Child health program in Nepal

Child Health Program

Ravi K MishraPublic Health Officer

Central Regional Health Directorate, Hetauda

Medical causes of infant mortality and morbidity

Neonatal mortality Low birth weight Birth injuries and difficulty in labor Congenital anomalies Hemolytic disease of new born Condition of placenta and cord Diarrhoel disease Acute respiratory infection Neonatal tetanus

Post neonatal

and pre school children mortality

Diarrhoel disease Acute respiratory infection Other communicable disease e.g. TB, Measles, whooping

cough etc. Mal nutrition Congenital anomalies Accidents

Causes of child morbidity

Malnutrition Infection- diarrhea, diphtheria, tetanus, whooping cough,

measles, eye and skin problems Parasitic infestation Accidents cause disability

Identification of “at risk” babies

It is necessary to identify particularly those “at risk” and give them special incentive care because it is those at risk babies that contribute to largely to perinatal, neonatal, infant mortality. The basic criteria for identifying these babies include

Birth weight less than 2.5kg Twins Birth order 5 and more Artificial feeding 2nd and 3rd degree malnutrition Failure to gain weight during three successive months Children with PEM, diarrhoea Working mother/ one parent

Child Health Program of Nepal

Immunization Nutrition Community Based Integrated

Management of Childhood Illness (CB-IMCI) and newborn care

National Immunization Programme

The National Immunization Programme (NIP) is a high priority programme (P1) of Government of Nepal.

Immunization is considered as one of the most cost-effective health interventions.

At present, National immunization Program provides vaccine against 10 diseases.

An immunization service is provided through static clinic at health facilities, outreach clinics and mobile clinics

In addition, immunization service is also provided through private, NGO/INGO clinics and medical colleges especially in municipalities.

Nationwide Surveillance of vaccine preventable diseases (AFP, Measles like illnesses, MNT and AES) is conducted through sentinel network of “Acute Flaccid Paralysis” (AFP) surveillance system supported by WHO/IPD.

National Immunization Programme

NATIONAL IMMUNIZATION PROGRAM IS GUIDED BY:

NEPAL HEALTH SECTOR SUPPORT PROGRAM- II (NHSP IP II)

Comprehensive Multi Years Plan of Action (2011- 2016)

GOALGOALS To reduce child, mortality, morbidity and disability associated with

vaccine preventable diseases

OBJECTIVES AND STRATEGIESObjective 1: Achieve and maintain at least 90% vaccination

coverage for all antigens at national and district level by 2016Key strategies:

Increase access and utilization to vaccination by implementing RED strategies in every district

Enhance human resources capacity for immunization management Strengthen immunization monitoring system at all levels Strengthen communication, social mobilization, and advocacy

activities Strengthen immunization services in the municipalities

GOALS, OBJECTIVES AND STRATEGIES

Objective 2: Ensure access to vaccines of assured quality and with appropriate waste managementKey strategies:

Strengthen the vaccine management system at all levelsObjective 3: Achieve and maintain polio free status

Key strategies: Achieve and maintain high immunity levels against Polio by

strengthening routine immunization and conducting high quality national polio immunization campaigns.

Respond adequately and timely to outbreak of poliomyelitis with appropriate vaccine

Achieve and maintain certification standard AFP surveillance


Objective 4: Maintain maternal and neonatal tetanus elimination statusKey strategies:

Achieve and maintain at least >80% TT2+ coverage for pregnant women in every districts

Conduct Td follow up campaigns in high risk districts Expand school based immunization program Continue surveillance of NT


Objective 5: Initiate measles eliminationKey strategies:

Achieve and sustain high population immunity to reduce measles incidence to elimination level

Investigate all suspected measles like outbreaks with program response

Use platform of measles elimination for Rubella / CRS control

Continue case-based measles surveillanceObjective 6: Accelerate control of vaccine-preventable

diseases through introduction of new and underused vaccinesKey strategies:

Introduction of new and under-used vaccines (rubella, pneumococcal, typhoid, rota) based on disease burden and financial sustainability


Objective 7: Strengthen and expand VPD surveillanceKey strategies:

Expand VPD surveillance to include vaccine preventable diseases of public health concern.

Strengthen and expand laboratory support for surveillance.

