ICHP's community mobilisation strategy (CMS) was developed early in the project to identify areas for intervention for behaviour change and to increase knowledge about harmful practices and motivate families to adopt healthy practices to promote child health. It is intended to help bridge the gap between service providers and communities. The CMS is evidence-based, using a quantitative baseline study and informal interviews with providers to gather information on knowledge and practices across agencies.

Key activities to increase knowledge and promote healthy behaviours for child health include:

• increasing community awareness through lady health workers (LHWs) and community health workers (CHWs) managed through subgrants with local NGOs - To improve the knowledge and skills of health care providers, the project conducts trainings in essential newborn care (ENC) and in integrated management of newborn and childhood illnesses (IMNCI). The project has established resource centres in all the agencies, providing furniture, whiteboards, multimedia equipment, and computers. These centres are used to conduct training for health care providers and health managers. The project also aims to train 1,520 LHWs in the FATA and another 58 in the Frontier Regions to increase community awareness of child health. LHWs conduct support groups for women and make home visits to reach women with messages about child health. LHWs also use counselling cards during these sessions. The project promotes the messages in a phased manner. The project has contracted with two local NGOs to work in non-LHW areas across the seven FATA tribal agencies. The NGOs are responsible for conducting outreach using CHWs, whose work mimics that of LHWs.
• community sensitisation events, such as formation of local committees - Organised by male and female community mobilisation officers, these events may take place at facilities and through teachers and community leaders but are most often conducted by men providing men with needed information. Reaching out through village elders and Ulamas (Muslim scholars trained in Islam and Islamic law) and through local structures is considered to be crucial to reaching men with vital information.
• formation of quality improvement teams (QIT) - These committees are comprised of influential community leaders and health facility staff who work to: promote awareness of health issues; enhance understanding of and trust in health care providers; raise community issues with health care providers; develop joint solutions with health care providers to meet the needs of the community; and advocate for additional resources. For example, one QIT was able to convince a mine rescue team to move out of the health care facility to make space for health services. In Ali Masjid, where malaria is endemic, the QIT received insecticide to prevent malaria in its village. Other QITs were able to resolve local water and electricity problems by generating funds for equipment repair. "One challenge for the QITs is that because the teams have no formal identity, higher officials often do not give them the importance they deserve. Nevertheless, the QIT teams seem to be an effective community-facility mechanism for finding local solutions to enhance access to and quality of health services."
• advocacy at the agency, tehsil, village, and facility levels - Organised for decision makers, these events give participants an orientation on improving child health and on project interventions. High-level advocacy has helped the project to ensure the safety of its workers across the region, which is vital to its work.
• Child Health Days (CHDs) - CHDs are a way to ensure that providers, medicines, vaccines, and micronutrients are all available to the community on the same day. The LHWs mobilise the community, and CHWs inform families about services available at local health facilities on CHDs and encourage them to use them. CHDs are held at a variety of health care facilities; the frequency of CHDs ranges from once a week in some health facilities to once a month in others. The project plans also to have CHDs in the communities in the future, working in close coordination with FATA officials, health care providers, and community leaders.

The project would like to add the child-to-child approach to its repertoire of community mobilisation interventions. This approach provides school-age children with information about their own health through school teachers; the aim is for the children to take the messages home to their parents and families. Given the security problems in the FATA region and the difficulty of organising events and group gatherings, this approach might be a viable means of spreading health information.

Children, Health.

FATA is a belt of seven semi-autonomous tribal agencies with a total population of 3.6 million people stretching north to south along the border between Pakistan and Afghanistan. More than 97% of the population lives in rural areas. Socioeconomically, FATA is much poorer than Pakistan as a whole. Moreover, tribal law, kidnappings, other criminal activities, and post-Afghanistan conflict factors are acute operating and security concerns for the project in most areas.

According to figures provided by the Global Health Technical Assistance Project (see the Source section, below), the 460 or more health facilities in FATA are severely underequipped and regularly not functional due to staff absenteeism. Community maternal and child health coverage through LHWs is low, ranging from 13% in Bajaur Agency to 55% in Kurram. The 926 or so LHWs in FATA reach approximately one-third of the population.

Child health indicators are generally poor throughout Pakistan; in FATA the child health situation is even worse: under-5 mortality is 135/1,000 live births, and the infant mortality rate (IMR) is 83/1,000 live births. Every year more than 100,000 FATA children under 5 suffer either diarrhoea or ARI, which are easily treatable. only 16% of infants are exclusively breastfed during the first 4 months of life. A 2002 World Health Organization (WHO) bulletin indicated that neonatal tetanus alone was the cause of 22% of all infant mortality and 36% of neonatal deaths in FATA. Moreover, only 50% of women are vaccinated against tetanus. With less than 20 percent of deliveries conducted by a skilled provider, women in FATA face one of the highest maternal mortality rates in the world. Female literacy in FATA is the lowest in South Asia. A lack of information makes it harder to improve child health. Conservative values not only restrict female mobility but also hinder their access to services. Women's lack of information about facilities and services, the nonacceptance of male service providers, lack of trust in modern medicine, misconceptions that vaccinations are birth control devices, and fatalism about morbidities and mortalities all contribute to declining health and social indicators.

SC conducted a household survey (November 2007-February 2008) to identify knowledge and attitudes about newborn, infant, and child health care practices. Key findings were that:

• Less than half the children are fully immunised (ranging from 53% in Bajour to 28% in Khyber Agency).
• 30% of women received no antenatal care (ANC) and 40 to 50% did not receive tetanus toxoid (TT) vaccinations.
• 50% to 60% of women deliver at home with the help of traditional birth attendants (TBAs) or female relatives.
• 70% to 84% of children receive Vitamin A supplements.
• Poor perceptions about colostrum lead to delays in breastfeeding: over 80% of newborns receive green tea or ghutti (a sweet Ayurvedic medicine) before breastfeeding.
• Diarrhoea is prevalent due to poor sanitary conditions, contaminated drinking water, and inadequate hand-washing practices.
• Knowledge of danger signs is fairly high, but understanding of appropriate treatments is not.

Simultaneously, SC assessed 464 health facilities, and found that:

• Less than 3% of health care providers have been trained on case management of diarrhoea and ARI, and those who have are based at agency headquarters hospitals (AHQH).
• Shortages of essential medicines, particularly injectable antibiotics, are a major problem. On average, only 28% of all health facilities offer vaccinations; the range is from 85% of rural health centres (RHC) and 53% of basic health units (BHU) to 14% of civil dispensaries (CD).
• Reporting through the health management information system (HMIS) is almost nonexistent.
• There is a chronic shortage of health care providers and absenteeism is very high, particularly in RHCs and BHUs.