Nepal: Achieving High Coverage at
Scale with Community-based
MNCH Services
Dr. Yashovardhan Pradhan
March 9, 2010
AME Meeting Bangkok
Presentation: NIC-P2
Mortality Trend and MDG Goal
(Under 5, Infant and Neonatal)
200
160
U5MR
153
120
NMR
118
102
80
91
79
64
40
IMR
45.9
50
39
61
48
33
54
34
15
0
1991
1996
2001
2006
2015 MDG
Source: NFHS (1991), DHS 1996, 2001, 2006 and MDG Progress Report 2005
Female Community Health Volunteers
Pillars to Nepal’s Public Health Programs
FCHVs are involved in:
23,151,423
Total Population
42,53,220
households
3,915 VDCs
NEPAL
i) Community based
management of
pneumonia & diarrhea
ii) Vitamin A & deworming
iii) Immunization
promotion
iv) Family Planning
75 Districts
Source: CBS 2001
v) Birth preparedness
and neonatal care
48,549 FCHVs
packages
vi) Innovative approaches
CB-IMCI
100
90
80
70
60
50
40
30
20
10
0
100
Under 5 population covered
by CB-IMCI program
85
61 64
58
56
22
9
9
28
31
38
45
14
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
% of < 5 population
• CHWs diagnose and treat pneumonia using cotrim-P
tablets; and refer severe cases
• CHWs manage diarrhea with ORS and zinc
• CHWs promote immunization and nutrition
Year
Trends in severe dehydration among
diarrhea cases
% of severe dehydration among total new diarrhea cases
14%
Central Hill
Central Mnt
12%
Central Terai
Eastern Hill
10%
Eastern Mnt
Eastern Terai
8%
Farwestern Hill
Farwestern Mnt
6%
Farwestern Terai
Midwestern Hill
4%
Midwestern Mnt
Midwestern Terai
2%
Western Hill
0%
Western Mnt
•Source: HMIS, from NAGA pg. 53
HMIS HMIS HMIS
57/58 58/59 59/60
HMIS
60/61
HMIS
61/62
HMIS
62/63
HMIS
63/64
HMIS
64/65
Western Terai
ARI
(Trend of Reported ARI Cases and Proportion of
Severe Pneumonia)
2063/64
2064/65
2065/66
1.2
3,500,000
2,847,409
1.0
2,800,000
2,274,046
1.1
0.9
0.8
2,100,000
0.6
0.6
1,498,359
1,400,000
0.4
700,000
0.2
0.0
0
Total ARI Cases (HF+VHW+MCHW+FCHV)
Source: HMIS Raw Data and DoHS Annual Reports
Proportion of Severe Pneumonia
6-59 months population reached by
Vitamin A program per year
>90% coverage
in all districts
since 2003
Birth Preparedness Package (BPP)
•
•
•
•
•
Antenatal care (TT, iron/folate)
Promotion of institutional delivery
Preparation for delivery
Essential Newborn Care
Danger signs (pregnancy,
delivery, postpartum, newborn)
• Postnatal care
BPP + includes all the above plus:
• Management of hypothermia
• Management of low birth weight
All 75 districts
42 districts
in 2010
Trends in ANC and TT Coverage in
Nepal
80%
70%
60%
50%
ANC (at least 1 visit)
TT (at least 2)
40%
30%
20%
10%
0%
NFHS 1996 NDHS 2001 NDHS 2006
Intensification of Maternal Iron
Supplementation Program (2003 -2008)
Far-Western
Region
Mid-Western Region
2003 – Initiated from 5 districts
2008 – Expanded to 52 districts
2010 -- Expanding to all 75 districts
Western Region
Central Region
UNICEF
WHO
MI
PLAN
Eastern Region
Result
Coverage and compliance increased in the program districts.
100
100
86
60
Compliance (%)
Coverage (%)
80
47
40
20
76
80
60
40
29
20
0
0
Baseline
2003
Endline
2008
Baseline
2003
Ref.: Impact Evaluation Survey- 2003 to 2008, New Era, MI
Endline
2008
Components of the Community-based
Newborn Care Package (CB-NCP)
1.
2.
3.
4.
5.
6.
7.
IEC/BCC on essential newborn care
Promotion of institutional delivery
Post-natal visit to mother and baby
Management of PSBI (sepsis)
Management of low birth weight
Management of hypothermia
Management of birth asphyxia
Initiated in
10
districts
Innovations: Misoprostol
•
Postpartum hemorrhage accounts for 46% of
maternal mortality in Nepal 1
•
70% of maternal deaths occur at home
•
Use of misoprostol shown to prevent hemorrhage
•
Community-based misoprostol use piloted in 1
district: 73% of expected pregnancies received
misoprostol, and 53% took dose (most others
received alternative treatment at HF)
•
Program initiated in 6 additional remote districts
Other innovations
• Chlorhexidine being piloted in 4 districts to
decrease newborn umbilical infection
• Newborn vitamin A supplementation piloted in 4
districts to decrease NMR (based on Asian
controlled trial results)
• Gentamicin in Uniject feasibility study done in one
district to determine acceptability of communitybased use in remote areas
Conclusions
• Nepal has pioneered community case management
for pneumonia and diarrhea and VAS
supplementation
• Nepal has expanded the role of CHW to address
causes of maternal and neonatal mortality
• Nepal has been successful in piloting and scalingup innovative approaches through phase-wise
expansion
• These approaches have likely reduced maternal,
child and neonatal mortality, and likelihood of
achieving MDG 4