OBJECTIVES

To determine if the Integrated Community-Based Health Systems-Strengthening (ICBHSS) initiative was effective in expanding health coverage, improving care quality, and reducing child mortality in Togo.

METHODS

Population-representative cross-sectional household surveys adapted from the Demographic Household Survey and Multiple Indicator Cluster Surveys were conducted at baseline (2015) and then annually (2016–2020) in 4 ICBHSS catchment sites in Kara, Togo. The primary outcome was under-5 mortality, with health service coverage and health-seeking behavior as secondary outcomes. Costing analyses were calculated by using “top-down” methodology with audited financial statements and programmatic data.

RESULTS

There were 10 022 household surveys completed from 2015 to 2020. At baseline (2015), under-5 mortality was 51.1 per 1000 live births (95% confidence interval [CI]: 35.5–66.8), and at the study end period (2020), under-5 mortality was 35.8 (95% CI: 23.4–48.2). From 2015 to 2020, home-based treatment by a community health worker increased from 24.1% (95% CI: 21.9%–26.4%) to 45.7% (95% CI: 43.3%–48.2%), and respondents reporting prenatal care in the first trimester likewise increased (37.5% to 50.1%). Among respondents who sought care for a child with fever, presenting for care within 1 day increased from 51.9% (95% CI: 47.1%–56.6%) in 2015 to 80.3% (95% CI: 74.6%–85.0%) in 2020. The estimated annual additional intervention cost was $8.84 per person.

CONCLUSIONS

Our findings suggest that the ICBHSS initiative, a bundle of evidence-based interventions implemented with a community-based strategy, improves care access and quality and was associated with reduction in child mortality.

What’s Known on This Subject:

Millions of children die annually from preventable or treatable conditions in low- and middle-income settings. Approaches that focus on improving access and quality of evidence-based practices have contributed to declines in some, but not all, settings.

What This Study Adds:

Evidence-based interventions centered on community-based implementation provide an effective path for addressing the know-do gap and reducing child mortality through increasing access to and improving quality of essential maternal and pediatric health care services.

From 1990 to 2015, the world observed a 53% reduction in deaths for children under 5.1  In September 2015, the United Nations established the Sustainable Development Goals, with goal 3 being to reduce under-5 mortality to 25 per 1000 live births by 2030.2,3  As of 2019, 118 countries had achieved this target; however, 5.3 million children under the age of 5 still die each year from conditions that are preventable or treatable through evidence-based health care interventions.4  This know-do gap, the difference between known, evidence-based care and what is done in practice, illustrates persistent health inequities and an opportunity to avert child deaths.5 

Togo, a country in West Africa, has experienced declines in child mortality since 2000 that lag behind peer nations6  and is not on track to achieve Sustainable Development Goals goal 3.7  Togo’s Ministry of Health (MoH) has developed a national health plan to align policy with global best practices to reduce child mortality, yet Togolese children continue to die of diseases that have effective and low-cost treatments.8  Only 30% of the Togolese population report using public facilities for health care,9,10  and quality measures around existing services are mixed11  and largely unknown.12 

Since 2004, Integrate Health (IH), an international nongovernmental organization, has collaborated closely with the Togolese MoH and community-based organizations in the Kara region of northern Togo to strengthen health care delivery. In 2014, this partnership was expanded to accelerate progress toward improving maternal and child health care by focusing on increasing access to and improving quality of evidence-based care, effectively addressing know-do gaps in care delivery. This new partnership was referred to as the Integrated Community-Based Health Systems-Strengthening (ICBHSS) initiative and includes evidence-based maternal and pediatric care interventions including professionalizing community health workers (CHWs), offering clinical operating grants to offset user fees, augmenting procurement and supply chains for essential medications and supplies, and investing in health center infrastructure.1315  We describe the ICBHSS evaluation focusing on impact and implementation outcomes over 5 years in the Kozah district of northern Togo.

The ICBHSS initiative uses a community engagement approach to implement a bundle of evidence-based interventions (Table 1), including (1) subsidizing point-of-care user fees for maternal and child health services (consultations, laboratories, and medication costs) at public health centers for pregnant women and children <51619 ; (2) proactive community case management of maternal care and acute pediatric illnesses provided by trained, equipped, supervised, and salaried CHWs13,18,2027 ; (3) clinical mentoring and enhanced supervision by designated clinical mentors assigned to each public sector health center to support quality improvement and adherence to Integrated Management of Childhood Illness guidelines14,28,29 ; and (4) targeted health facility and supply-chain operational improvements related to basic infrastructure investments and pharmacy supplies.3033  In coordination with Togo’s MoH, the initiative was launched in July 2015.

TABLE 1

ICBHSS Model Overview of Implementation Strategy Components

No.Implementation Strategy Component OverviewDescription
Removal of point-of-care costs in IH selected public sector health facilities Subsidized facility-based consultation fees, medications, supplies, and services provided at IH intervention sites and advanced care referrals at the district or regional hospital for children <5, pregnant or postpartum women, women of reproductive age for family planning services, and people living with HIV infections who seek care at study sites. 
Proactive community case management using trained, equipped, supervised, and salaried CHWs CHWs provide proactive community-based care and health center referrals for sick children <5 y of age, pregnant women, and women of childbearing age who wish to adopt a contraceptive method provided. CHWs treat simple cases of child illnesses and refer complicated cases to the health center; monitor pregnant and postpartum women at home and refer them for antenatal care, delivery and postnatal care; and provide family planning counseling and contraceptive method administration to women at home. Consultations, referrals, medicines, and materials are provided free of charge. CHWs are salaried; trained in IMCI, maternal health, HIV counseling and testing, and family planning; and equipped with materials for care provision. They receive supportive supervision with coaching and mentoring by IH supervisors (nurses/medical assistants). 
Clinical mentoring and enhanced supervision by a trained peer coach at public sector facilities IH clinical mentors (nurses, midwives, medical assistants) with previous experience in public sector health facilities provide regular facility-based supportive supervision and coaching to health care providers. IH clinical mentors evaluate service delivery and support clinical training and skill development for clinic staff and support the introduction of health care tools such as checklists. 
Basic infrastructure and equipment improvements and supply-chain management training of pharmacy managers Formal infrastructure and equipment are assessed using a tool adapted from the WHO Service Availability and Readiness Assessment tool. Structural improvements (eg, installation of plumbing systems, solar power, and other basic renovations) are conducted at health centers to improve care delivery. Pharmacy managers are trained and supported in the procurement of essential medicines and equipment. IH clinical mentors conduct on-site training in supply-chain management practices, including proper storage of medicines, filling of stock cards, and orders based on average monthly input consumption. 
No.Implementation Strategy Component OverviewDescription
Removal of point-of-care costs in IH selected public sector health facilities Subsidized facility-based consultation fees, medications, supplies, and services provided at IH intervention sites and advanced care referrals at the district or regional hospital for children <5, pregnant or postpartum women, women of reproductive age for family planning services, and people living with HIV infections who seek care at study sites. 
Proactive community case management using trained, equipped, supervised, and salaried CHWs CHWs provide proactive community-based care and health center referrals for sick children <5 y of age, pregnant women, and women of childbearing age who wish to adopt a contraceptive method provided. CHWs treat simple cases of child illnesses and refer complicated cases to the health center; monitor pregnant and postpartum women at home and refer them for antenatal care, delivery and postnatal care; and provide family planning counseling and contraceptive method administration to women at home. Consultations, referrals, medicines, and materials are provided free of charge. CHWs are salaried; trained in IMCI, maternal health, HIV counseling and testing, and family planning; and equipped with materials for care provision. They receive supportive supervision with coaching and mentoring by IH supervisors (nurses/medical assistants). 
Clinical mentoring and enhanced supervision by a trained peer coach at public sector facilities IH clinical mentors (nurses, midwives, medical assistants) with previous experience in public sector health facilities provide regular facility-based supportive supervision and coaching to health care providers. IH clinical mentors evaluate service delivery and support clinical training and skill development for clinic staff and support the introduction of health care tools such as checklists. 
Basic infrastructure and equipment improvements and supply-chain management training of pharmacy managers Formal infrastructure and equipment are assessed using a tool adapted from the WHO Service Availability and Readiness Assessment tool. Structural improvements (eg, installation of plumbing systems, solar power, and other basic renovations) are conducted at health centers to improve care delivery. Pharmacy managers are trained and supported in the procurement of essential medicines and equipment. IH clinical mentors conduct on-site training in supply-chain management practices, including proper storage of medicines, filling of stock cards, and orders based on average monthly input consumption. 

