Background: Integrated community case management (iCCM) is an equity-focused strategy adopted by WHO/UNICEF to improve access to essential treatment services for children. In 2010, the Government of Ethiopia used its health extension workers (HEWs) programme to scale up the iCCM of childhood illness strategy throughout the country. However, after two years, utilization of HEWs remained low despite the presence of a service delivery strategy that focused on minimizing several common access barriers related to cost, distance and quality of services. For instance, HEWs were trained and subsequently supported, volunteer community health workers were deployed to the villages and children below the age of five years received free healthcare. In addition, the HEW’s community mobilization and education activities were part of existing national child health initiatives to promote community engagement and programme sustainability. Research was undertaken to elucidate perceptions and experiences of caregivers and to better understand the reportedly low utilization of iCCM services. The parameters used to define accessibility were availability of qualified health providers and health commodities at the health post; geographic accessibility; affordability of the services; and acceptability of the providers and services.

Rapid ethnographic assessments in eight rural health post catchment areas of Jimma and West Hararghe zone were conducted using focus group discussions (FGDs) and in-depth interviews (IDIs). FGDs focused on social norms of care-seeking and community perceptions regarding HEWs and iCCM services. IDIs focused on care-seeking experiences of caregivers over the course of the most recent illness of a child, including perceptions relating to barriers and facilitators to utilizing HEWs delivering iCCM services at the health post. The study participants were mothers, fathers, HEWs and community health workers.

Findings: HEWs were frequently absent. Although the services were free, many caregivers could not access services due to related social and transport costs. Long distances to the health posts, bad terrain coupled with inadequate transportation frequently rendered the health posts inaccessible. Lack of ownership of the health posts due to insensitive HEWs, lack of trust of the quality of care provided and lack of decision-making power of the primary caregiver regarding care choices for their child were also cited as prohibiting factors. However, caregivers also had limited awareness of child illness and the services provided at the health posts.

Conclusions: In spite of the conducive and supportive health policies, the use of iCCM services was suboptimal due to challenges at the personal and systems level.

Lessons: Innovative approaches are needed to address challenges identified and in order to reduce barriers and promote utilization of iCCM services for all caregivers and children in need.