scholarly journals Initiation, scale-up and outcomes of the Cambodian National MDR-TB programme 2006–2016: hospital and community-based treatment through an NGO–NTP partnership

2018 ◽  
Vol 5 (1) ◽  
pp. e000256 ◽  
Author(s):  
Sophan Sam ◽  
Adrienne E Shapiro ◽  
Thim Sok ◽  
Sokhan Khann ◽  
Rassi So ◽  
...  
Keyword(s):  
Large Scale ◽  
Health Workers ◽  
Treatment Success ◽  
Scale Up ◽  
Treatment Programme ◽  
Limited Information ◽  
Community Based ◽  
Tb Treatment ◽  
Adherence Support ◽  
Mdr Tb

IntroductionProlonged inpatient multidrug-resistant tuberculosis (MDR-TB) treatment for all patients is not sustainable for high-burden settings, but there is limited information on community-based treatment programme outcomes for MDR-TB.MethodsThe Cambodian Health Committee, a non-governmental organisation (NGO), launched the Cambodian MDR-TB programme in 2006 in cooperation with the National Tuberculosis Program (NTP) including a community-based treatment option as a key programme component. The programme was transferred to NTP oversight in 2011 with NGO clinical management continuing. Patients electing to receive home-based treatment were followed by a dedicated adherence supporter and a multidisciplinary outpatient team of nurses, physicians and community health workers. Patients hospitalised for >1 month of treatment (hospital based) received similar management after discharge. All patients received a standardised second-line MDR-TB regimen and were provided nutritional and adherence support. Outcomes were reviewed for patients completing 24 months of treatment and predictors of treatment success were evaluated using logistic regression.ResultsOf 582 patients with MDR-TB who initiated treatment between September 2006 and June 2016, 20% were HIV coinfected, 288 (49%) initiated community-based treatment and 294 (51%) received hospital-based treatment. Of 486 patients with outcomes available, 364 (75%) were cured, 10 (2%) completed, 28 (6%) were lost to follow-up, 3 (0.6%) failed and 77 (16%) died. There was no difference between treatment success in community versus hospital-based groups (adjusted OR (aOR) 1.0, p=0.99). HIV infection, older age and body mass index <16 were strongly associated with decreased treatment success (aOR 0.33, p<0.001; aOR 0.40, p<0.001; aOR 0.40; p<0.001).ConclusionsCambodia’s NGO–NTP partnership successfully developed and scaled up a model MDR-TB treatment programme. The first large-scale MDR-TB programme in Asia with a significant community-based component, the programme achieved equally high treatment success in patients with community-based compared with hospital-based initiation of MDR treatment.

Examining the cost of community-based tuberculosis treatment in South Africa

2020 ◽  
Vol 24 (6) ◽  
pp. 612-618
Author(s):  
A. Moran ◽  
N. Kula ◽  
G. Jagwer ◽  
E. Broughton ◽  
Y. Pillay ◽  
...  
Keyword(s):  
South Africa ◽  
Treatment Success ◽  
Standard Of Care ◽  
Multidrug Resistant ◽  
National Standard ◽  
Eastern Cape ◽  
Community Based ◽  
Tb Treatment ◽  
Adherence Support ◽  
The Cost

SETTING: While South Africa has improved access to tuberculosis (TB) treatment and care, the 2015 treatment success rate for multidrug-resistant TB (MDR-TB) remains low, at 55%. Community-based TB treatment and care improves patient retention compared to the standard of care alone.OBJECTIVE: To assess the cost of a USAID-funded community-based TB model in Nelson Mandela Bay Health District (NMBHD), Eastern Cape Province, South Africa compared to the national standard of care alone.DESIGN: We estimated the cost of community-based DR-TB treatment and adherence support compared to the standard of care alone.RESULTS: Average overall costs were US$2827 lower per patient on the community-based model than the standard of care alone.CONCLUSION: The per-patient cost of the community-based model is lower than the standard of care alone. Assuming the costs and effects of a community-based model implemented in NMBHD were observed at a larger scale, implementing the model could reduce overall health system costs.

scholarly journals Bottlenecks to Intervention Scale Up: Supply and Demand Side Perspectives From a Large, Community-based Trial of Malaria Testing

2021 ◽  
Author(s):  
Joseph Kirui ◽  
Josephine Malinga ◽  
Edna Sang ◽  
George Ambani ◽  
Lucy Abel ◽  
...  
Keyword(s):  
Community Health ◽  
Large Scale ◽  
Health Workers ◽  
Supply And Demand ◽  
Scale Up ◽  
Demand Side ◽  
Endemic Region ◽  
Community Based ◽  
The Impact ◽  
Malaria Test