IMCI, Integrated Management of Childhood Illness; WHO, World Health Organization.

This study was conducted in the catchment areas of 4 public sector health facilities in the Kozah district within the Kara region of northern Togo, including 1 urban site, Adabawere, and 3 rural sites, Djamdé, Kpindi, and Sarakawa. A population-representative cross-sectional household survey was conducted at baseline and annually from 2015 to 2020 among female residents aged 15 to 49. The 2015 baseline survey respondents were restricted to women aged 18 to 49. Data were collected in the same time frame annually (January to February). To facilitate data collection, each facility catchment area was divided into 15 geographic zones by using geographic information system technology, and households were selected from each zone by using a systematic sampling strategy. To avoid bias, data collectors determined collection location starting points by dropping a pen on a map. If >1 female individual resided in a household, participants were chosen by using a Kish selection grid method.34  All participants were consented to participate.

The primary outcome used to determine sample size was under-5 childhood mortality rate per 1000 live births. With a sample size of ∼1500 respondents annually, we were powered to detect a >50% reduction in under-5 mortality35  over the study period in the 4 catchment areas, using a baseline rate of 88 deaths per 1000 live births,8  a design effect of 1.5, a total fertility rate of 4.8,8  a 20% nonresponse rate, and an α of .05.36 

Data were collected by using paper surveys (2015) and electronic tablets with questionnaires developed in KoBoToolbox with built in consistency checks (2016–2020) by trained data collectors.37  The questionnaire was adapted from the Demographic Household Survey (DHS) and Multiple Indicator Cluster Survey, respectively implemented by Togo in 2013 and 2010 (Supplemental Fig 3).8  Questionnaires were initially developed in English, were then translated into French, and then were back translated into English for accuracy. Data collectors conducted the survey in either French or the local language, Kabiyé, depending on respondent preference. Questions included measures of demographic characteristics, childhood illness prevalence, health service coverage, barriers to care, and health-seeking behavior.38  Programmatic data on process and quality measures were collected at the community and facility level by ICBHSS staff.

Ethical approvals for this study were obtained from the institutional review boards of the Togolese MoH in Lomé, Togo (reference: CBRS/031/2014) and the Albert Einstein College of Medicine, New York (reference: 005127).

Analysis and presentation of data were organized by using a modified Reach, Effectiveness, Adoption, Implementation, Maintenance evaluation framework.39  Frequencies for demographic characteristics and Reach, Effectiveness, Adoption, Implementation, Maintenance measures were reported as raw counts and weighted population percentages, accounting for complex sampling, estimated through the R function svydesign. Weights were created to account for the proportion of households approached in each catchment area, individual household nonresponse, and number of eligible women per household.

Reach measures were defined as the population who received ICBHSS-related interventions related to maternal and child health facility services. These included the proportion of eligible individuals receiving antenatal care during the first trimester, facility-based delivery, postnatal care, and acute care for pediatric illness symptoms.

The primary effectiveness end point was the change in the under-5 mortality rate assessed at baseline and annually. Under-5 mortality was defined as the probability of a child dying between birth and 60 months of age and is expressed as a rate per 1000 live births.8  Mortality rates were calculated from household survey data birth tables that asked respondents to provide month and year of birth, survival status of each live birth, and age at death of each deceased live birth occurring in the previous 5 years.40  Estimates were calculated from the DHS mortality rates methodology by using a publicly available R package that included population-based survey weights and a Jackknife repeated replication approach to estimate 95% confidence intervals (CIs) (DHS.rates).41,42  Although this study did not have sufficient power to assess mortality changes in specific time periods after birth (ie, neonatal mortality rate, postneonatal mortality rate, infant mortality rate, or child mortality rate), these rates are also presented to provide additional contextual information.

Adoption was focused on behavior change and was determined by community-based coverage by CHWs, as measured by the proportion of the population (1) reporting a home visit from a CHW, and (2) receiving treatment from a CHW in the last year.

Implementation measures used ICBHSS program data to assess fidelity and were organized by 2 Institute of Medicine quality domains43 : timely and efficient. “Timely” was defined as the time between onset of symptoms and assessment by a CHW or at the health center. “Efficient” referred to the proportion of referrals to higher levels of care that were successful.

Maintenance was assessed by using factors associated with sustainability in sub-Saharan Africa cited in previous studies44 : stakeholder involvement, community mobilization, public sector engagement, and cost. Stakeholder and community-level engagement were reported as the number of community forums completed. Public sector engagement was defined as the participation of MoH leadership at the district, regional, and national levels in ICBHSS implementation.

To determine annual maintenance costs, we conducted a retrospective “top-down”45  costing analysis using audited financial statements, programmatic data, and financial data for the period between July 1, 2018, and June 30, 2019. All financial data, including direct and indirect costs, were collected from accounting records, whereas programmatic data were captured from mHealth applications and Togo’s Demographic and Health Information System.

All described analyses for reach, effectiveness, and adoption measures were conducted by using R software, version 3.6.3. Analyses were described according to the Standards for Reporting Implementation Studies reporting checklist.46 

From 2015 to 2020, a total of 10 022 households completed surveys (Table 2). Refusal rates were similar across the 4 sites (range 0.3%–1.8%). However, the proportion of residents not at home was notably higher in 2015 (28.4%). There were no meaningful differences observed from 2015 to 2020 in the distribution of demographic or socioeconomic factors (Table 2). The distribution of age group differed in 2015 because of the exclusion of 15- to 17-year-old respondents, but they did not differ from 2016 to 2020.

TABLE 2

Demographic Characteristics of Survey Participants by Survey Year by Site, Kozah District, Togo

