Meeting of South-East Asia Regional
Programme Managers on Child Health,
Kathmandu, 15 – 18 Nov 2011
Progress in Implementation
of Child Health
Programme
Nepal
15 Nov 2011
Regional CH Meeting, Kathmandu
1
Trend of Child Mortality in Nepal
140
120
118
100
91
79
80
64
61
60
50
48
54
46
39
40
33
33
20
0
1996 NFHS
2001 NDHS
Neonatal Mortality Rate
2006 NDHS
Infant Mortality Rate
2011 NDHS
Under 5 Mortality Rate
Trend of Nutritional Status of under 5 Children
60
57
49
50
43
41
39
40
29
30
20
10
11
13
11
0
2001 NDHS
Stunting (Ht/Age)
2006 NDHS
Underweight (Wt/Age)
2011 NDHS
Wasting (Wt/Ht)
Causes of neonatal mortality in Nepal
Combined
Infection
40%
Preterm/LBW
6%
Others
10%
Tetanus
2%
Congenitial
abnormality
8%
Birth injury
19%
Birth asphyxia
15%
DHS-2006
Causes of under five mortality in Nepal
ARI and
diarrhea ,
7.50%
Others, 8.60%
Injury, 10.70%
Combined
infection, 60%
Diarrhea,
13.20%
DHS-2006
IMCI Implementation
CDD program started
1982
ARI program started
1986/87
ARI strengthening program at community focused on
pneumonia treatment as a pilot in 4 districts
1995
Evaluation of ARI pilot program
1997
Scale up Pneumonia treatment program at community with
CBAC
1998/1999
IMCI piloted in Mahottari
1997
Merged Community component and program management
component in IMCI in and named as CB-IMCI.
1999/2000
Initially expanded in CB-IMCI in three districts
1999/2000
Revised the package and incorporated zinc
2006
Scaled up through out the country in 2010
2010
IMCI Implementation
Number and proportion of MOs trained
Appx 50%
Number and proportion of Nurses/other workers trained
Above 75%
ANM & AHW
Appx 7000 (100%)
VHW and MCHW
Appx 7000 (100%)
FCHV
Appx 50,000 (100%)
Proportion of districts (out of IMCI districts) with 60 % or more health
providers trained
All 75
IMCI supervisory checklists introduced
…………………
Proportion of first-level health facilities that had at least one supervisory visit
over a period of 6 month during previous year
Regular supervision by IMCI
focal person (district) and
implementing partners
Proportion of districts (out of IMCI districts) covered with Follow-up IMCI
training (since 1998)
75 (100%)
IMCI implementation review conducted (If yes, year; National or sub-national)
Annual review at district,
regional and central levels
Pre-Service IMCI teaching/training:
ANM, AHW, HA, PCL Nursing,
BPH, BN, BSc Nursing, MBBS,
MPH, MN
Number and proportion of Medical Schools teaching IMCI
20 (100%)
Ref. Nepal Medical council
Number and proportion of Nursing Schools teaching IMCI
103 (100%) ref. Nursing Council
ICATT introduced
No
Scaling-up of CBIMCI Programme
Under 5 population covered by the program
Year
100
85
80
64
56 58 61
60
45
38
40
3
200
4
200
5
200
6
200
7
200
200 8
9 /1
0
2
200
1
200
9
200
8
199
7
0
0
9
3 3
25
18
200
20
199
6 7 8 9 0 1 2 3 4 5 6 7 8 0
91 9 199 199 199 200 200 200 200 200 200 200 200 200 9/1
0
20
100
199
75
80
70
59
60
44
50
35
40
30
28
30
22
16 18
20
14
4 4 6 11
10
0
120
% of < 5 population
Number of districts
Districts covered by program
Year
CB-IMCI Implementation
A. Key factors that helped scaling up
1.
2.
3.
4.
5.
Strong government ownership (priority 1 programme)
Partner support (EDPs, Professional Societies, NGOs)
Strong network of health workers and volunteers at community level
Treatment success
Community mobilization and utilization of local resource to support the
program and FCHVs,
B. Key challenges to scaling up:
1.