Abstract Background: Maximizing the impact of community-based programs requires understanding how the supply of and demand for the intervention interact at the point of delivery. We present results from a large-scale community health worker study designed to increase the availability of and demand for malaria diagnostic testing in a rural, malaria-endemic region in western Kenya between 2015 and 2017. Methods: Community Health Workers (CHWs) provided free malaria Rapid Diagnostic Test(mRDT) in the community. Those with a positive malaria test were provided with a discounted first-line antimalarial over-the-counter. We conducted a community-based survey to collect individual study outcomes at 12- and 18-months post-implementation. In addition, we collected monthly testing data from the 244 participating CHWs and also conducted in-depth interviews with a random sample of 70 CHWs. Results: From the survey, 55% (n=948/1738) reported having a malaria test for their recent illness with 38% having been tested by a CHW. Being aware of a local CHW (95% CI:1.10-2.04) and belonging to a wealthy household (95% CI:1.14-2.06) were associated with higher malaria testing uptake from any source. Poorer households were more likely to receive a test from a CHW. School-aged children between 5-17 years were more than twice as likely to be tested by a CHW (95% CI:1.47-4.14). Both confidence in AL treatment (95% CI:1.54-4.92) and perceived accuracy of an RDT performed by a CHW (95% CI:1.12-5.27) were strongly and positively associated with testing by a CHW. In adjusted analyses, specific CHWs attributes were significantly associated with higher testing rates including formal employment (95% CI:0.05-2.70), those serving more than 50 households (95% CI:0.70-2.74) and those serving areas with a higher proportion of positive tests (95% CI:1.05, 3.22). On both the supply side and the demand side, confidence in a test performed by a CHW was strongly correlated with the success of the intervention.Conclusion: Scale-up of community-based malaria testing intervention through CHWs is feasible and effective at reaching the poorest households. In order to maximize the impact of such interventions, it is important to recognize factors that may restrict both delivery and demand for such services.

scholarly journals Addressing the drug-resistant tuberculosis challenge through implementing a mixed model of care in Uganda

PLoS ONE ◽  
2020 ◽  
Vol 15 (12) ◽  
pp. e0244451
Author(s):  
Samuel Kasozi ◽  
Nicholas Sebuliba Kirirabwa ◽  
Derrick Kimuli ◽  
Henry Luwaga ◽  
Enock Kizito ◽  
...  
Keyword(s):  
Mixed Model ◽  
Treatment Initiation ◽  
Treatment Success ◽  
Scale Up ◽  
Drug Resistant ◽  
Model Of Care ◽  
Drug Resistant Tuberculosis ◽  
Tb Treatment ◽  
Resistant Tuberculosis ◽  
Mdr Tb

Worldwide, Drug-resistant Tuberculosis (DR-TB) remains a big problem; the diagnostic capacity has superseded the clinical management capacity thereby causing ethical challenges. In Sub-Saharan Africa, treatment is either inadequate or lacking and some diagnosed patients are on treatment waiting lists. In Uganda, various health system challenges impeded scale-up of DR-TB care in 2012; only three treatment initiation facilities existed, with only 41 of the estimated 1010 RR-TB/MDR-TB cases enrolled on treatment yet 300 were on the waiting list and there was no DR-TB treatment scale-up plan. To scale up care, the National TB and leprosy Program (NTLP) with partners rolled out a DR-TB mixed model of care. In this paper, we share achievements and outcomes resulting from the implementation of this mixed Model of DR-TB care. Routine NTLP DR-TB program data on treatment initiation site, number of patients enrolled, their demographic characteristics, patient category, disease classification (based on disease site and human immunodeficiency virus (HIV) status), on co-trimoxazole preventive therapy (CPT) and antiretroviral therapy (ART) statuses, culture results, smear results and treatment outcomes (6, 12, and 24 months) from 2012 to 2017 RR-TB/MDR-TB cohorts were collected from all the 15 DR-TB treatment initiation sites and descriptive analysis was done using STATA version 14.2. We presented outcomes as the number of patient backlog cleared, DR-TB initiation sites, RR-TB/DR-TB cumulative patients enrolled, percentage of co-infected patients on the six, twelve interim and 24 months treatment outcomes as per the Uganda NTLP 2016 Programmatic Management of drug-resistant Tuberculosis (PMDT) guidelines (NTLP, 2016). Over the period 2013–2015, the RR-TB/MDR-TB Treatment success rate (TSR) was sustained between 70.1% and 74.1%, a performance that is well above the global TSR average rate of 50%. Additionally, the cure rate increased from 48.8% to 66.8% (P = 0.03). The Uganda DR-TB mixed model of care coupled with early application of continuous improvement approaches, enhanced cohort reviews and use of multi-disciplinary teams allowed for rapid DR-TB program expansion, rapid clearance of patient backlog, attainment of high cumulative enrollment and high treatment success rates. Sustainability of these achievements is needed to further reduce the DR-TB burden in the country. We highly recommend this mixed model of care in settings with similar challenges.