Actual Sample Size and Weighted PercentagesBaseline (2014–2015)Year 1 (2015–2016)Year 2 (2016–2017)Year 3 (2017–2018)Year 4 (2018–2019)Year 5 (2019–2020)
Selected households,an (%)       
 Completed surveys 1331 (69.6) 1517 (96.1) 1551 (95.8) 1733 (97.1) 1795 (96.6) 2095 (97.8) 
 Partially completed surveys 5 (0.3) 9 (0.6) 18 (1.1) 5 (0.3) 4 (0.2) 0 (0) 
 No eligible member home 543 (28.4) 30 (1.9) 29 (1.8) 42 (2.4) 44 (2.4) 42 (2.0) 
 Refused 34 (1.8) 22 (1.4) 21 (1.3) 5 (0.3) 15 (0.8) 5 (0.2) 
Total surveys included,an (%) 1336 1526 1569 1738 1799 2095 
 Adabawere 523 (39.1) 678 (44.4) 690 (44.0) 732 (42.1) 757 (42.1) 837 (40.0) 
 Djamdé 293 (21.9) 263 (17.2) 282 (18.0) 316 (18.2) 321 (17.8) 448 (21.4) 
 Kpindi 239 (17.9) 308 (20.2) 299 (19.1) 346 (19.9) 349 (19.4) 322 (15.4) 
 Sarakawa 281 (21.0) 277 (18.2) 298 (19.0) 344 (19.8) 372 (20.7) 488 (23.3) 
Age group, n (%)       
 15–17b NA 63 (5.9) 73 (5.1) 82 (6.5) 116 (8.1) 96 (6.8) 
 18–24 312 (24.3) 416 (28.6) 427 (28.9) 446 (29.5) 490 (30.8) 528 (30.1) 
 25–34 552 (38.3) 639 (39.7) 628 (38.2) 751 (38.9) 744 (38.1) 820 (35.3) 
 35–49 472 (37.4) 408 (25.9) 441 (27.8) 459 (25.1) 449 (23.0) 651 (27.8) 
Education level completed, n (%)       
 None 276 (17.9) 250 (11.9) 252 (12.1) 275 (12.3) 231 (10.0) 271 (8.0) 
 Primary 586 (40.2) 597 (33.7) 577 (32.0) 625 (29.6) 603 (28.1) 836 (30.8) 
 Secondary or above 470 (41.8) 679 (54.4) 740 (55.9) 838 (58.0) 965 (62.0) 988 (61.2) 
Relationship status, n (%)       
 Single 204 (18.0) 239 (22.8) 314 (24.2) 353 (27.9) 367 (27.9) 473 (32.4) 
 Married or living together 1130 (82.0) 1287 (77.2) 1255 (75.8) 1385 (72.1) 1432 (72.1) 1622 (67.6) 
Cowives if not single, n (%)       
 No 733 (64.3) 924 (71.1) 894 (70.9) 967 (68.2) 1026 (70.4) 1179 (73.8) 
 Yes 387 (34.8) 345 (27.0) 354 (28.6) 395 (29.5) 385 (27.6) 431 (25.4) 
 Do not know 11 (0.9) 18 (1.8) 7 (0.5) 23 (2.2) 21 (2.0) 12 (0.8) 
Distance from facility, n (%)       
 0–2 km 458 (35.5) 516 (39.3) 582 (39.5) 609 (39.7) 621 (40.2) 760 (42.8) 
 3–5 km 551 (45.3) 658 (45.0) 642 (45.0) 717 (43.3) 744 (42.9) 788 (45.1) 
 5+ km 327 (19.2) 352 (15.7) 345 (15.5) 412 (17.0) 434 (17.0) 547 (12.2) 
Location type, n (%)       
 Rural 813 (46.4) 848 (38.4) 879 (37.3) 1006 (41.0) 1042 (41.9) 1258 (31.4) 
 Urban 523 (53.6) 678 (61.6) 690 (62.7) 732 (59.0) 757 (58.1) 837 (68.6) 
Wealth quintilesc, n (%)       
 1 370 (23.5) 283 (13.7) 293 (13.5) 292 (12.0) 265 (10.3) 341 (8.6) 
 2 525 (36.0) 635 (36.9) 580 (33.0) 659 (33.0) 744 (36.1) 894 (33.1) 
 3 327 (27.4) 421 (31.8) 473 (34.2) 526 (34.6) 504 (31.8) 545 (33.2) 
 4 89 (10.0) 153 (13.6) 177 (14.8) 215 (16.1) 227 (16.9) 246 (18.3) 
 5 25 (3.2) 34 (3.9) 46 (4.4) 46 (4.3) 59 (5.0) 69 (6.8) 
Recent birth, n (%)       
 Yes, births in last 2 y 512 (34.6) 542 (30.7) 549 (31.3) 638 (31.1) 615 (30.5) 666 (25.7) 
 Yes, births in last 5 y 890 (60.3) 965 (55.4) 980 (57.6) 1109 (56.0) 1084 (53.5) 1286 (50.6) 
 Yes, births in last 10 y 1077 (74.1) 1141 (67.1) 1155 (68.7) 1311 (67.1) 1301 (64.6) 1569 (62.8) 
Actual Sample Size and Weighted PercentagesBaseline (2014–2015)Year 1 (2015–2016)Year 2 (2016–2017)Year 3 (2017–2018)Year 4 (2018–2019)Year 5 (2019–2020)
Selected households,an (%)       
 Completed surveys 1331 (69.6) 1517 (96.1) 1551 (95.8) 1733 (97.1) 1795 (96.6) 2095 (97.8) 
 Partially completed surveys 5 (0.3) 9 (0.6) 18 (1.1) 5 (0.3) 4 (0.2) 0 (0) 
 No eligible member home 543 (28.4) 30 (1.9) 29 (1.8) 42 (2.4) 44 (2.4) 42 (2.0) 
 Refused 34 (1.8) 22 (1.4) 21 (1.3) 5 (0.3) 15 (0.8) 5 (0.2) 
Total surveys included,an (%) 1336 1526 1569 1738 1799 2095 
 Adabawere 523 (39.1) 678 (44.4) 690 (44.0) 732 (42.1) 757 (42.1) 837 (40.0) 
 Djamdé 293 (21.9) 263 (17.2) 282 (18.0) 316 (18.2) 321 (17.8) 448 (21.4) 
 Kpindi 239 (17.9) 308 (20.2) 299 (19.1) 346 (19.9) 349 (19.4) 322 (15.4) 
 Sarakawa 281 (21.0) 277 (18.2) 298 (19.0) 344 (19.8) 372 (20.7) 488 (23.3) 
Age group, n (%)       
 15–17b NA 63 (5.9) 73 (5.1) 82 (6.5) 116 (8.1) 96 (6.8) 
 18–24 312 (24.3) 416 (28.6) 427 (28.9) 446 (29.5) 490 (30.8) 528 (30.1) 
 25–34 552 (38.3) 639 (39.7) 628 (38.2) 751 (38.9) 744 (38.1) 820 (35.3) 
 35–49 472 (37.4) 408 (25.9) 441 (27.8) 459 (25.1) 449 (23.0) 651 (27.8) 
Education level completed, n (%)       
 None 276 (17.9) 250 (11.9) 252 (12.1) 275 (12.3) 231 (10.0) 271 (8.0) 
 Primary 586 (40.2) 597 (33.7) 577 (32.0) 625 (29.6) 603 (28.1) 836 (30.8) 
 Secondary or above 470 (41.8) 679 (54.4) 740 (55.9) 838 (58.0) 965 (62.0) 988 (61.2) 
Relationship status, n (%)       
 Single 204 (18.0) 239 (22.8) 314 (24.2) 353 (27.9) 367 (27.9) 473 (32.4) 
 Married or living together 1130 (82.0) 1287 (77.2) 1255 (75.8) 1385 (72.1) 1432 (72.1) 1622 (67.6) 
Cowives if not single, n (%)       
 No 733 (64.3) 924 (71.1) 894 (70.9) 967 (68.2) 1026 (70.4) 1179 (73.8) 
 Yes 387 (34.8) 345 (27.0) 354 (28.6) 395 (29.5) 385 (27.6) 431 (25.4) 
 Do not know 11 (0.9) 18 (1.8) 7 (0.5) 23 (2.2) 21 (2.0) 12 (0.8) 
Distance from facility, n (%)       
 0–2 km 458 (35.5) 516 (39.3) 582 (39.5) 609 (39.7) 621 (40.2) 760 (42.8) 
 3–5 km 551 (45.3) 658 (45.0) 642 (45.0) 717 (43.3) 744 (42.9) 788 (45.1) 
 5+ km 327 (19.2) 352 (15.7) 345 (15.5) 412 (17.0) 434 (17.0) 547 (12.2) 
Location type, n (%)       
 Rural 813 (46.4) 848 (38.4) 879 (37.3) 1006 (41.0) 1042 (41.9) 1258 (31.4) 
 Urban 523 (53.6) 678 (61.6) 690 (62.7) 732 (59.0) 757 (58.1) 837 (68.6) 
Wealth quintilesc, n (%)       
 1 370 (23.5) 283 (13.7) 293 (13.5) 292 (12.0) 265 (10.3) 341 (8.6) 
 2 525 (36.0) 635 (36.9) 580 (33.0) 659 (33.0) 744 (36.1) 894 (33.1) 
 3 327 (27.4) 421 (31.8) 473 (34.2) 526 (34.6) 504 (31.8) 545 (33.2) 
 4 89 (10.0) 153 (13.6) 177 (14.8) 215 (16.1) 227 (16.9) 246 (18.3) 
 5 25 (3.2) 34 (3.9) 46 (4.4) 46 (4.3) 59 (5.0) 69 (6.8) 
Recent birth, n (%)       
 Yes, births in last 2 y 512 (34.6) 542 (30.7) 549 (31.3) 638 (31.1) 615 (30.5) 666 (25.7) 
 Yes, births in last 5 y 890 (60.3) 965 (55.4) 980 (57.6) 1109 (56.0) 1084 (53.5) 1286 (50.6) 
 Yes, births in last 10 y 1077 (74.1) 1141 (67.1) 1155 (68.7) 1311 (67.1) 1301 (64.6) 1569 (62.8) 
a

Unweighted percentages.

b

Baseline survey included participants 18–49; 2016–2020 included participants aged 15–49.

c

Wealth quintiles were calculated using standard DHS methods for wealth index.

Before the ICBHSS launch, the under-5 mortality rate was 51.1 (95% CI: 35.5–66.8) deaths per 1000 live births at baseline, with infant mortality (deaths under 1 year) and child mortality (deaths in children aged 1–5 years) contributing approximately equally to the observed rate (Table 3). There was an observed decrease in the under-5 mortality rate from 2015 to 2020 (Fig 1). In year 5 (2020), the under-5 mortality rate was 35.8 (95% CI: 23.4–48.2) deaths per 1000 live births. This reduction in under-5 mortality was accompanied by declines in both the child mortality rate and infant mortality rate. The overall decline in infant mortality was composed of a decline in the postneonatal mortality rate, but no decline was observed in neonatal mortality, with similar rates and CIs reported in 2015 and 2020. Mortality rates are not presented by site because of the small number of events and lack of precision in stratified estimates.

