Special Supplement on integrated Community Case Management
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645



Current World Health Organization (WHO) guidelines for severe pneumonia treatment of under-5 children recommend hospital referral. However, high treatment cost is a major barrier for communities. We compared household costs for referred cases with management by lady health workers (LHWs) using oral antibiotics. This study was nested within a cluster randomized trial in Haripur, Pakistan. Data on direct and indirect costs were collected through interviews and record reviews in the 14 intervention and 14 control clusters. The average household cost/case for a LHW managed case was $1.46 compared with $7.60 for referred cases. When the cost of antibiotics provided by the LHW program was excluded from the estimates, the cost/case came to $0.25 and $7.51 for the community managed and referred cases, respectively, a 30-fold difference. Expanding severe pneumonia treatment with oral amoxicillin to community level could significantly reduce household costs and improve access to the underprivileged population, preventing many child deaths.

[open-access] This is an Open Access article distributed under the terms of the American Society of Tropical Medicine and Hygiene's Re-use License which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.


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  1. UNICEF, WHO, The World Bank, United Nations Population Division, 2012. Levels and Trends in Child Mortality: Report 2012. New York: UNICEF.
  2. Liu L, Johnson HL, Cousens S, Perin J, Scott S, Lawn JE, Rudan I, Campbell H, Cibulskis R, Li M, Mathers C, Black RE, Child Health Epidemiology Reference Group of WHO and UNICEF; , 2010. Global, regional, and national causes of child mortality in 2008: a systematic analysis. Lancet 375: 19691987.[Crossref]
  3. Rudan I, Boschi-Pinto C, Biloglav Z, Mulholland K, Campbell H, , 2008. Epidemiology and etiology of childhood pneumonia. Bull World Health Organ 86: 408416.[Crossref]
  4. UNICEF, 2010. Countdown to 2015 Decade Report (2000–2010): Taking Stock of Maternal, Newborn and Child Survival. New York: UNICEF.
  5. NIPS, Macro International, 2008. Pakistan Demographic and Health Survey 2006–07. Islamabad, Pakistan: National Institute of Population Studies Islamabad; Calverton, MD: Macro International.
  6. Sazawal S, Black RE, , 2003. Effect of pneumonia case management on mortality in neonates, infants, and preschool children: a meta-analysis of community-based trials. Lancet Infect Dis 3: 547556.[Crossref]
  7. WHO, UNICEF, 2005. Handbook: IMCI Management of Childhood Illness. 2005 edition. Geneva: WHO; New York: UNICEF.
  8. Marsh DR, Gilroy KE, Weerdt RV, Wansi E, Qazi S, , 2008. Community case management of pneumonia: at a tipping point? Bull World Health Organ 86: 381389.[Crossref]
  9. Peterson S, Nsungwa-Sabiiti J, Were W, Nsabagasani X, Magumba G, Nambooze J, Mukasa G, , 2004. Coping with pediatric referral—Ugandan parents' experience. Lancet 363: 19551956.[Crossref]
  10. Chowdhury EK, Arifeen SE, Rehman M, Hoque DE, Hossain MA, Begum K, Siddik A, Begum N, Sadeq-ur Rahman Q, Akter T, Haque TM, Al-Helal ZM, Baqui AH, Bryce J, Black RE, , 2008. Care at first-level facilities for children with severe pneumonia in Bangladesh: a cohort study. Lancet 372: 822830.[Crossref]
  11. Hazir T, Fox LM, Nasir YB, Fox MP, Ashraf YP, MacLeod WB, Ramzan A, Maqbool S, Masood T, Hussain W, Murtaza A, Khawar N, Tariq P, Asghar R, Simon JL, Thea DM, Qazi SA, New Outpatient Short-Course Home Oral Therapy for Severe Pneumonia Study Group; , 2008. Ambulatory short-course high-dose amoxicillin for treatment of severe pneumonia in children: a randomized equivalency trial. Lancet 371: 4956.[Crossref]
  12. Addo-Yobo E, Duc Anh D, El-Sayed HF, Fox L, Fox MP, MacLeod W, Saha S, Anh Tuan T, Thea DM, Qazi S, , 2011. Outpatient treatment of children with severe pneumonia with oral amoxicillin in four countries: the MASS Study. Trop Med Int Health 16: 9951006.[Crossref]
  13. Hussain H, Waters H, Khan AJ, Omer SB, Halsey NA, , 2008. Economic analysis of childhood pneumonia in northern Pakistan. Health Policy Plan 1: 15.
  14. Madsen HO, Hanehøj M, Rani A, Prabhakar D, Winsley M, Mammen R, Flemming P, John K, Anuradha KR, , 2009. Costing of severe pneumonia in hospitalized infants and children aged 2–36 months at a secondary and tertiary level hospital of a not-for-profit organization. Trop Med Int Health 14: 13151322.[Crossref]
  15. Ayeiko P, Akumu AO, Griffiths UK, English M, , 2009. The economic burden of inpatient pediatric care in Kenya: household and provider costs for treatment of pneumonia, malaria and meningitis. Cost Eff Resour Alloc 7: 3.[Crossref]
  16. Bari A, Sadruddin S, Khan A, Haque I, Khan A, Lehri I, Macleod WB, Fox MP, Thea DM, Qazi S, , 2011. Community case management of severe pneumonia with oral amoxicillin in children aged 2–59 months in Haripur district, Pakistan: a cluster randomized trial. Lancet 378: 17961803.[Crossref]
  17. Soofi S, Ahmed S, Fox MP, MacLeod WB, Thea DM, Qazi SA, Bhutta ZA, , 2012. Effectiveness of community case management of severe pneumonia with oral amoxicillin in children aged 2–59 months in Matiari district, rural Pakistan: a cluster-randomized controlled trial. Lancet 379: 729737.[Crossref]
  18. Oxford Policy Management, 2009. Lady Health Worker Programme External Evaluation of the National Programme for Family Planning and Primary Health Care Quantitative Survey Report. Oxford, UK: Oxford Policy Management.
  19. The World Bank, 2012. Available at: http://data.worldbank.org/indicator/SH.XPD.PCAP/countries. Accessed February 10, 2012.
  20. Mehnaz A, Billo G, Yasmee T, Nankani K, , 1997. Detection and management of pneumonia by community health workers: A community intervention study in Rehri village, Pakistan. J Pak Med Assoc 47: 4245.
  21. UNICEF/WHO, 2004. Management of Pneumonia in Community Settings. UNICEF/WHO joint statement. Available at: http://whqlibdoc.who.int/hq/2004/WHO_FCH_CAH_04.06.pdf. Accessed October 3, 2010.
  22. WHO, UNICEF, 2009. Global Action Plan for Prevention and Control of Pneumonia (GAPP): Technical Consensus Statement. Geneva: World Health Organization and United Nations Children's Fund.

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  • Received : 14 Apr 2012
  • Accepted : 07 Sep 2012

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