scholarly journals Mobile community-based active case-finding for tuberculosis among older populations in rural Cambodia

2019 ◽  
Vol 23 (10) ◽  
pp. 1107-1114 ◽  
Author(s):  
O. Camelique ◽  
S. Scholtissen ◽  
J.-P. Dousset ◽  
M. Bonnet ◽  
M. Bastard ◽  
...  
Keyword(s):  
Risk Group ◽  
Treatment Success ◽  
Case Finding ◽  
High Risk Group ◽  
Active Case Finding ◽  
Community Based ◽  
Active Case ◽  
Tb Treatment ◽  
Mobile Community ◽  
Older Populations

OBJECTIVE: To systematically screen older rural populations in Cambodia for tuberculosis (TB) and develop an effective active case-finding (ACF) model for this TB high-risk group.DESIGN: A retrospective study using routinely collected programmatic data on community-based ACF among people aged ≥55 years using TB symptoms and systematic chest radiography (CXR) screening, followed by Xpert® MTB/RIF testing for participants with positive screening results and TB culture for certain Xpert-negative specimens.RESULTS: Of 22 101 participants included in the analysis, 7469 (33.8%) were screening-positive and 5960 (27.0%) underwent Xpert testing. Pulmonary TB was identified in 482 (2.2%) individuals: 288 (1.3%) were bacteriologically confirmed (253 using Xpert, 35 using culture) and 194 (0.9%) were clinically diagnosed. Eighty-seven people needed to be screened in order to diagnose one Xpert-positive case. Among the Xpert-positive cases, only 31.6% (80/253) reported cough ≥2 weeks, and 39.9% (101/253) were asymptomatic but had a CXR suggestive of active TB. Treatment uptake was 97.3% (469/482), and treatment success was 88.0% (424/482).CONCLUSIONS: Community-based ACF was effective in detecting and successfully treating older TB patients, most of whom might otherwise have remained undiagnosed. Mobile CXR appears to be crucial in identifying a high number of asymptomatic, bacteriologically confirmed cases.

scholarly journals Task-shifting directly observed treatment and multidrug-resistant tuberculosis injection administration to lay health workers: stakeholder perceptions in rural Eswatini

2020 ◽  
Vol 18 (1) ◽  
Author(s):  
Ernest Peresu ◽  
J. Christo Heunis ◽  
N. Gladys Kigozi ◽  
Diana De Graeve
Keyword(s):  
Healthcare Workers ◽  
Health Workers ◽  
Multidrug Resistant ◽  
Task Shifting ◽  
Tb Treatment ◽  
Resistant Tuberculosis ◽  
Multidrug Resistant Tuberculosis ◽  
Key Stakeholders ◽  
Mdr Tb ◽  
Directly Observed Treatment