FIGURE 1

Annual under-5 mortality rates of comparing ICBHSS catchment areas, Kozah district (2015–2020), compared with Togo national estimates from United Nations (UN) Inter-agency Group for Child Mortality Estimation (IGME).

FIGURE 1

Annual under-5 mortality rates of comparing ICBHSS catchment areas, Kozah district (2015–2020), compared with Togo national estimates from United Nations (UN) Inter-agency Group for Child Mortality Estimation (IGME).

Close modal
TABLE 3

Annual Mortality Rates Among Participating Sites at Baseline (2015) and After Implementation of the Initiative (2020)

IndicatorBaseline (2015), n = 1336Year 5 (2020), n = 2095
Under-5 mortality rate per 1000 live births (95% CI) 51.1 (35.5–66.8) 35.8 (23.4–48.2) 
 Child mortality rate 27.7 (17.3–38.1) 17.3 (7.5–27.1) 
 Infant mortality rate 24.1 (13.9–34.3) 18.8 (11.8–25.9) 
  Postneonatal mortality rate 14.9 (7.8–22.0) 8.1 (4.1–12.2) 
  Neonatal mortality rate 9.2 (2.7–15.8) 10.7 (5.6–15.9) 
IndicatorBaseline (2015), n = 1336Year 5 (2020), n = 2095
Under-5 mortality rate per 1000 live births (95% CI) 51.1 (35.5–66.8) 35.8 (23.4–48.2) 
 Child mortality rate 27.7 (17.3–38.1) 17.3 (7.5–27.1) 
 Infant mortality rate 24.1 (13.9–34.3) 18.8 (11.8–25.9) 
  Postneonatal mortality rate 14.9 (7.8–22.0) 8.1 (4.1–12.2) 
  Neonatal mortality rate 9.2 (2.7–15.8) 10.7 (5.6–15.9) 

Estimations were conducted with annual community-based household survey data from 5-year period birth history tables for women ages 15–49 (18–49 baseline); population-weighted mortality rate analyses were conducted by using DHS rates methodology (DHS.rates R package); 95% CIs were calculated by using jackknife approach. Child, infant, postneonatal, and neonatal mortality rates were calculated from all births reported by respondents by using the same methods described above with adjustments for 1–5 y, 1 y, 29 d to 1 y, and 28 days.

We summarized reach and coverage measures related to maternal and pediatric care as follows (Table 4). The percentage of women reporting receiving any antenatal care in the first trimester of the most recent pregnancy was observed to increase in all sites from 37.5% (95% CI: 33.4%–41.7%) at baseline to 50.1% in year 5 (95% CI: 45.6%–54.7%). In the 3 rural sites, there was an increase in the proportion of the women who reported a health facility–based childbirth, at baseline between 47.6% and 66.0% to 79.5% to 89.4% at year 5 (2020). The proportion of women who received postnatal care after leaving the health facility increased from 38.1% (95% CI: 33.3%–43.1%) at baseline to >60% in each of the last 4 years. Among respondents who sought care for a child with a fever in the 2 weeks preceding the survey, there was an increasing trend of presenting for care within 1 day over the study period, from 51.9% (95% CI: 47.1%–56.6%) at baseline to 80.3% (95% CI: 74.6%–85.0%) at year 5 (2020).

TABLE 4

Summary of Key Measures Among Respondents in Intervention Catchment Areas at Baseline (2014–2015) and After Implementation of the Initiative (2015–2020)