Objective 8: Continue to expand immunization beyond infancyKey strategies:

Consider for booster dose of currently used antigen based on evidence and protection of adult from potential VPDs.


National Immunization Schedule

SN Type of Antigen Against Disease

Age

1 BCG TB At Birth

2 DPT Hep B Hib, 1st 2nd 3rd

Diptheria, Pertusis,Tetanus,Hepatitis BHemophilus Influenza b

6 Week10 Week14 week

3 Oral Polio , 1st 2nd 3rd IPV

Poliomylitis 6, 10, 14 week14 week

4 PCV Pneumonia,Meningitis

6, 14 week9 month

5 Measles- Rubella Measles, Rubella

9 month

6 JE Japanese Encephilitis

13-23 month

MAJOR ACTIVITIES CARRIED OUT IN FY 2069/70 (2012/2013)

Micro plans updated in 19 districts of Central Development Region (CDR)

Municipal immunization micro plan reviewed in 8 municipalities

Training of Trainer's on vaccine and cold chain management conducted in all 5 regions

Training of Trainer's on cold chain repair maintenance conducted in 3 regions

Immunization Performance Review (conducted at all level) Internal review of VPD surveillance Cold chain strategic guideline development and endorsement Vaccinators training guideline development One round of Polio campaign in 75 districts and 2nd dose of

OPV clubbed with MRcampaign Measles rubella campaign in 60 districts in 2012 and 15

districts in 2011 Continued Integrated Vaccine Preventable Diseases

Surveillance Initiation of declaration of fully immunization VDC/Municipality

Nutrition

Section I

1. Mortality and nutrition status of children and women in Nepal

2. Global initiatives in nutrition

3. National nutrition policy and strategy

4. Adopting the multi-sector approach for nutrition

Mortality and nutrition status of children and women in Nepal

Mortality status of children and women

Without improvement in Nutrition, further child mortality reduction is

less likely Sources: Nepal Demographic an Health Survey 2006 & 2011The Lancet Series on Maternal and Child Undernutrition 2013

MDG Target: 134/100,000

Nutrition status of children and women

Source: Nepal Demographic an Health Survey 2011

Classification for assessing severity of malnutrition by prevalence ranges among children under 5 years of age

Indicator Severity of malnutrition by prevalence ranges (%)

Low Medium High Very high

Stunting <20 20-29 30-39 >=40*Underweight

<10 10-19 20-29* >=30

Wasting <5 5-9 10-14* >=15

Source: http://www.who.int/nutgrowthdb/about/introduction/en/index5.html

* Nepal

Problem of micro-nutrient deficiencies is still serious

6-8 9-11 12-17 18-23 24-35 36-47 48-59 Mountain Hill Terai Total0

102030405060708090

46%

Age in months

NATIONAL AVERAGE

Prevalence of anemia in under 5 years children

0

10

20

30

40

50

60

7067.7

36.23527.6

36.2

47.638.9

3326.5

19.2

33.126.1

19.5

35.9

22.528.8

44.9 42.6

32.7

4941.9

Prevalence of anemia in women (15-49 years)

68.6 percent


Infant & Young Child Feeding (IYCF) practices in Nepal – Breastfeeding

Source: DHS 2011 – Tables 11.3 & 11.6 and DHS 2006 – Tables 12.2 & 12.5 and WHO recalculation of 2006 data based on new IYCF indicators, published in WHO “Indicators for assessing infant and young child feeding practices. Part 3: Country Profiles

45% of newborns are breastfed within the first hour of life, and 85% within the first day.

Infant & Young Child Feeding (IYCF) practices in Nepal – Complementary feeding


Global initiatives in nutrition – SUN and REACH

Initiating Partners

REACH focuses on scaling-up nutrition (SUN) actions

Scaling up of evidence-based-cost-effective interventions to prevent and treat under-nutrition with special focus on 1000 days “window of opportunity’Adopting multi-sector approach which includes integrating nutrition in relevant sectors

http://www.who.int/en/

http://www.fao.org/

National nutrition policy and strategy

Overall objective: To reduce child and maternal mortality through nutritional interventions

Specific objectives: Reduce general malnutrition among children and women, i.e.