Abstract Background Eswatini is facing a critical shortage of human resources for health (HRH) and limited access to multidrug-resistant tuberculosis (MDR-TB) treatment in rural areas. This study assessed multiple stakeholders’ perceptions of task-shifting directly observed treatment (DOT) supervision and administration of intramuscular MDR-TB injections to lay health workers (LHWs). Methods A mixed methods study comprising a cross-sectional survey using a semi-structured questionnaire with community treatment supporters (CTSs) and a focus group discussion with key stakeholders including representatives from the Eswatini Ministry of Health (MOH), donor organisations, professional regulatory institutions, nursing academia, civil society and healthcare providers was conducted in May 2017. Descriptive statistics, thematic content analysis and data triangulation aided in the interpretation of results. Results A large majority of CTSs (n = 78; 95.1%) were female and 33 (40.2%) were older than 50 years. Most (n = 7; 70.0%) key stakeholders had over 10 years of work experience in policy-making, advocacy in the fields of HRH or day-to-day practice in MDR-TB management. Task-shifting of MDR-TB injection administration was implemented without national policy guidance and regulation. Stakeholders viewed the strategy to be driven by the prevailing shortage of professional frontline HRH and limited access to MDR-TB treatment. Task-shifting was perceived to improve medication adherence, and reduce stigma and transport-related MDR-TB treatment access barriers. Frontline healthcare workers and implementing donor partners fully supported task-shifting. Policy-makers and other stakeholders accepted task-shifting conditionally due to fears of poor standards of care related to perceived incompetence of CTSs. Appropriate compensation, adequate training and supervision, and non-financial incentives were suggested to retain CTSs. A holistic task-shifting policy and collaboration between the MOH, academia and nursing council in regulating the practice were recommended. Conclusions Stakeholders generally accepted the delegation of DOT supervision and administration of intramuscular MDR-TB injections to LHWs as a strategy to increase access to treatment, albeit with some apprehension. Findings from this study stress that task-shifting is not a panacea for HRH shortages, but a short-term solution that must form part of an overall simultaneous strategy to train, attract and retain adequate numbers of professional healthcare workers in Eswatini. To address some of the apprehension and ambivalence about expanding access to MDR-TB services through task-shifting, attention should be paid to important aspects such as competence-based training, certification and accreditation, adequate supportive on-the-job supervision, recognition, compensation, and expediting policy and regulatory support for LHWs.

scholarly journals Health system readiness for innovation scale-up: the experience of community-based distribution of injectable contraceptives in Nigeria

2019 ◽  
Vol 19 (1) ◽  
Author(s):  
Oluwaseun Akinyemi ◽  
Bronwyn Harris ◽  
Mary Kawonga
Keyword(s):  
Health System ◽  
Community Health ◽  
Health Workers ◽  
Scale Up ◽  
Task Shifting ◽  
Policy Framework ◽  
Framework Analysis ◽  
Community Based ◽  
System Readiness ◽  
Injectable Contraceptives

Abstract Background Following the successful pilot of the community-based distribution of injectable contraceptives (CBDIC) by community health extension workers (CHEWs) in Gombe, northern Nigeria in 2010, there was a policy decision to scale-up the innovation to other parts of the country. However, there is limited understanding of health system factors that may facilitate or impede the successful scale-up of this innovation beyond the pilot site. Thus, this study assessed the health system readiness to deliver CBDIC in Nigeria and how this may influence the scale-up process. Methods This study was conducted in two Local Government Areas in Gombe State in September 2016. Seven key informant interviews were held with purposively sampled senior officials of the ministries of health at the federal and state levels as well as NGO program managers. Also, 10 in-depth interviews were carried out with health workers. All transcripts were analyzed using the thematic framework analysis approach. Result The availability of a policy framework that supports task-shifting and task-sharing, as well as application of evidence from the pilot programme and capacity building programmes for health workers provided a favourable environment for scale-up. Health system challenges for the scale-up process included insufficient community health workers, resistance to the task-shifting policy from professional health groups (who should support the CHEWs), limited funding and poor logistics management which affected commodity distribution and availability. However, there were also a number of health worker innovations which kept the scale-up going. Health workers sometimes used personal resources to make up for logistics failures and poor funding. They often modify the process in order to adapt to the realities on the ground. Conclusion This study shows health system weaknesses that may undermine scale-up of CBDIC. The study also highlights what happens when scale-up is narrowly focused on the intervention without considering system context, capacity and readiness. However, agency and discretionary decision-making among frontline health workers facilitated the process of scaling up, although the sustainability of this is questionable. Benefits observed during the pilot may not be realised on a larger scale if health system challenges are not addressed.

scholarly journals Addressing the drug resistant tuberculosis challenge through implementing a mixed model of care in Uganda, 2012- 2017

2019 ◽  
Author(s):  
Samuel Kasozi ◽  
Nicholas Sebuliba Kirirabwa ◽  
Derrick Kimuli ◽  
Henry Luwaga ◽  
Enock Kizito ◽  
...  
Keyword(s):  
Mixed Model ◽  
Treatment Initiation ◽  
Treatment Success ◽  
Scale Up ◽  
Sub Saharan Africa ◽  
Drug Resistant ◽  
Model Of Care ◽  
Drug Resistant Tuberculosis ◽  
Tb Treatment ◽  
Resistant Tuberculosis