Indicator Weighted (95% CIs)aBaseline (2014–2015)Year 1 (2015–2016)Year 2 (2016–2017)Year 3 (2017–2018)Year 4 (2018–2019)Year 5 (2019–2020)
A prenatal visit during the first trimester of last pregnancyb       
 Total (%) 37.5 (33.4–41.7) 39.0 (35.1–43.0) 40.4 (36.4–44.6) 50.5 (46.4–54.6)a 53.3 (49.1–57.5)a 50.1 (45.6–54.7)a 
  Adabawere 42.2 (35.0–49.7) 41.5 (35.4–47.8) 40.8 (34.3–47.7) 54.9 (47.9–61.7) 57.1 (49.7–64.2) 50.4 (43.0–57.8) 
  Djamdé 34.0 (27.0–41.7) 36.1 (27.3–45.8) 40.8 (33.1–49.0) 60.6 (52.1–68.4)a 58.4 (50.4–65.9)a 58.5 (53.3–63.6)a 
  Kpindi 40.6 (32.9–48.8) 34.4 (27.5–42.0) 46.8 (39.6–54.3) 44.6 (36.8–52.6) 46.3 (38.6–54.2) 46.7 (38.6–54.9) 
  Sarakawa 24.9 (19.1–31.8) 38.4 (30.3–47.1) 30.3 (23.4–38.1) 37.8 (30.3–46.0) 45.3 (37.1–53.7)a 47.3 (42.4–52.2)a 
Delivery at health facility for last birthc       
 Total (%) 73.0 (70.1–75.8) 79.7 (76.9–82.4)a 84.8 (82.2–87.2)a 87.8 (85.5–89.8)a 89.3 (86.6–91.5)a 89.4 (86.5–91.8)a 
  Adabawere 91.6 (87.2–94.6) 91.5 (86.9–94.7) 95.8 (91.5–97.9) 97.5 (93.7–99.0) 94.4 (89.4–97.1) 93.8 (88.3–96.8) 
  Djamdé 66.0 (58.9–72.4) 85.0 (78.7–89.6)a 84.9 (78.4–89.7)a 83.7 (76.3–89.1)a 90.8 (85.4–94.3)a 89.4 (86.0–92.1)a 
  Kpindi 56.6 (49.1–63.8) 72.0 (64.7–78.2)a 70.2 (62.9–76.5) 86.7 (80.7–91.1)a 86.2 (80.3–90.6)a 79.5 (72.0–85.4)a 
  Sarakawa 47.6 (40.6–54.8) 46.9 (39.0–54.9) 65.3 (57.0–72.8)a 68.7 (61.5–75.2)a 77.2 (68.9–83.8)a 85.2 (81.1–88.6)a 
Any postnatal care after leaving health facilityd       
 Total (%) 38.1 (33.3–43.1) 45.7 (41.2–50.3) 68.8 (64.4–72.9)a 77.0 (73.3–80.4)a 69.8 (65.4–73.9)a 60.1 (55.2–64.8)a 
 Adabawere 41.0 (33.8–48.7) 41.6 (35.3–48.1) 69.8 (63.0–75.8)a 78.1 (72.1–83.1)a 65.2 (57.6–72.1)a 58.2 (50.5–65.5)a 
 Djamdé 39.0 (31.1–47.6) 45.4 (35.5–55.6) 84.4 (76.8–89.8)a 78.9 (70.7–85.3)a 78.7 (70.7–84.9)a 84.9 (80.3–88.5)a 
 Kpindi 26.7 (18.7–36.6) 57.2 (46.8–66.9)a 50.4 (41.9–58.9)a 75.2 (66.7–82.0)a 71.2 (62.7–78.4)a 48.3 (39.3–57.4)a 
 Sarakawa 35.2 (25.3–46.5) 52.3 (39.8–64.6) 70.6 (60.6–78.9)a 74.0 (64.8–81.4)a 73.2 (64.5–80.4)a 63.5 (58.3–68.5)a 
Reporting breastfeeding childc       
 Total (%) 99.7 (99.2–99.9) 97.0 (95.7–97.9) 94.8 (92.6–96.4) 94.1 (91.4–96.0) 93.2 (90.5–95.2) 97.2 (94.8–98.5) 
  Adabawere 100.0 (100–100) 98.6 (96.6–99.4) 95.0 (90.8–97.3) 92.8 (87.7–95.9) 89.5 (84.0–93.3) 96.0 (91.5–98.1) 
  Djamdé 100.0 (100–100) 94.3 (89.4–97.0) 94.5 (89.0–97.4) 92.5 (84.6–96.6) 97.8 (94.1–99.2) 100.0 (100–100) 
  Kpindi 99.1 (96.4–99.8) 93.2 (88.4–96.1) 91.5 (86.7–94.7) 96.1 (90.9–98.4) 96.1 (90.4–98.5) 100.0 (100–100)a 
  Sarakawa 99.3 (97.1–99.8) 98.3 (95.7–99.3) 98.7 (95.7–99.6) 96.5 (91.3–98.6) 95.7 (91.0–98.0) 96.4 (93.5–98.0) 
Sought treatment of sick child on same day or next day from onset       
 Fevere 51.9 (47.1–56.6) 64.9 (59.1–70.2) 69.9 (63.7–75.5) 80.1 (74.4–84.8)a 83.3 (78.5–87.2)a 80.3 (74.6–85.0)a 
 Respiratory Illnessf 39.7 (32.3–47.6) 51.8 (30.4–72.6) 42.5 (17.9–71.5) 58.0 (44.2–70.7) 76.5 (65.1–85.1)a 57.2 (47.5–66.3) 
 Diarrheag 53.8 (45.7–61.8) 34.5 (25.4–44.7) 30.8 (21.2–42.5) 33.9 (23.2–46.6) 44.1 (32.3–56.6) 55.4 (43.6–66.7) 
Indicator Weighted (95% CIs)aBaseline (2014–2015)Year 1 (2015–2016)Year 2 (2016–2017)Year 3 (2017–2018)Year 4 (2018–2019)Year 5 (2019–2020)
A prenatal visit during the first trimester of last pregnancyb       
 Total (%) 37.5 (33.4–41.7) 39.0 (35.1–43.0) 40.4 (36.4–44.6) 50.5 (46.4–54.6)a 53.3 (49.1–57.5)a 50.1 (45.6–54.7)a 
  Adabawere 42.2 (35.0–49.7) 41.5 (35.4–47.8) 40.8 (34.3–47.7) 54.9 (47.9–61.7) 57.1 (49.7–64.2) 50.4 (43.0–57.8) 
  Djamdé 34.0 (27.0–41.7) 36.1 (27.3–45.8) 40.8 (33.1–49.0) 60.6 (52.1–68.4)a 58.4 (50.4–65.9)a 58.5 (53.3–63.6)a 
  Kpindi 40.6 (32.9–48.8) 34.4 (27.5–42.0) 46.8 (39.6–54.3) 44.6 (36.8–52.6) 46.3 (38.6–54.2) 46.7 (38.6–54.9) 
  Sarakawa 24.9 (19.1–31.8) 38.4 (30.3–47.1) 30.3 (23.4–38.1) 37.8 (30.3–46.0) 45.3 (37.1–53.7)a 47.3 (42.4–52.2)a 
Delivery at health facility for last birthc       
 Total (%) 73.0 (70.1–75.8) 79.7 (76.9–82.4)a 84.8 (82.2–87.2)a 87.8 (85.5–89.8)a 89.3 (86.6–91.5)a 89.4 (86.5–91.8)a 
  Adabawere 91.6 (87.2–94.6) 91.5 (86.9–94.7) 95.8 (91.5–97.9) 97.5 (93.7–99.0) 94.4 (89.4–97.1) 93.8 (88.3–96.8) 
  Djamdé 66.0 (58.9–72.4) 85.0 (78.7–89.6)a 84.9 (78.4–89.7)a 83.7 (76.3–89.1)a 90.8 (85.4–94.3)a 89.4 (86.0–92.1)a 
  Kpindi 56.6 (49.1–63.8) 72.0 (64.7–78.2)a 70.2 (62.9–76.5) 86.7 (80.7–91.1)a 86.2 (80.3–90.6)a 79.5 (72.0–85.4)a 
  Sarakawa 47.6 (40.6–54.8) 46.9 (39.0–54.9) 65.3 (57.0–72.8)a 68.7 (61.5–75.2)a 77.2 (68.9–83.8)a 85.2 (81.1–88.6)a 
Any postnatal care after leaving health facilityd       
 Total (%) 38.1 (33.3–43.1) 45.7 (41.2–50.3) 68.8 (64.4–72.9)a 77.0 (73.3–80.4)a 69.8 (65.4–73.9)a 60.1 (55.2–64.8)a 
 Adabawere 41.0 (33.8–48.7) 41.6 (35.3–48.1) 69.8 (63.0–75.8)a 78.1 (72.1–83.1)a 65.2 (57.6–72.1)a 58.2 (50.5–65.5)a 
 Djamdé 39.0 (31.1–47.6) 45.4 (35.5–55.6) 84.4 (76.8–89.8)a 78.9 (70.7–85.3)a 78.7 (70.7–84.9)a 84.9 (80.3–88.5)a 
 Kpindi 26.7 (18.7–36.6) 57.2 (46.8–66.9)a 50.4 (41.9–58.9)a 75.2 (66.7–82.0)a 71.2 (62.7–78.4)a 48.3 (39.3–57.4)a 
 Sarakawa 35.2 (25.3–46.5) 52.3 (39.8–64.6) 70.6 (60.6–78.9)a 74.0 (64.8–81.4)a 73.2 (64.5–80.4)a 63.5 (58.3–68.5)a 
Reporting breastfeeding childc       
 Total (%) 99.7 (99.2–99.9) 97.0 (95.7–97.9) 94.8 (92.6–96.4) 94.1 (91.4–96.0) 93.2 (90.5–95.2) 97.2 (94.8–98.5) 
  Adabawere 100.0 (100–100) 98.6 (96.6–99.4) 95.0 (90.8–97.3) 92.8 (87.7–95.9) 89.5 (84.0–93.3) 96.0 (91.5–98.1) 
  Djamdé 100.0 (100–100) 94.3 (89.4–97.0) 94.5 (89.0–97.4) 92.5 (84.6–96.6) 97.8 (94.1–99.2) 100.0 (100–100) 
  Kpindi 99.1 (96.4–99.8) 93.2 (88.4–96.1) 91.5 (86.7–94.7) 96.1 (90.9–98.4) 96.1 (90.4–98.5) 100.0 (100–100)a 
  Sarakawa 99.3 (97.1–99.8) 98.3 (95.7–99.3) 98.7 (95.7–99.6) 96.5 (91.3–98.6) 95.7 (91.0–98.0) 96.4 (93.5–98.0) 
Sought treatment of sick child on same day or next day from onset       
 Fevere 51.9 (47.1–56.6) 64.9 (59.1–70.2) 69.9 (63.7–75.5) 80.1 (74.4–84.8)a 83.3 (78.5–87.2)a 80.3 (74.6–85.0)a 
 Respiratory Illnessf 39.7 (32.3–47.6) 51.8 (30.4–72.6) 42.5 (17.9–71.5) 58.0 (44.2–70.7) 76.5 (65.1–85.1)a 57.2 (47.5–66.3) 
 Diarrheag 53.8 (45.7–61.8) 34.5 (25.4–44.7) 30.8 (21.2–42.5) 33.9 (23.2–46.6) 44.1 (32.3–56.6) 55.4 (43.6–66.7) 

Denominator distinct for each variable and defined by year as follows.

a

Estimates represent a statistically significant increase from baseline (2015) as determined by nonoverlapping 95% CIs.

b

Respondents with any prenatal care in last 2 y: 2015 (n = 469), 2016 (n = 602), 2017 (n = 566), 2018 (n = 574), 2019 (n = 566), 2020 (n = 608).

c

Respondents who reported birth in last 2 y: 2015 (n = 529), 2016 (n = 624), 2017 (n = 581), 2018 (n = 586), 2019 (n = 573), 2020 (n = 612).

d

Respondents who delivered at health facility in last 2 y: 2015 (n = 362), 2016 (n = 471), 2017 (n = 478), 2018 (n = 497), 2019 (n = 502), 2020 (n = 540).

e

Respondents who sought treatment of a child with fever in last 2 wk: 2015 (n = 379), 2016 (n = 307), 2017 (n = 253), 2018 (n = 295), 2019 (n = 273), 2020 (n = 340).

f

Respondents who sought treatment of a child with respiratory illness in last 2 wk: 2015 (n = 156), 2016 (n = 23), 2017 (n = 10), 2018 (n = 58), 2019 (n = 56), 2020 (n = 141).

g

Respondents who sought treatment of a child with diarrheal illness in last 2 wk: 2015 (n = 133), 2016 (n = 108), 2017 (n = 65), 2018 (n = 66), 2019 (n = 62), 2020 (n = 100).

