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Objective: This study compares two methods for clinical diagnosis of childhood pneumonia that aim to estimate rates of underdiagnosis and overdiagnosis of childhood pneumonia by examining the sensitivity of Integrated Management of Childhood Diseases implementation in routine care against lung ultrasound (LUS) diagnosis., Setting: We conducted observations in 83 public health facilities (dispensaries, health centres and district hospitals) in Pwani, Dodoma and Tabora, Tanzania between October and December 2017., Methods: We used a novel method to estimate rates of underdiagnosis and overdiagnosis of childhood pneumonia by comparing directly observed public provider diagnoses to the results of diagnoses made by trained clinicians using Mindray DP-10 ultrasound machines. We perform multivariate analysis to identify confounding effects and robustness checks to bound the result. We also explore a number of observable characteristics correlated with higher rates of agreement between provider diagnoses and ultrasound diagnoses., Results: We observed 93 providers conducting exams on patients aged 2 months-5 years who presented respiratory symptoms or were given a respiratory diagnosis by the provider. Of these 957 patients, 110 were excluded from analysis resulting in a final sample of 847.17.6% of cases identified as pneumonia via LUS examinations in our sample were diagnosed as pneumonia by providers, suggesting that a significant number of pneumonia cases for which care is sought in the public sector go undiagnosed. Provider knowledge of breath counting and years of experience are positively correlated with higher agreement. While clinical examination rates are not statistically correlated with agreement, it is notable that providers conducted a clinical examination on only about one-third of patients in the sample., Conclusion: Our results suggest that provider training and knowledge of clinical examination protocols for pneumonia diagnosis are predictive of correct diagnosis of pneumonia and should be further explored in future research as a tool for improving quality of care., Competing Interests: Competing interests: Results for Development reports grants from Good Ventures and the Bill and Melinda Gates Foundation on pneumonia in East Africa., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)