Abstract Background Worldwide, Drug resistant Tuberculosis (DR-TB) remains a big problem; the diagnostic capacity has superseded the DR-TB clinical management capacity thereby causing ethical challenges. In Sub-Saharan Africa, treatment is either inadequate or lacking and some diagnosed patients are on treatment waiting lists. In Uganda, various health system challenges impeded scale up of DR-TB care in 2012; only three treatment initiation facilities existed, with only 41 of the estimated 1010 cases enrolled on treatment yet 300 were on the waiting list and there was no DR-TB treatment scale up plan. To scale up care, National TB/Leprosy Program (NTLP) with partners rolled out a DR-TB mixed model of care. In this paper, we share achievements and outcomes resulting from the implementation of this mixed Model of DR-TB care. Methods Routine NTLP DR-TB program data from 2013 to 2017 cohorts was collected from all the 15 DR-TB treatment initiation sites and analyzed using STATA version 14.2. We presented outcomes as the number of patient backlog cleared, DR-TB initiation sites, cumulative patients enrolled, percentage of co-infected patients on co-trimoxazole preventive therapy (CPT) and antiretroviral therapy (ART) as well as the six, twelve interim and 24 months treatment outcomes as per the Uganda NTLP 2016 Programmatic Management of drug Resistant Tuberculosis (PMDT) guidelines. Results Over the period 2013-2017, DR-TB treatment initiation sites increased from three to 15, cumulative patient enrollment rose from 41 to 1,311 and the 300-patient backlog was cleared. Treatment success rate (TSR) of 73% was achieved above the global TSR average rate of 50%. Conclusions The Uganda DR-TB mixed model of care coupled with early application of continuous improvement approaches, enhanced cohort reviews and use of multi-disciplinary teams allowed for rapid DR-TB program expansion, rapid clearance of patient backlog, attainment of high cumulative enrollment and high treatment success rates. Sustainability of these achievements is needed to further reduce the DR-TB burden in the country. We highly recommend this mixed model of care in settings with similar challenges.

scholarly journals Challenging drug-resistant TB treatment journey for children, adolescents and their care-givers: A qualitative study

PLoS ONE ◽  
2021 ◽  
Vol 16 (3) ◽  
pp. e0248408
Author(s):  
Mrinalini Das ◽  
Taanya Mathur ◽  
Shilpa Ravi ◽  
Augusto C. Meneguim ◽  
Aparna Iyer ◽  
...  
Keyword(s):  
Qualitative Study ◽  
Children And Adolescents ◽  
Health Care Providers ◽  
Treatment Success ◽  
Healthcare Providers ◽  
Drug Resistant ◽  
Care Providers ◽  
Tb Treatment ◽  
Adolescent Patients ◽  
Mdr Tb

Background Childhood multidrug-resistant TB (MDR-TB) still affects around 25000 children every year across the globe. Though the treatment success rates for drug-resistant TB (DR-TB) in children are better than adults, children and adolescents face unique hurdles during DR-TB (MDR-TB, Pre-XDR TB and XDR-TB) treatment. This study aimed to understand the patients, guardians and healthcare providers’ perspectives about DR-TB treatment journey of patients and caregivers. Methods This is a qualitative study involving in depth-interviews of purposively selected adolescents (n = 6), patients guardians (for children and adolescents, n = 5) and health care providers (n = 8) of Médecins Sans Frontières (MSF) clinic, Mumbai, India. In-depth face to face interviews were conducted in English or Hindi language using interview guides during September-November 2019. The interviews were audio-recorded after consent. Thematic network analysis was used to summarize textual data. ATLAS.ti (version 7) was used for analysis. Result The age of adolescent patients ranged from 15–19 years and four were female. Five guardians (of three child and two adolescent patients) and eight healthcare providers (including clinicians- 2, DOT providers-2, counselors-2 and programme managers-2) were interviewed. The overarching theme of the analysis was: Challenging DR-TB treatment journey which consisted of four sub-themes: 1) physical-trauma, 2) emotional-trauma, 3) unavailable social-support and 4) non-adapted healthcare services. Difficulties in compounding of drugs were noted for children while adolescents shared experiences around disruption in social life due to disease and treatment. Most of the patients and caregivers experienced treatment fatigue and burnout during the DR-TB treatment. Participants during interviews gave recommendations to improve care. Discussion The TB programmes must consider the patient and family as one unit when designing the package of care for paediatric DR-TB. Child and adolescent friendly services (paediatric-formulations, age-specific counselling tools and regular interaction with patients and caregivers) will help minimizing burnout in patients and caregivers.

scholarly journals Treatment success using novel and adapted treatment regimens in registered DR-TB children in Dushanbe, Tajikistan, 2013-2019