stunting, underweight, wasting, low BMI Reduce Iron Deficiency Anemia among children, children under

age 2 year and pregnant women Maintain and sustain Iodine Deficiency Disorders and Vitamin A

Deficiency control activities Improve maternal nutrition Align with multi-sectoral nutrition initiative Improve Nutrition related behavior change and communication Improve Monitoring and Evaluation for Nutrition related

Programmes/Activities

Source: DoHS Annual Report 2011-12

Strategies

Strategies Protect, promote and support optimal feeding practice of

children through IYCF expansion, increasing coverage of GM Reduce IDA through iron tablet supplementation to pregnant,

adolescents, preschool and school deworming and flour fortification

Increase accessibility and Social Marketing of 2-Child Logo iodized packet salt

Bi-annual mass supplementation of VA to under 5 years children

Gradual expansion of the School Health and Nutrition activities in all districts

BCC for changing dietary practices for improved maternal and child nutrition practices

Expansion of Community as well as facility based Management of Acute Malnutrition through IMAM and rehabilitation homes

Source: DoHS Annual Report 2011-12

Adopting the multi-sector approach for nutrition

Need of multi-sector approach

Need of a nutrition architecture

Identify information and HR gaps

Multi-Sector Nutrition Plan Framework

Section II

National nutrition programmes

National nutrition programmes

Infant and Young Child Feeding (IYCF) programme1. Basic IYCF package training to

HWs and FCHVs (7)2. Integrated IYCF and Baal Vita

Community Promotion Programme (15)

3. IYCF linked with Child Cash Grant Programme (5)

4. SUAAHARA/USAID promoting ENA and EHA (20)

5. Agriculture and Food Security Project (AFSP) (20)

6. Knowledge-based Integrated Sustainable Agriculture and Nutrition (KISAN) (19)

7. Sunaula Hazar Din (15)

1. IYCF practices: Breastfeeding and Complementary feeding F = Frequency

A = AmountT = TextureV = VarietyA = Active feedingH = HygieneAg

e sp

ecifi

c

2. Integrated Management of Acute Malnutrition (IMAM) programmePreviously known as Community based Management of Acute Malnutrition (CMAM) Programme

IMAM Program began in 2007/8 and in 2012/13 the program covered 11 districts.

IMAM manages acute malnutrition in children age 6-59 months through inpatient and outpatient services at the community level.

IMAM

pro

gram

me

serv

ice m

odel

in

dist

rict

Ilaka HF / PHC

DHO / DPHOHospital / SC &/

OTPSHP / HPCommuni

ty

Ilaka HF / PHC

Hospital

PHC

FCHV

Region / Centre

SHP / HP

Recording of new cases,

referral, follow up

(6-59 months)

Recording & reporting

Supp

ly

3. Nutrition Rehabilitation Homes (NRHs)

HospitalN

RH

Management of acute

malnutrition in the facility

4. Micronutrient deficiencies control programmes

1. National Vitamin A Programme

2. Intensification of Maternal & Neonatal Micronutrient Programme (IMNMP)

3. Iodine Deficiency Disorder (IDD) Control Programme

4. IYCF and Baal Vita Community Promotion Programme

5. Flour fortification Programme

6. Fortified flour distribution programme

1. N

atio

nal V

itam

in A

Pro

gram

me DHO /

DPHOHealth Facilit

yRegion / Centre

Vitamin A: 6-59 months

De-worming: 12-59 months

Vita

min

A

caps

ule

De-w

orm

ing

tabl

et Repo

rting

Recording

VAS piloting to reach the unreached: 6-11 months

Supply

6-11 months: ½ capsule i.e. 1,00,000 IU12-59 months: 1 capsule i.e. 2,00,000 IU

12-2

3 m

onth

s: ½

tab

i.e

. 200

mg

24-5

9 m

onth

s: 1

tab

i.e.

40

0 m

g

Post

partu

m V

itam

in A

SupplyDistribution

House

Within 6 weeks of delivery

Dose: 1 capsule = 2,00,000 IU

2. In

tens

ifica

tion

of M

ater

nal &

Ne

onat

al M

icron

utrie

nt P

rogr

amm

e (IM

NMP)

DHO / DPHO

180 tablets

45 tablets

Supp

ly

Reco

rdin

g &

repo

rting

Distributio

n

Distribution


Region / Centre

Supply

Dose: 1 IFA tab i.e. 60 mg iron + 400 µg folic acid

Once 1 tab i.e.