2.
3.
4.
5.
15 Nov 2011
Cost
Quality of training
Follow up.
Frequent transferred of HF staff and drop FCHVs.
Supportive supervision monitoring at all level
Regional CH Meeting, Kathmandu
9
Newborn Health
GON and partners prepared Neonantal strategy
2004
Neonatal component (In addition to referral ENC at
community and Jaundice, hypothermia and low weight
at HF) incorporated into CB-IMCI package
2004
MINI pilot started focusing on Community based
management of newborn infection.
2005
CB-NCP package developed focusing on 7
components based on CB-IMCI and MINI
2008/2009
CB-NCP package developed focusing on 7
components based on CB-IMCI and MINI
2008/2009
CB-NCP piloted in 10 districts
2009/2010
CB-NCP scale up in additional 15 district in 2010/2011
and planned to expand in 10 in 2011/2012
2011/2012
Community Based Newborn Care Package: A pilot
intervention of Government of Nepal
Status:
• 61% of U5 mortality is neonatal
• 72% of deliveries occur at home (NDHS 2011)
• CBNCP and Health facility based newborn care being promoted
•
•
On 21 Dec. 2007, MOHP Nepal endorsed the newborn package
The package was piloted in 10 districts in 2009-2010 and is now
gradually being scaled up nationwide.
Newborn care interventions
1.
Behavior Change and Communication (BCC) for newborn health
2.
Promotion of institutional delivery and clean delivery practices in case of
home deliveries
3.
Postnatal care
4.
Community case management of pneumonia/ Possible Severe Bacterial
Infection (PSBI)
5.
6.
7.
Care of low birth weight newborns
Prevention and management of hypothermia
Recognition of asphyxia initial stimulation and resuscitation of newborn
baby
11
Newborn Health
•
ENC Course adapted: 1997
•
Other training courses: CB-NCP training
•
Healthcare providers trained on CBNCP:
Healthcare providers Total no.
No. Trained
%
1569
Nurses
……..
……..
………
………
CHW
……..
953
………
Volunteers
……..
MO
15 Nov 2011
……..
Regional CH Meeting, Kathmandu
………
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In-Patient (Hospital) care of sick
newborns and children
• WHO Pocket Book introduced: Training material
adapted and approved
• Training courses for Hospital care done: Planned for
2012
• Number and proportion of Healthcare providers trained:
– MOs: N/A
– Nurses: N/A
• Hospital assessment using WHO tools carried out:
– Ongoing, will be completed by Dec 2011
– How many hospitals covered: 4 (Central, regional and Subregional)
15 Nov 2011
Regional CH Meeting, Kathmandu
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CHW approach for care of sick
newborns and children
District implementing CHW
approach
Total No. of Implementing
District
Districts
%
Home based newborn care
75
25
33%
Sick child package
75
75
100%
Early childhood
development
75
75
100%
Any review of the
experience
15 Nov 2011
……………………………
……………………………
Regional CH Meeting, Kathmandu
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Development of Aama Suraksha Programme
 2005: Initiation of nationwide Maternity Incentives
Programme (MIS)—providing transportation
incentives to women who have institutional
deliveries.
 Incorporation of more institution through Safe
Delivery Incentives Programme (SDIP) in 2006
 Launching of Aama Suraksha Programme,
which combines free delivery care with incentives
for women (14th Jan 2009- Magh 1st 2065) aiming
at reducing both first and second delay
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Aama Suraksha Programme
Recipients
Incentives
Incentives to Women
cash payment after delivery at a facility NRs.1,500
(mountain), NRs.1,000 (hill) and Rs.500 (terai).
Incentive to Health
Facility as
Institutional Cost
Unit cost paid to institution for free delivery care:
Normal Delivery NRs. 1000 (NRs 1500 if > 25 bedded
HF)
Complication NRs. 3,000
C-Section NRs. 5,000 (NRs7000)
(Included in this unit cost is actual cost of all required drugs,
supplies, instruments, and small incentives for SBA)
Incentives to Health
Workers
•Institutional delivery: HFMC can decide to give NRs.
