15 Nov 2011 Regional CH Meeting, Kathmandu 1 Meeting of South-East Asia Regional Programme Managers...

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

33

465450

3933

79

64

48

91

118

61

0

20

40

60

80

100

120

140

1996 NFHS 2001 NDHS 2006 NDHS 2011 NDHS

Neonatal Mortality Rate Infant Mortality Rate Under 5 Mortality Rate

Trend of Nutritional Status of under 5 Children

57

49

4143

39

29

1311 11

0

10

20

30

40

50

60

2001 NDHS 2006 NDHS 2011 NDHS

Stunting (Ht/Age) Underweight (Wt/Age) Wasting (Wt/Ht)

DHS-2006

Others10%

Birth asphyxia15%

Tetanus2%

Preterm/LBW6%

Birth injury19%

Combined Infection

40%

Congenitial abnormality

8%

Causes of neonatal mortality in Nepal

Combined infection, 60%

Diarrhea, 13.20%

Injury, 10.70%

ARI and diarrhea ,

7.50%

Others, 8.60%

Causes of under five mortality in Nepal

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 ImplementationNumber 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

D istric t s c o v e re d b y p ro g ra m

1 6 1 8 2 22 8 3 0

3 54 4

5 9

7 5

64 4 1 1 1 4

01 02 03 04 05 06 07 08 0

Y e a r

Numb

er of

distric

ts

U n d e r 5 p o p u la t io n c o v e re d b y t h e p ro g ra m

3 84 5

5 6 5 8 6 1 6 4

8 51 0 0

93 3

1 82 5

0

2 0

4 0

6 0

8 0

1 0 0

1 2 0

Y e a r

% of <

5 popu

lation

Scaling-up of CBIMCI Programme


A. Key factors that helped scaling up1. Strong government ownership (priority 1 programme)2. Partner support (EDPs, Professional Societies, NGOs)3. Strong network of health workers and volunteers at community level4. Treatment success5. Community mobilization and utilization of local resource to support the

program and FCHVs,

B. Key challenges to scaling up:1. Cost 2. Quality of training3. 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 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

11

Status:•61% of U5 mortality is neonatal 61% of U5 mortality is neonatal •72% of 72% of deliveries occur at home (NDHS 2011) occur at home (NDHS 2011)•CBNCP and Health facility based newborn care being promoted CBNCP 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 2009-2010 and is now gradually being scaled up nationwide.


Newborn Health• ENC Course adapted: 1997

• Other training courses: CB-NCP training

• Healthcare providers trained on CBNCP:

Healthcare providers Total no. No. Trained %

MO …….. 1569 ………Nurses …….. ………CHW …….. 953 ………Volunteers …….. …….. ………


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)


CHW approach for care of sick newborns and children

District implementing CHW approach

Total No. of District

Implementing 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

……………………………

……………………………

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

15

Development of Aama Suraksha Programme

Recipients IncentivesIncentives 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. 3,000C-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 40017

Free Primary Health Care:


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


Health Management Information Systems (HMIS) and DHS/MICS

List the key indicators for newborn and child health included in HMIS and DHS/MICSARI •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.



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, Kathmandu21


MOH

National Centers

Divisions

RHD

DHO

PHC/HP

NPC

DoHSMD/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

Monthly

Central/Regional/Zonal Hospital

Reporting Line

Feedback Line


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 2011 Regional CH Meeting, Kathmandu 1 Meeting of South-East Asia Regional Programme Managers...

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