400 mg of de-

worming table to

pregnant women after 1st

trimester

3. Io

dine

Defi

cienc

y Di

sord

er (I

DD)

Cont

rol P

rogr

amm

eWorld fit for children target on micronutrients• 90% HH use adequately iodized salt

Iodized Salt Social Marketing Campaign – ISSMaC approach

4. IY

CF a

nd B

aal V

ita C

omm

unity

Pr

omot

ion

Prog

ram

me

Community

6-23 months

Supp

ly

Reco

rdin

g &

repo

rting

DHO / DPHORecording &

reporting

Region / Centre

Supply

Protocol: 60 Sachets of MNP

supplement for 2 months (on daily

use basis) for children with age

group 6-23 months

Pilot: Makwanpur, Parsa, Gorkha, Rasuwa, Palpa, Rupandehi Roll out: Achham, Bardiya, Dadeldhura, Dang, Rukum, Kapilbastu, Sankhuwasabha, Sunsari, Morang

5. F

lour

forti

ficat

ion

Prog

ram

me

Government of Nepal adopted wheat flour fortification as one of the national strategies to reduce iron deficiency anemia in Nepal.

Nepal Government made flour fortification at roller mills mandatory in August 2011 based on satisfactory voluntary fortification experience.Nepal has become the first country in South Asia to have mandatory legislation for fortification at roller mills.

6. F

ortifi

ed fl

our d

istrib

utio

n pr

ogra

mm

e

Karnali & Solukhum

bu

6-11 months

1.5

kg/child/month

6-23 months

11-23 months2.5 kg/child/month

5. Community based growth monitoring programme Growth

monitoring in outreach clinic

Growth monitoring in health facility

Mon

thly

gro

wth

m

onit

orin

g fr

om 0

-23

mon

ths

Gro

wth

mon

itor

ing

com

bine

d w

ith

IYCF

Operational feasibility of new CH card: Dang, Jumla, Rukum and Udayapur

6. School health and nutrition programme (SHNP) – a joint programme of MoHP & MoE

Scho

ol h

ealth

and

nut

ritio

n pr

ogra

mm

e

Supply

Supply


Private & Public

Gra

de 1

- 10

EMIS

Adolescent iron

Region / Centre

Refilling by HF & SMC

Private & Public

Gra

de 1

- 10

Private & Public

Gra

de 1

- 10

RC

Supp

ly

Supply

Reco

rdin

g &

repo

rting


Recording &

reporting

SupplySupply Supply

Supply during orientation (Public only; 1 First Aid Kit box/school)


School health and nutrition programme (SHNP) coverage

COMMUNITY BASED INTREGRATED MANAGEMENT OF CHILDHOOD ILLNESS (CB IMCI) AND NEONATE CARE

COMMUNITY BASED INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESSES (CB‐IMCI)

An integrated package of child-survival interventions and addresses major childhood killer diseases like Pneumonia, Diarrhoea, Malaria, Measles and Malnutrition in 2 months to 5 years children in a holistic way.

CB-IMCI also includes management of infection, Jaundice, Hypothermia and counselling on breastfeeding for young infants less than 2 months of age.

In 1997, the IMCI program was initiated in Mahottari district as a pilot.

Based on the recommendations it was decided to include a community component, enabling mobilization of community health workers (VHWs and MCHWs) and FCHVs to provide CDD, ARI, Nutrition and Immunization services to the community

As a result the Community based ARI and CDD (CBAC) program was merged into IMCI in 1999 and is now called the Community Based Integrated Management of Childhood Illness (CB-IMCI).

CB-IMCI Program has covered 75 districts by the end of fiscal year 2066/67 (2009/2010).

Newborn component was added to CB-IMCI in 2004.

COMMUNITY BASED INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESSES (CB‐IMCI)

Vision Contribute to survival, healthy growth and development of under five years children of Nepal.

Achieve MDG 4 by 2015.Goal To reduce morbidity and mortality among children under-five due to pneumonia, diarrhoea, malnutrition, measles and malaria.