The proportion of the population who reported receiving a CHW home visit in the previous year at baseline, 49.3% (95% CI: 46.7%–51.9%), compared with 58.7% (95% CI: 56.1%–61.1%) at year 5, and treatment at home, 24.1% (95% CI: 21.9%–26.4%) at baseline compared with 45.7% (95% CI 43.3%–48.2%) at year 5 (Fig 2). Analyses disaggregated by site revealed larger gains observed at the 3 rural sites (Djamdé, Kpindi, and Sarakawa), compared with the urban site (Adabawere).

FIGURE 2

Weighted proportion of households reporting that a CHW conducted a (A) home visit and (B) provided any home treatment in the past year in ICBHSS catchment areas, Kozah district, Togo (2015–2020).

FIGURE 2

Weighted proportion of households reporting that a CHW conducted a (A) home visit and (B) provided any home treatment in the past year in ICBHSS catchment areas, Kozah district, Togo (2015–2020).

Close modal

There were 253 290 CHW home visits and 76 388 maternal and pediatric (<5 years old) health facility visits conducted over the 5-year intervention period across the 4 sites (Table 5). Timeliness of treatment, the proportion of cases of child illness treated within 72 hours of onset, improved from 80% in 2016 to 97% in 2020. The proportion of successful referrals to higher levels of care increased overall from 56% in 2016 to 79% in 2019 and 76% in 2020.

TABLE 5

Summary of ICBHSS Program Indicators, Process Measures, and Assessment of Implementation Quality Domains Within Catchment Areas for Pediatric (<5 Years Old) and Maternal Health Services, Kozah District, Togo

Year 1 (2015–2016)Year 2 (2016–2017)Year 3 (2017–2018)Year 4 (2018–2019)Year 5 (2019–2020)
CHW home visits conducted, annually, n total 51 874 55 734 49 290 46 425 49 967 
 Adabawere 18 921 21 498 19 171 14 791 14 486 
 Djamdé 11 312 10 634 8670 9454 10 848 
 Kpindi 7972 8850 9196 9265 9810 
 Sarakawa 13 669 14 752 12 253 12 915 14 823 
Health facility visits, annually, n total 11 752 15 511 15 946 20 221 12 958 
 Adabawere 3999 5725 6446 6696 2751 
 Djamdé 2408 2949 2946 3713 3491 
 Kpindi 2582 2956 2642 4081 2909 
 Sarakawa 2764 3881 3912 5731 3807 
Timely: percentage of children assessed by CHW or at health facility since onset of symptoms, %, h      
 <24 41 38 43 44 38 
 <48 66 67 74 76 73 
 <72 80 86 93 95 97 
Efficient: percentage of referrals to higher level of care effectuated,%, total 56 68 64 79 76 
 Adabawere 44 49 46 51 51 
 Djamdé 53 63 53 64 74 
 Kpindi 60 76 69 93 72 
 Sarakawa 70 80 84 94 89 
Year 1 (2015–2016)Year 2 (2016–2017)Year 3 (2017–2018)Year 4 (2018–2019)Year 5 (2019–2020)
CHW home visits conducted, annually, n total 51 874 55 734 49 290 46 425 49 967 
 Adabawere 18 921 21 498 19 171 14 791 14 486 
 Djamdé 11 312 10 634 8670 9454 10 848 
 Kpindi 7972 8850 9196 9265 9810 
 Sarakawa 13 669 14 752 12 253 12 915 14 823 
Health facility visits, annually, n total 11 752 15 511 15 946 20 221 12 958 
 Adabawere 3999 5725 6446 6696 2751 
 Djamdé 2408 2949 2946 3713 3491 
 Kpindi 2582 2956 2642 4081 2909 
 Sarakawa 2764 3881 3912 5731 3807 
Timely: percentage of children assessed by CHW or at health facility since onset of symptoms, %, h      
 <24 41 38 43 44 38 
 <48 66 67 74 76 73 
 <72 80 86 93 95 97 
Efficient: percentage of referrals to higher level of care effectuated,%, total 56 68 64 79 76 
 Adabawere 44 49 46 51 51 
 Djamdé 53 63 53 64 74 
 Kpindi 60 76 69 93 72 
 Sarakawa 70 80 84 94 89 

Data represent only postbaseline programmatic data.

As part of the community-based implementation strategy to support stakeholder engagement between 2014 and 2020, the team conducted 1379 community meetings, including town halls, educational events, and exchanges in partnership with MOH staff, CHWs, and community members. From 2016 to 2020, there were 10 program implementation meetings with district and regional health officials and 17 joint supervision visits with district and regional health officials to support public sector integration. We estimated that the total annual cost of the ICBHSS intervention in 2019 was to $389 412, or $8.84 per person per year.

In our study, we observed a decline in the under-5 mortality rate in the Kozah district of Togo after the implementation of the ICBHSS initiative over 5 years. The decline observed in 4 ICBHSS catchment areas was greater, 30%, compared with the estimated 14% decline observed throughout Togo during the same time period, as published by the United Nations Inter-agency Group for Child Mortality Estimation.6,47  This reduction in mortality was associated with observed increases in health care coverage, use of health services, and improved quality of service delivery known to reduce child mortality. Population-representative community surveys suggested increased in-home care and treatment by CHWs; increased uptake of antenatal care, especially in the first trimester; more births occurring at health facilities; more women receiving postnatal care after leaving the health facility; and improved health-seeking behaviors when children fell ill. In addition, programmatic data suggested improvements in quality. The estimated annual cost of the ICBHSS program was $389 412, or $8.84 per person per year, and would be a significant new investment to the MOH; however, this amount would represent <25% of the estimated per capita health expenditure in Togo ($38 in 2017).48  To our knowledge, this is the first pragmatic study in Togo to evaluate a complex evidence-based intervention bundle in terms of both effectiveness and secondary explanatory factors including health-seeking behaviors and clinic use.

The plausibility of observed mortality reduction being in part an effect of the intervention is supported by the “3 delays”49,50  model, as the ICBHSS initiative was designed to reduce (1) delays in seeking care through CHWs; (2) delays in accessing facility-based care through eliminating of point-of-care costs, improved referrals, and CHWs; and (3) delays in receiving appropriate treatment through health facility and supply-chain operational improvements, clinical mentoring, and enhanced supervision. Our findings are consistent with the evaluation of other evidence-based practice interventions addressing multiple barriers to health care access and quality. Authors of a recent systematic review examining the impact of community-based implementation strategies employing trained health outreach workers (eg, CHWs) found that these programs were associated with a reduction in maternal morbidity, neonatal mortality, stillbirths, perinatal mortality, and likely maternal mortality, with 6 studies from Africa.22  Improvements in child health and mortality outcomes have also been observed after the implementation of integrated facility- and community-based health systems-strengthening initiatives in Mali,18  Rwanda,51  Madagascar,52  the Gambia,21  Ghana,53  and Benin.54 

This study has several important limitations. Because we used a pre–post study design without a subnational control group, we cannot rule out larger temporal trends in Togo contributing to the greater-than-expected reductions in under-5 mortality. We are not aware of demographic or socioeconomic changes that could explain the reduction in the district during this time period. Although there are limitations to the comparison with national mortality estimates, the lack of routinely collected reliable mortality data at the subnational level in low-income settings like Togo precludes other assessments. Direct comparison with the United Nations Inter-agency Group for Child Mortality Estimation national estimates is complicated by different methodologic approaches to the estimates. Although collection of full birth histories from household survey data are considered the standard for mortality estimates in low-income countries, there are significant data quality challenges that complicate the ability to monitor yearly changes in mortality through these data.55  In addition, it should be noted that estimated mortality rates from this study were based on a small (<100) absolute number of reported child deaths. In addition, although demographic and household surveys are a fundamental data source for assessing reproductive, maternal, and child health care services in low-income countries, issues regarding the validity and associated self-report biases of household survey data have been widely recognized.35,55  Although we attempted to identify clinic catchment population using our sampling techniques, it is possible that participants surveyed are not the “true” catchment population, that they may seek care at other locations, and that this may be more likely to occur in the urban location. An important limitation includes the distinct number of households “not at home” during baseline sampling, which may have reduced the representativeness of the respondents in 2015. In 2016, because of this high rate, data collectors changed the data collection protocol to include returning to a household 3 times before marking “not at home” to align with Togo national DHS recommendations and Multiple Indicator Cluster Survey guidance. In addition, the age range was changed in 2016 to include 15- to 17-year-olds to similarly align with the Togolese MoH community survey protocols. Additional sensitivity analyses excluding 15- to 17-year-old respondents in the calculation of under-5 mortality in 2020 did not meaningfully change the estimate (not shown). Differences in population density in the urban site compared with the rural sites may have influenced the implementation of the systematic sampling strategy and the representativeness of respondents. In 2018, we initiated a type II pragmatic effectiveness-implementation study including a cluster-randomized stepped-wedge trial to address some of the methodologic limitations cited, specifically adding control clusters, and to further evaluate the impact of the ICBHSS initiative on primary health care uptake and child mortality in northern Togo.56 

We observed gains in access to and quality of evidence-based maternal and child health services that were associated with an observed decline in under-5 mortality over the first 5 years of the ICBHSS initiative. There are several areas of research that remain to better understand this potential causal relationship. The ICBHSS initiative aimed to address a know-do gap related to maternal and child health care for families in Togo and put what is known into practice using community-based implementation strategies. Our experience may provide a path forward to reduce infant and child mortality in similar low-income settings and to eliminate preventable child death globally.

