCCM) is a strategy to train, support, and supply community health workers (CHWs) to provide diagnostics and treatments for pneumonia, diarrhea, and malaria for sick children of families with difficult access to case management at health facilities. A pro-equity strategy, iCCM is not easy to implement.6 Health systems tend to be the most challenged in those high mortality settings in which iCCM is most needed. Moreover, iCCM has many steps that must be performed sequentially and completely for care to be successful. Deviations can result in bad outcomes for the sick child, the community (i.e., increased drug resistance), and the program. In addition, CHWs delivering iCCM must master ancillary skills, such as documentation and supply management, among others. The global health community needs guidance for implementing iCCM. In response, a World Health Organization–Tropical Disease Research/United Nations Children's Fund (WHO-TDR/UNICEF) Joint Meeting for Community Case Management of Fever (Geneva, June 2008) produced a CCM research agenda.7 The global CCM Operations Research Group (ccm.org) further refined the agenda at a UNICEF meeting in New York (October 2008) and at a Program for Global Pediatric Research workshop on CCM for pneumonia in Vancouver (May 2010).8 This agenda remains in place today (Table 1).9 In Stockholm (May 2009), ccm.org proposed a generic evaluation framework for iCCM (Figure 1).9 On the basis of a results framework,10 the schema includes outcomes (boxes in top three rows) and processes (partitioned box at the bottom) to implement the strategy. Figure 1. Evaluation framework. The World Health Organization and UNICEF have just released a Joint Statement for iCCM as an equity-focused strategy to improve access to case management.11 This supplement commences with a re-publication of this document,12 which summarizes much of the global evidence base until now. The purpose of these papers is to augment the experience base and evidence base for iCCM, and then chart the way forward for future research. We have mapped the included contributions against the research questions (Table 1) and results and/or processes (Figure 2). This large collection of CCM research informs 16 research questions. The country reports are almost exclusively from sub-Saharan Africa, with analyses from the Democratic Republic of the Congo, Ethiopia, Ghana, Côte d'Ivoire, Malawi, Mali, Rwanda, Sierra Leone, Uganda, Zambia, and Pakistan. Other papers address global issues, such as methods to measure access to case management13 and indicators to monitor iCCM programs.14 Figure 2. Evaluation framework with Supplement contributions. iCCM = integrated community case management; CHW = community health worker; WHO-UNICEF = World Health Organization–United Nations Children's Fund. This supplement informs nearly all results and processes in the evaluation framework (Figure 2). Chinbuah and others15 evaluated the impact on all-cause mortality of children 2–59 months of age, adding an antibiotic for pneumonia to an existing home-based antimalarial for fever strategy in Ghana. Mukanga and others16 reported the effect of implementing the iCCM package on the clinical outcome of febrile disease and on the quality of drug use in Uganda, Ghana, and Burkina Faso. Regarding use of CCM in eastern Uganda, Rutebemberwa and others17 measured care-seeking from community medicine distributors in urban and rural settings, and Kalyango and others18 compared the effect of iCCM and home-based management of fever strategies on care-seeking from community medicine distributors and on community drug use. Kayemba and others.19 reported health system implications for adding newborn care to iCCM in Uganda. In Malawi, Nsona and others20 described the national scale-up of iCCM, and Callaghan-Koru and others21 studied health workers' and managers' perceptions of the iCCM strategy and the CHWs delivering it. McGorman and others14 proposed, through a health systems lens, benchmarks and indicators for planning, introducing, and scaling up iCCM. Guenther and others13 measured and modeled access to case management with and without iCCM in Malawi, Mali, and Zambia. George and others22 characterized the CHWs relied upon to increase access to case management across sub-Saharan Africa. Regarding demand for iCCM in Uganda, Awor and others23 studied care-seeking for sick children, noting the potential role for and the uneven quality of care in the private sector; and Nanyongo and others24 reported community acceptability of iCCM. In Zambia, Seidenberg and others25 reported the effect of iCCM on care-seeking practices for sick children. Regarding policy, the joint statement of Young and others12 endorses iCCM globally, to encourage countries and donors alike. Regarding processes to ensure access, Strachan and others26 reported stakeholder perceptions of approaches to improve CHW retention and motivation. Chandani and others27 studied determinants of medicine supply for CCM in three countries, and Cardemil and others28 compared methods to assess case management performance; both papers highlighted processes to ensure service quality. Sadruddin and others29 reported the household cost savings afforded by CCM for severe pneumonia in Pakistan, an important process to enable the policy environment. Lainez and others30 report practical applications of routine CCM service statistics, a cross-cutting process informing several intermediate results. The 19 reports in this supplement make important additions to a growing evidence base, which must still grow further.31
