Reducing Child Mortality in Togo With an Integrated Primary Care Program: A Cluster Randomized Clinical Trial

The objective of this study was to evaluate the effectiveness and implementation of the Integrated Primary Care Program (IPCP) in reducing under-five mortality rate (U5M) in Togo when implemented at scale.

Using a stepped-wedge cluster randomized trial design (identifier NCT03694366), the IPCP was sequentially implemented across 4 districts (ie, Bassar, Binah, Dankpen, and Kéran) in Togo between 2018 and 2021. This pragmatic type II hybrid effectiveness-implementation study collected data from the following: (1) household surveys adapted from the Demographic Household Survey and Multiple Indicator Cluster Survey; (2) health center surveys using the Service Availability and Readiness Assessment; (3) key informant interviews using the Consolidated Framework for Implementation Research; and (4) costing data using the Community Health Planning and Costing Tool. Effectiveness was assessed through longitudinal measurements in U5M and quality of care. Implementation strategies were evaluated through secondary measures including reach, adoption, implementation, and maintenance.

A total of 50 404 household surveys were completed from 2018 to 2023 across the 4 districts. The hazard of U5M was 29% lower (95% CI: 4%-48%; P = .02675) in the intervention (45.5 deaths per 1000 live births) compared with the control periods (64.5 deaths per 1000 live births), adjusting for sociodemographic confounders. Health center assessments of service readiness and availability increased in all districts from baseline. Key informant interviews identified caregiver trust and engagement as critical success factors. The estimated annual average program cost was $10.28 per person.

Our findings suggest that successful implementation of the IPCP, a package of evidence-based interventions with integrated implementation strategies, reduces U5M, improves care quality, and can be delivered at scale.