This manuscript is dedicated to our late colleague, Dr Abdourahmane Diparidé Agbèrè, who was a tireless advocate for Togolese children. He was not able to see the results of this work that he supported, but we know that the progress described and the lives of children saved because of his work remain his lasting legacy. We acknowledge and thank the following partners and advisers for their integral assistance in developing and implementing this study: the health authorities in the Kara region and the districts of Kozah; IH staff in Togo and New York; faculty advisers at the Albert Einstein College of Medicine, City University of New York, and the University of Washington; and collaborators from New York University School of Public Health. We extend our gratitude for the partnership between Dr Ari Johnson and his team at Muso and thank Dr Johnson specifically for his help designed the evaluation, review and feedback of this manuscript. We also thank our colleague, Stephanie Anderson, who assisted with the editing process.

FUNDING: Funded by Integrate Health through generous philanthropic support.

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2021-051026.

Dr Fiori conceptualized and designed the study, drafted the initial manuscript, interpreted results, and reviewed and revised the manuscript; Ms Lauria conducted the initial analyses and supported final analyses, coordinated and supervised data collection at years 3 and 4, drafted the initial manuscript, interpreted results, and reviewed and revised the manuscript; Dr Singer supported final analyses, drafted the initial manuscript, interpreted results, and reviewed and revised the manuscript; Dr Jones conceptualized and designed the study, conducted the final analyses, interpreted results, and reviewed and revised the manuscript; Dr Belli conducted the final analyses, interpreted results, and reviewed and revised the manuscript; Mr Aylward conducted the costing analysis, interpreted results, and reviewed and revised the manuscript; Mr Sowu coordinated and supervised data collection and reviewed and revised the manuscript; Mr Gbeleou and Drs Agoro, Ekouevi, and Grunitsky-Bekele reviewed and revised the manuscript; Ms Singham Goodwin designed the data collection instruments, coordinated and supervised data collection at baseline and second year, and reviewed and revised the manuscript; Ms Morrison designed the data collection instruments, coordinated and supervised data collection at baseline, and reviewed and revised the manuscript; Dr Hirschhorn conceptualized and designed the study, interpreted results, and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

This trial has been registered at ClinicalTrials.gov (identifier NCT03773913).