2021 ◽  
Vol 15 (09.1) ◽  
pp. 7S-16S
Author(s):  
Bobojon Pirmahmadzoda ◽  
Katrina Hann ◽  
Kristina Akopyan ◽  
Ruzanna Grigoryan ◽  
Evgenia Geliukh ◽  
...  
Keyword(s):  
Treatment Outcomes ◽  
Treatment Success ◽  
Short Treatment ◽  
Female Ratio ◽  
Treatment Regimens ◽  
Tb Treatment ◽  
National Tuberculosis ◽  
Mdr Tb ◽  
Pediatric Tb ◽  
Culture Conversion

Introduction: Approximately 3% of all pediatric TB cases develop MDR-TB, with only 3–4% of such children receiving MDR-TB treatment. In Tajikistan, children as a proportion of all DR-TB in the country increased from 4.3 to 7.5% during 2013-2018. Despite limited evidence on the use of new anti-TB drugs in children, WHO has updated its guidelines for DR-TB treatment for children, and Tajikistan did so in 2013 and 2017. Novel and adapted regimens included individual regimens for RR/MDR, XDR (with and without Bedaquiline and Delamanid) and short treatment regimens with and without injectables. It is important to document the outcomes of the treatment regimens. Therefore, the aim of this study was to describe characteristics of children receiving different treatment regimens for DR-TB, the culture conversion and treatment outcomes. Methodology: Cohort study of children enrolled in DR-TB treatment by the National Tuberculosis Program in Dushanbe, Tajikistan, January 2013 to July 2019. Results: The study included 60 DR-TB children. The male to female ratio was 1:2 and mean age 13.6 years. Median time to culture conversion was 66 days [IQR:31-103; Range:2-232]. In children with treatment outcomes (N = 58), 93% had favorable outcomes. There were four children (7%) with unfavorable treatment outcomes, all of whom were female 15-17 years, on standard (RR/MDR) treatment during 2013-2015. Favorable outcomes by DR-TB type were 91%, 90%, and 100% in RR/MDR, PreXDR, and XDR-TB patients, respectively. Conclusions: All children enrolled after the introduction of modified guidelines for novel and adapted regimens for DR-TB showed positive TB treatment outcomes.

scholarly journals Pakistan’s Community-based Lady Health Workers (LHWs): Change Agents for Child Health?

2020 ◽  
Vol 12 (11) ◽  
pp. 177
Author(s):  
Shehla Zaidi ◽  
Maryam Huda ◽  
Ammarah Ali ◽  
Xaher Gul ◽  
Rawshan Jabeen ◽  
...  
Keyword(s):  
Child Health ◽  
Large Scale ◽  
Health Workers ◽  
Information Source ◽  
Child Health Services ◽  
Growth Monitoring ◽  
Continuous Variables ◽  
Maternal Knowledge ◽  
Community Based ◽  
Child Illness

BACKGROUND: In Pakistan&rsquo;s high child mortality context, a large-scale Lady Health Worker (LHW) Program raises the need to look at whether LHWs are delivering their key mandate as agents of change for child health. This study examines the quantity and quality of LHW interactions with mothers for child health and their impact on mothers&#39; knowledge and child health practices. METHODS: 1,968 mothers of children &lt;2 years (n=1,968) were interviewed through a cross-sectional survey in two rural districts of Pakistan focusing on immunization, nutrition, and early child illness. Data on frequency of LHW&rsquo;s visits; services provided, specific services related to routine immunization (RI), nutrition and child illness, and maternal knowledge and practices were analyzed using median values for continuous variables and counts and percentages for categorical data. RESULTS: Monthly visits by LHW were reported by only 63% of LHW covered households. During LHW monthly encounters, Oral Polio drops administration was most frequently reported (77%), followed by RI (59%), breastfeeding counseling (20%), child illness management advice (18%), growth monitoring (9.5%), while none reported receiving hygiene counseling. Although LHWs were reported to be the main information source for child health; limited impact of LHW-mother interaction was seen on maternal knowledge and practices: 76% mothers reported receiving ORS packets from LHWs but only 27% knew of correct usage, only 34% washed hands before feeding children, less than a third could correctly recall early signs of pneumonia and awareness of Vaccine Preventable Diseases other than Polio ranged from 42%-9% only. CONCLUSION: Although LHWs are main information source for child health services but infrequent, poor quality household encounters indicate ineffective delivery on the key mandate of community-based child health. Policy debate instead of focusing on scaling up or downsizing the program, should prioritize quality and supervision to improve value for money of a critical community resource.

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