1. Nepal: Achieving High Coverage at Scale with Community-based MNCH Services Dr. Yashovardhan Pradhan March 9, 2010 AME Meeting Bangkok Presentation: NIC-P2

2. Mortality Trend and MDG Goal (Under 5, Infant and Neonatal) Source: NFHS (1991), DHS 1996, 2001, 2006 and MDG Progress Report 2005

3. Female Community Health Volunteers Pillars to Nepal’s Public Health Programs FCHVs are involved in: i)Community based management of pneumonia & diarrhea ii)Vitamin A & de- worming iii)Immunization promotion iv)Family Planning v)Birth preparedness and neonatal care packages vi)Innovative approaches 48,549 FCHVs 75 Districts 3,915 VDCs 42,53,220 households NEPAL 23,151,423 Total Population Source: CBS 2001

4. CB-IMCI 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 Under 5 population covered by CB-IMCI program

5. Trends in severe dehydration among diarrhea cases Source: HMIS, from NAGA pg. 53

6. ARI (Trend of Reported ARI Cases and Proportion of Severe Pneumonia) Source: HMIS Raw Data and DoHS Annual Reports

7. 6-59 months population reached by Vitamin A program per year >90% coverage in all districts since 2003

8. 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

9. Trends in ANC and TT Coverage in Nepal

10. Intensification of Maternal Iron Supplementation Program (2003 -2008) Far-Western Region Eastern Region Mid-Western Region Western Region Central Region UNICEF PLAN MI WHO 2003 – Initiated from 5 districts 2008 – Expanded to 52 districts 2010 -- Expanding to all 75 districts

11. Result Ref.: Impact Evaluation Survey- 2003 to 2008, New Era, MI Coverage and compliance increased in the program districts.

12. Components of the Community-based Newborn Care Package (CB-NCP) 1.IEC/BCC on essential newborn care 2.Promotion of institutional delivery 3.Post-natal visit to mother and baby 4.Management of PSBI (sepsis) 5.Management of low birth weight 6.Management of hypothermia 7.Management of birth asphyxia Initiated in 10 districts

13. 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

14. 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 community- based use in remote areas

15. 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 scaling- up innovative approaches through phase-wise expansion These approaches have likely reduced maternal, child and neonatal mortality, and likelihood of achieving MDG 4