     
  • CI

    confidence interval

  •  
  • CHW

    community health worker

  •  
  • DHS

    Demographic and Health Survey

  •  
  • ICBHSS

    Integrated Community-Based Health Systems-Strengthening

  •  
  • IH

    Integrate Health

  •  
  • MoH

    Ministry of Health and Public Hygiene

1
You
D
,
Hug
L
,
Ejdemyr
S
, et al;
United Nations Inter-agency Group for Child Mortality Estimation (UN IGME)
.
Global, regional, and national levels and trends in under-5 mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Inter-agency Group for Child Mortality Estimation
.
Lancet
.
2015
;
386
(
10010
):
2275
2286
2
World Health Organization
.
World health statistics 2015. 2015
.
3
Golding
N
,
Burstein
R
,
Longbottom
J
, et al
.
Mapping under-5 and neonatal mortality in Africa, 2000–15: a baseline analysis for the Sustainable Development Goals
.
Lancet
.
2017
;
390
(
10108
):
2171
2182
4
United Nations Children’s Fund (UNICEF)
.
For Every Child, Every Right: The Convention on the Rights of the Child at a Crossroads
.
New York, NY
:
United Nations Children’s Fund (UNICEF)
;
2019
5
World Health Organization (WHO)
.
Bridging the “Know–Do” Gap Meeting on Knowledge Translation in Global Health
.
Vol 25
.
Geneva, Switzerland
:
World Health Organization (WHO)
;
2005
6
UN Inter-agency Group for Child Mortality Estimation
.
Levels and Trends in Child Mortality: Report 2020
.
New York
;
2019
.
7
Bcheraoui
C El
,
Mimche
H
,
Miangotar
Y
, et al
.
Burden of disease in francophone Africa, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017
.
Lancet Glob Health
.
2020
;
8
(
3
):
e341
e351
8
Ministère de la Planification du Développement et de l’Aménagement du Territoire (MPDAT) M de la SM et II
.
Enquête Démographique et de Sante Au Togo 2013 – 2014
.
Rockville, MD
;
2015
.
9
Togo Ministry of Health
.
Togo Ministère de La Santé: rapport Annuel de Performance Gestion 2014
.
2014
.
10
Togo Ministry of Health
.
Togo Ministère de La Santé: principaux indicateurs de Sante 2014
.
2014
.
11
Ekouevi
DK
,
Gbeasor-Komlanvi
FA
,
Yaya
I
, et al
.
Incomplete immunization among children aged 12-23 months in Togo: a multilevel analysis of individual and contextual factors
.
BMC Public Health
.
2018
;
18
(
1
):
952
12
Kruk
ME
,
Gage
AD
,
Arsenault
C
, et al
.
High-quality health systems in the Sustainable Development Goals era: time for a revolution
.
Lancet Glob Health
.
2018
;
6
(
11
):
e1196
e1252
13
Johnson
AD
,
Thomson
DR
,
Atwood
S
, et al
.
Assessing early access to care and child survival during a health system strengthening intervention in Mali: a repeated cross sectional survey
.
PLoS One
.
2013
;
8
(
12
):
e81304
14
Magge
H
,
Anatole
M
,
Cyamatare
FR
, et al
.
Mentoring and quality improvement strengthen integrated management of childhood illness implementation in rural Rwanda
.
Arch Dis Child
.
2015
;
100
(
6
):
565
570
15
Manzi
A
,
Nyirazinyoye
L
,
Ntaganira
J
, et al
.
Beyond coverage: improving the quality of antenatal care delivery through integrated mentorship and quality improvement at health centers in rural Rwanda
.
BMC Health Serv Res
.
2018
;
18
(
1
):
136
16
Johri
M
,
Ridde
V
,
Heinmüller
R
,
Haddad
S
.
Estimation of maternal and child mortality one year after user-fee elimination: an impact evaluation and modelling study in Burkina Faso
.
Bull World Health Organ
.
2014
;
92
(
10
):
706
715
17
Calhoun
LM
,
Speizer
IS
,
Guilkey
D
,
Bukusi
E
.
The effect of the removal of user fees for delivery at public health facilities on institutional delivery in urban Kenya
.
Matern Child Health J
.
2018
;
22
(
3
):
409
418
18
Johnson
AD
,
Thiero
O
,
Whidden
C
, et al
.
Proactive community case management and child survival in periurban Mali
.
BMJ Glob Health
.
2018
;
3
(
2
):
e000634
19
Yates
R
.
Universal health care and the removal of user fees
.
Lancet
.
2009
;
373
(
9680
):
2078
2081
20
Armstrong Schellenberg
JR
,
Adam
T
,
Mshinda
H
, et al
.
Effectiveness and cost of facility-based Integrated Management of Childhood Illness (IMCI) in Tanzania
.
Lancet
.
2004
;
364
(
9445
):
1583
1594
21
Christopher
JB
,
Le May
A
,
Lewin
S
,
Ross
DA
.
Thirty years after Alma-Ata: a systematic review of the impact of community health workers delivering curative interventions against malaria, pneumonia and diarrhoea on child mortality and morbidity in sub-Saharan Africa
.
Hum Resour Health
.
2011
;
9
:
27
22
Lassi
ZS
,
Bhutta
ZA
.
Community-based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes
.
Cochrane Database Syst Rev
.
2015
;(
3
):
CD007754
23
Amouzou
A
,
Morris
S
,
Moulton
LH
,
Mukanga
D
.
Assessing the impact of integrated community case management (iCCM) programs on child mortality: review of early results and lessons learned in sub-Saharan Africa
.
J Glob Health
.
2014
;
4
(
2
):
020411
24
Gogia
S
,
Sachdev
HS
.
Home visits by community health workers to prevent neonatal deaths in developing countries: a systematic review
.
Bull World Health Organ
.
2010
;
88
(
9
):
658
666B
25
Gogia
S
,
Sachdev
HPS
.
Home-based neonatal care by community health workers for preventing mortality in neonates in low- and middle-income countries: a systematic review
.
J Perinatol
.
2016
;
36
(
suppl 1
):
S55
S73
26
Dawson
AJ
,
Buchan
J
,
Duffield
C
,
Homer
CSE
,
Wijewardena
K
.
Task shifting and sharing in maternal and reproductive health in low-income countries: a narrative synthesis of current evidence
.
Health Policy Plan
.
2014
;
29
(
3
):
396
408
27
Tso
LS
,
Best
J
,
Beanland
R
, et al
.
Facilitators and barriers in HIV linkage to care interventions: a qualitative evidence review
.
AIDS
.
2016
;
30
(
10
):
1639
1653
28
Hirschhorn
LR
,
Baynes
C
,
Sherr
K
, et al
.
Approaches to ensuring and improving quality in the context of health system strengthening: a cross-site analysis of the five African Health Initiative Partnership programs
.
BMC Health Serv Res
.
2013
;
13
(
suppl 2
):
S8
29
Manzi
A
,
Magge
H
,
Hedt-Gauthier
BL
, et al
.
Clinical mentorship to improve pediatric quality of care at the health centers in rural Rwanda: a qualitative study of perceptions and acceptability of health care workers
.
BMC Health Serv Res
.
2014
;
14
:
275
30
Zulu
JM
,
Kinsman
J
,
Michelo
C
,
Hurtig
A-K
.
Integrating national community-based health worker programmes into health systems: a systematic review identifying lessons learned from low-and middle-income countries
.
BMC Public Health
.
2014
;
14
:
987
31
Noordam
AC
,
Carvajal-Velez
L
,
Sharkey
AB
,
Young
M
,
Cals
JWL
.
Care seeking behaviour for children with suspected pneumonia in countries in sub-Saharan Africa with high pneumonia mortality
.
PLoS One
.
2015
;
10
(
2
):
e0117919
32
Sunguya
BF
,
Mlunde
LB
,
Ayer
R
,
Jimba
M
.
Towards eliminating malaria in high endemic countries: the roles of community health workers and related cadres and their challenges in integrated community case management for malaria: a systematic review
.
Malar J
.
2017
;
16
(
1
):
10
33
Kok
MC
,
Dieleman
M
,
Taegtmeyer
M
, et al
.
Which intervention design factors influence performance of community health workers in low- and middle-income countries? A systematic review
.
Health Policy Plan
.
2015
;
30
(
9
):
1207
1227
34
Kish
L
.
A procedure for objective respondent selection within the household
.
J Am Stat Assoc
.
1949
;
44
(
247
):
380
387
35
Korenromp
EL
,
Arnold
F
,
Williams
BG
,
Nahlen
BL
,
Snow
RW
.
Monitoring trends in under-5 mortality rates through national birth history surveys
.
Int J Epidemiol
.
2004
;
33
(
6
):
1293
1301
36
Direction Générale de la Statistique et de la Comptabilité Nationiale
.
Togo: recensement général de la population et de l’habitat (2009-2011), quatrième recensement générale au togo
.
37
KoBoToolbox
.
Data collection tools for challenging environments
.
2017
.
Available at: https://github.com/kobotoolbox. Accessed August 2, 2021
.
38
Hatcher
AM
,
Tsai
AC
,
Kumbakumba
E
, et al
.
Sexual relationship power and depression among HIV-infected women in Rural Uganda
.
PLoS One
.
2012
;
7
(
12
):
e49821
39
Glasgow
RE
,
Vogt
TM
,
Boles
SM
.
Evaluating the public health impact of health promotion interventions: the RE-AIM framework
.
Am J Public Health
.
1999
;
89
(
9
):
1322
1327
40
Pedersen
J
,
Liu
J
.
Child mortality estimation: appropriate time periods for child mortality estimates from full birth histories
.
PLoS Med
.
2012
;
9
(
8
):
e1001289
41
Elkasabi
M
.
Calculating fertility and childhood mortality rates from survey data using the DHS.rates R package
.
PLoS One
.
2019
;
14
(
5
):
e0216403
42
Pullum
TW
.
A unified statistical framework for demographic rates using demographic and health survey data
. In:
IUSSP International Population Conference
;
Cape Town, South Africa
;
2017
43
Institute of Medicine
.
Crossing the Quality Chasm: A New Health System for the 21st Century
.
Washington, DC
:
National Academies Press (US)
;
2001
44
Iwelunmor
J
,
Blackstone
S
,
Veira
D
, et al
.
Toward the sustainability of health interventions implemented in sub-Saharan Africa: a systematic review and conceptual framework
.
Implement Sci
.
2016
;
11
(
1
):
43
45
Özaltın
A
,
Cashin
C
.
Costing of Health Services for Provider Payment: A Practical Manual Based on Country Costing Challenges, Trade-Offs, and Solutions
.
Joint Learning Network for Universal Health Coverage
;
Washington, DC
;
2014
46
Pinnock
H
,
Barwick
M
,
Carpenter
CR
, et al;
StaRI Group
.
Standards for Reporting Implementation Studies (StaRI) statement
.
BMJ
.
2017
;
356
:
i6795
47
UN Inter-agency Group for Child Mortality Estimation (UN IGME)
.
Country-specific under-five mortality rate
.
2020
.
Available at: https://childmortality.org/data/Togo/. Accessed August 21, 2020
48
Current health expenditure per capita (current US$) – Togo. The World Bank
.
49
Thaddeus
S
,
Maine
D
.
Too far to walk: maternal mortality in context
.
Soc Sci Med
.
1994
;
38
(
8
):
1091
1110
50
Moyer
CA
,
Johnson
C
,
Kaselitz
E
,
Aborigo
R
.
Using social autopsy to understand maternal, newborn, and child mortality in low-resource settings: a systematic review of the literature
.
Glob Health Action
.
2017
;
10
(
1
):
1413917
51
Thomson
DR
,
Amoroso
C
,
Atwood
S
, et al
.
Impact of a health system strengthening intervention on maternal and child health outputs and outcomes in rural Rwanda 2005-2010
.
BMJ Glob Health
.
2018
;
3
(
2
):
e000674
52
Garchitorena
A
,
Miller
AC
,
Cordier
LF
, et al
.
Early changes in intervention coverage and mortality rates following the implementation of an integrated health system intervention in Madagascar
.
BMJ Glob Health
.
2018
;
3
(
3
):
e000762
53
Bawah
AA
,
Awoonor-Williams
JK
,
Asuming
PO
, et al
.
The child survival impact of the Ghana Essential Health Interventions Program: a health systems strengthening plausibility trial in Northern Ghana
.
PLoS One
.
2019
;
14
(
6
):
e0218025
54
Rowe
AK
,
Onikpo
F
,
Lama
M
,
Osterholt
DM
,
Deming
MS
.
Impact of a malaria-control project in Benin that included the integrated management of childhood illness strategy
.
Am J Public Health
.
2011
;
101
(
12
):
2333
2341
55
Bryce
J
,
Arnold
F
,
Blanc
A
, et al;
CHERG Working Group on Improving Coverage Measurement
.
Measuring coverage in MNCH: new findings, new strategies, and recommendations for action
.
PLoS Med
.
2013
;
10
(
5
):
e1001423
56
Lauria
ME
,
Fiori
KP
,
Jones
HE
, et al
.
Assessing the Integrated Community-Based Health Systems Strengthening initiative in northern Togo: a pragmatic effectiveness-implementation study protocol
.
Implement Sci
.
2019
;
14
(
1
):
92

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.