15 Nov 2011 Regional CH Meeting, Kathmandu 1 Meeting of South-East Asia Regional Programme Managers on Child Health, Kathmandu, 15 – 18 Nov 2011 Progress in Implementation of Child Health Programme Nepal

Trend of Child Mortality in Nepal

Trend of Nutritional Status of under 5 Children

DHS-2006 Causes of neonatal mortality in Nepal

Causes of under five mortality in Nepal DHS-2006

IMCI Implementation CDD program started1982 ARI program started1986/87 ARI strengthening program at community focused on pneumonia treatment as a pilot in 4 districts 1995 Evaluation of ARI pilot program1997 Scale up Pneumonia treatment program at community with CBAC 1998/1999 IMCI piloted in Mahottari1997 Merged Community component and program management component in IMCI in and named as CB-IMCI. 1999/2000 Initially expanded in CB-IMCI in three districts1999/2000 Revised the package and incorporated zinc2006 Scaled up through out the country in

IMCI Implementation Number and proportion of MOs trainedAppx 50% Number and proportion of Nurses/other workers trainedAbove 75% ANM & AHWAppx 7000 (100%) VHW and MCHWAppx 7000 (100%) FCHVAppx 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 IMCI20 (100%) Ref. Nepal Medical council Number and proportion of Nursing Schools teaching IMCI103 (100%) ref. Nursing Council ICATT introducedNo

Scaling-up of CBIMCI Programme

15 Nov 2011Regional CH Meeting, Kathmandu9 A. Key factors that helped scaling up 1.Strong government ownership (priority 1 programme) 2.Partner support (EDPs, Professional Societies, NGOs) 3.Strong network of health workers and volunteers at community level 4.Treatment success 5.Community mobilization and utilization of local resource to support the program and FCHVs, B. Key challenges to scaling up: 1. Cost 2.Quality of training 3. Follow up. 4. Frequent transferred of HF staff and drop FCHVs. 5. Supportive supervision monitoring at all level CB-IMCI Implementation

Newborn Health GON and partners prepared Neonantal strategy2004 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 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 districts2009/2010 CB-NCP scale up in additional 15 district in 2010/2011 and planned to expand in 10 in 2011/ /2012

Community Based Newborn Care Package: A pilot intervention of Government of Nepal 11 Status: 61% of U5 mortality is neonatal61% of U5 mortality is neonatal 72% of occur at home (NDHS 2011)72% of deliveries occur at home (NDHS 2011) CBNCP and Health facility based newborn care being promotedCBNCP and Health facility based newborn care being promoted 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.Care of low birth weight newborns 6.Prevention and management of hypothermia 7.Recognition of asphyxia initial stimulation and resuscitation of newborn baby On 21 Dec. 2007, MOHP Nepal endorsed the newborn package The package was piloted in 10 districts in and is now gradually being scaled up nationwide.

15 Nov 2011Regional CH Meeting, Kathmandu12 Newborn Health ENC Course adapted: 1997 Other training courses: CB-NCP training Healthcare providers trained on CBNCP: Healthcare providersTotal no.No. Trained% MO …… ……… Nurses ……..……… CHW …… ……… Volunteers …….. ………

15 Nov 2011Regional CH Meeting, Kathmandu13 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 Sub- regional)

15 Nov 2011Regional CH Meeting, Kathmandu14 CHW approach for care of sick newborns and children District implementing CHW approach Total No. of District Implementing Districts % Home based newborn care752533% Sick child package75 100% Early childhood development % Any review of the experience ……………………………

 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 (14 th Jan Magh 1 st 2065) aiming at reducing both first and second delay 15 Development of Aama Suraksha Programme

RecipientsIncentives 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 (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 Aama Suraksha Programme

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 Free Primary Health Care:

15 Nov 2011Regional CH Meeting, Kathmandu18 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 2011Regional CH Meeting, Kathmandu19 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, Proportion of Measles like disease.

15 Nov 2011Regional CH Meeting, Kathmandu20 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 21 Health Management Information Systems (HMIS) and DHS/MICS MOH National Centers Divisions RHD DHO PHC/HP NPC DoHS MD/HMIS SHP Data Collection/Information Flow Chart VHW/MCHW/FCHV Hospital National/ Central Regional District Catchment area and Community Reporting Frequency Trimesterly Monthly Trimesterly/ Periodic Monthly Central/Regional /Zonal Hospital Reporting Line Feedback Line

15 Nov 2011Regional CH Meeting, Kathmandu22 Future Plans Revitalization/ Strengthening and scale-up plans for Next 2 years Maintenance/Strengthening of CB- IMCI: 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 Expansion of Community Based newborn Care Package –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

Thank You 15 Nov 2011Regional CH Meeting, Kathmandu23