200 from institutional cost (Nrs 300)
•Home delivery originally part of the MIS and SDIP
reduced to NRs. 200 per case. Health workers need to
submit the birth certificate for this payment
16
Free Primary Health Care:
• ANC
• PNC
• Free drugs included in essential drug list:
– Iron tablets
– Inj TT
– Albendazole
– Inj Oxytocin (new list)
– Inj magnesium sulphate (new list)
• Incentive to pregnant woman who
completes 4 focused ANC visits--NRs 40017
Programme Review and Management
• CH Short Programme Review introduced,
if yes :
– Year: N/A
– National or sub-national: N/A
• Programme Management Course
introduced, if yes:
– 5 govt officials trained in Dec 2010
15 Nov 2011
Regional CH Meeting, Kathmandu
18
Health Management Information Systems
(HMIS) and DHS/MICS
List the key indicators for newborn and child health included in HMIS and DHS/MICS
ARI
• Incidence (ARI, Pneumonia, Severe Pneumonia)
• % Pneumonia and severe pneumonia among new ARI cases
• Case Fatality Rate of ARI
• Treatment by antibiotic
• % of Cases at (HF, VHW/MCHW, FCHV)
CDD:
•
Incidence (Diarrhoea, Dehydration, Severe Dehydration)
• % Dehydration and severe dehydration
• Treated with ORS and Zinc and IV fluid
• Case fatality rate
• % of Cases at (HF, VHW/MCHW, FCHV)
Malaria (information available for <5 years)
• PV/PF/PM (indigenous and Imported
• Clinical Malaria
• Suspected/Possible Death
• Confirmed Falciparum
• Proportion of Malaria cases by Age among total positive cases
Proportion of ear infections among reported cases,
Proportion of severe malnutrition cases among reported cases,
15 Nov 2011
Regional CH Meeting, Kathmandu
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Proportion of Measles like disease.
Health Management Information Systems
(HMIS) and DHS/MICS
List the key indicators for new born and child health included in HMIS and
DHS/MICS under two months
•
•
•
•
Percentage of PSBI cases managed by HFs.
Percentage of LBI cases managed by HFs.
Percentage of cases having low/weight and feeding problems managed by
HFs.
Percentage of under two months sick young infants referred by CHWs.
15 Nov 2011
Regional CH Meeting, Kathmandu
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Health Management Information Systems
(HMIS) and DHS/MICS
Data Collection/Information Flow Chart
Reporting
Frequency
NPC
National/
Central
National
Centers
Regional
Trimesterly
MOH
DoHS
MD/HMIS
RHD
District
DHO
Catchment
area and
Community
PHC/HP
Divisions
Trimesterly/
Periodic
Central/Regional
/Zonal Hospital
Hospital
SHP
Monthly
Monthly
Monthly
Reporting Line
Feedback Line
15 Nov 2011
VHW/MCHW/FCHV
21
Regional CH Meeting, Kathmandu
Future Plans
Revitalization/ Strengthening and scale-up plans for Next 2 years
•
Maintenance/Strengthening of CB- IMCI:
•
•
•
•
•
•
•
•
Expansion of Community Based newborn Care Package
–
–
–
–
•
Development of multi years costed plan of Action for IMCI
Revision of IMCI protocol including the job aids and recording/reporting forms of HF and
community level
Revision of pre-service curriculum
Development of IMCI referral guideline
Expansion of color coded supervision to all districts
Capacity building of CBIMCI focal person
Development of CBIMCI revitalization package and rapid implementation
Assessment of CBNCP package
Monitoring and Supervision
Revision of pre-service curriculum
Referral service strengthening
ICATT use: ICATT platform can be used for university level pre-service training,
and in the longer term it can be used at the district level training
15 Nov 2011
Regional CH Meeting, Kathmandu
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Thank You
15 Nov 2011
Regional CH Meeting, Kathmandu
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