VISION AND GOALS

To reduce under five mortality from the current rate of 54/1,000 live births to 38/1,000 live births and infant mortality from the current rate of 46/1,000 live births to 32/1,000 live births by 2015.

To reduce neonatal mortality from the current rate of 33/1,000 live births to 16/1,000 live births by 2015.

To reduce morbidity among infants less than 2 months of age.

TARGETS

Reduce frequency and severity of illness and death related to ARI, Diarrhoea, Malnutrition, Measles and Malaria.

Contribute to improved growth and development.

OBJECTIVES

The following strategies have been adopted by CB-IMCI program:

1. Improving knowledge and case management skills of health service providersCB-IMCI aims to improve the skills of health service providers through

Training to all health service providers on CB-IMCI including zinc treatment for diarrhea;

Regular integrated review and refresher trainings to health service providers;

Inclusion of CB-IMCI component in the curriculum of pre-service medical and paramedical schools;

Technical support visit from higher levels to respective institutions; central to regional to district to HFs to FCHVs

Capacity building training to the CB-IMCI focal persons of the districts

STRATEGIES

2. Improving overall health systems Carry out CB-IMCI program maintenance activities as per the recommendations made by IMCI technical working group and global context.

Improve logistic supply. Regularize mother’s group meeting. Strengthen reporting system at all levels. Strengthen supervision and monitoring.

STRATEGIES

3. Improving family and community practices

Disseminating key behavioral message through FCHVs to families and communities using relevant IEC materials.

Reaching the disadvantaged and hard-to-reach communities through reactivated mother’s group meeting.

Dissemination of key family practice messages through interpersonal communication.

STRATEGIES

1. Management of sick children below 2 months of age

2. Management of sick children 2 months to 5 years of age

Management of Diarrhoeal Diseases Zinc Supplementation

COMPONENTS OF CB‐IMCI

Major activities carried out in FY 2069/70 include the following:

Capacity building training to CB-IMCI Focal Persons.

Intensive monitoring of CB-IMCI program districts (in low performing districts).

Development and finalization of Referral IMNCI Protocol for Medical Doctors and HWs.

CB-IMCI training to newly recruited medical doctors and HWs.

Revised IMCI Protocol Training – 2 Districts. Revision of CB-IMCI and NCP IEC materials with printing, editing etc.

Celebration of World Pneumonia Day (12 November).

Advocacy and marketing of CHX, Zinc, Cotrim, ORS.

MAJOR ACTIVITIES

Community Based Newborn Care Program (CB‐NCP)

The 2006 and 2011 Nepal Demographic and Health Survey have shown that neonatal mortality in Nepal has been stagnant at 33 deaths per 1,000 live births which account for 61 percent of under 5 deaths.

The major causes of neonatal deaths in Nepal are infection, birth asphyxia, preterm birth, and hypothermia.

Hence, reduction of high neonatal mortality is an urgent priority for achieving MDG 4.

MoHP has binitiated integrated newborn health care package called “Community Based Newborn Care Program (CBNCP)” based on the National Neonatal Health Strategy 2004.

The program was implemented as a pilot in 10 districts in FY 2065/66 and further expanded covering 39 districts by the end of FY 2069/70. The plan is to cover all 75 districts by 2015.

The goal of CBNCP is to reduce neonatal mortality (NMR) through the sustained high coverage of effective community based interventions.The specific objectives of CBNCP include:

To prevent and manage newborn infection

To prevent and manage hypothermia and LBW babies

To manage post-delivery asphyxia, and To develop an effective system of

referral of sick newborns

GOAL AND OBJECTIVE OF CB‐NCP

Expansion of CB-NCP in new 5 districts (Bajura, Pyuthan, Rupandehi, Udayapur and Dadeldhura)

Intensive monitoring of CB-NCP program districts (in low performing districts)

Capacity Building Training for New-born Care for health service providers (30 persons)

Orientation training on CB-IMCI, CB-NCP and Zinc, CHX to the HWs of private sectors (CBNCP Program Districts)

CB-NCP training to newly recruited medical doctors and HWs

Construction/renovation of newborn care facilities in 37 sites

MAJOR ACTIVITIES

Thank you

Child health program in Nepal

Healthcare

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