Child Health

2 Definition

 Neonate- A neonate is a baby who is 4 weeks old or younger.

 Neonatal morbidity- A disease condition or state during first 28 days of

life. Includes hypoglycemia, hypocalcemia, hyperbilirubinemia,
polycythemia.

03:42
3 Neonatal Mortality

 Neonatal mortality: The death of a live-born baby within 28 days of life.

Sub-divided into two:

 Early neonatal deaths: deaths between 0 and 7 completed days of birth.

 Late neonatal deaths: deaths after 7 days to 28 completed days of birth.

03:42
4 Indicators of Neonatal Mortality

 Neonatal mortality rate=

Number of neonatal deaths in a given year * 1000
Total number of live births in the same year

03:42
5 INDICATORS

 x 1000
 Under 5 mortality rate x 1000
 Child Health : Introduction

A child is any person under the age of 18. 1

Child health is concerned with preventive aspects of child care and

their attaining full potentials as an adult.

However, considering the vulnerability, child health programs are

focused mainly on children under the age of five years.

1. Convention on the Rights of the Child, 1989 6

Maternal and Child health in different
plans and policy documents

7
 The Nepal Health Sector Strategy (NHSS) 2015-
2020
Identifies equity and quality of care gaps as areas of concern for
achieving the maternal and child health sustainable development
goal (SDG) target.

 Gives guidance for improving quality of care, equitable

distribution of health services and utilization and universal health
coverage with better financing mechanism to reduce financial
hardship and out of pocket expenditure for ill health.

8
 The National Safe Motherhood and Newborn
Health Long term Plan 2006–2017
Aimed to have functioning Comprehensive Emergency Obstetric and
Newborn Care (CEONC) sites in 63 districts

 Functioning Basic Emergency Obstetric and Newborn Care (BEONC)

facilities in all 137 Primary Health Care Centres (PHCCs) by 2017

Health Posts (HPs) with Skilled Birth Attendants (SBAs) increased to 60

percent by 2017.

9
The Safe Motherhood and Reproductive Health
Act 2018 /Regulation 2020

The Safe Motherhood and Reproductive

Health Act (2018) guarantees the
reproductive rights of every woman.

10
 The Public Health Act 2018/ Regulation 2020
The most recent addition.
Focuses on integrated service provision for
reproductive, maternal, newborn, children, and
adolescent’s health with an emphasis on quality of
care and strengthening of referral mechanisms.

11
 Maternal and Child Health Programs In
Nepal: Background
Noted for its remarkable achievement in bringing down the number of
maternal deaths by more than 75 percent since 1990, and for significantly
reducing under-5 child mortality by more than 66 percent over the past 20
years. - (USAID)

Consistent policy focus and sustained financial commitment by the

government and donors throughout the past two decades, including substantial
increases in funding for maternal and child health since the early 1990s, has
allowed for widespread improvements in access to medical services, particularly
in remote areas.

12
Status of child Health

13
Trend in child mortality

Decreased
by 59%
from 1990
to 2018

14
Globally, 1 in 11 children dying before
reaching age 5 in 1990, compared to 1 in 26
in 2018.
5.3 million children under age five died in
2018
(WHO 2019)

15
In 2018 alone, an estimated 6.2 million children and young
adolescents under age 15 died, mostly from preventable
causes.
◦ Newborns: 2.5 million of these deaths,
◦ children aged 1−11 months: 1.5 million,
◦ children aged 1−4 years for 1.3 million, and
◦ 1 million deaths for children and young adolescents aged 5-14
years.
In 2018, global estimates,
◦ NMR:18 deaths per 1,000 live births
◦ IMR is 29/1000 live birth and
◦ U5MR was 39/1000 live birth.
◦ For children aged 5–14 years, the probability of dying was
estimated at 7 per 1,000 children aged 5 years.

16
17
Trend in child mortality

Decreased
by 59%
from 1990
to 2018
18

 Globally, 1 in 11 children dying before

reaching age 5 in 1990, compared to 1 in
26 in 2018.
 5.3 million children under age five died
in 2018
(WHO 2019)
  In 2018 alone, an estimated 6.2 million children and
19 young adolescents under age 15 died, mostly from
preventable causes.
 Newborns: 2.5 million of these deaths,
 children aged 1−11 months: 1.5 million,
 children aged 1−4 years for 1.3 million, and
 1 million deaths for children and young adolescents aged 5-14
years.
 In 2018, global estimates,
 NMR:18 deaths per 1,000 live births
 IMR is 29/1000 live birth and
 U5MR was 39/1000 live birth.
 For children aged 5–14 years, the probability of dying was
estimated at 7 per 1,000 children aged 5 years.
20 Neonatal Mortality

• Although the global number of newborns deaths declined from 5

million in 1990 to 2.4 million in 2019, children face the greatest risk of
death in their first 28 days.

• In 2019, 47% of all under-5 deaths occurred in the newborn period

with about one third dying on the day of birth and close to three
quarters dying within the first week of life.

Ref: https://www.who.int/news-room/fact-sheets/detail/newborns-reducing-mortality 03:42

 The average global neonatal mortality rate
(NMR) in 2018 is 18 per 1000 live births.

Globally 2.5 million children died in the first

month of life in 2018.
21 International
status …
contd Approximately 7000 newborn deaths every day
with about one third dying on the day of birth
and close to three quarters dying within the first
week of life.
03:42
22 INTERNATIONAL STATUS OF NEONATAL
MORTALITY
Average Neonatal mortality rate per 1000 live births by WHO region
30
27.2 25.9
25

20.2
20

average Neonatal mortality rate per 1000 live births

15

10
7.4
5.8 4.6
5

0
Africa Eastern South east Asia Americas Western Pacific Europe
Mediterranean

Ref: https://www.who.int/gho/child_health/mortality/neonatal/en /
 Neonatal Mortality Rate per 1000 liver birth
23

03:42
 Global
situation
24

Source: WHO/ UNICEF 2017

 NMR is 21 deaths per 1,000 live
births in the most recent 5-year
period. (NDHS 2016 and 2022)
In 2015, approximately 600,000
25 National babies were born in Nepal, or around
Status 1,600 every day.
Approximately 34 babies will die
each day before reaching their first
month ; 28 stillbirths occur every day.
03:42
 NMR in rural areas is 24 deaths per
1,000 live births and 15 deaths per
1,000 live births in urban areas.
26 National
Status…contd NMR among the poorest households
is 32 deaths per 1,000 live births,
compared to 14 deaths per 1,000 live
births among the richest households.

03:42
 Baseline Target Progress Target
Targets and Indicators 2015 2019 2019 2030

3.1. By 2030, reduce the global maternal mortality ratio

3.1.1 Maternal mortality ratio
258 125 239 70
3.1.2 Proportion of births attended by skilled health
personnel 55.6 69 79.3 90

3.2 By 2030, end preventable deaths of newborns and children under 5 years of age

3.2.1 Under-five mortality rate

38 28 28 20
3.2.2 Neonatal mortality rate
23 18 16 12
12/11/2023
28 Trends of Under-5 Mortality in Nepal
160
Under-five mortality rate  by 73%
140 142
Infant mortality rate  by 68%
120 118 Neonatal mortality rate  by 60%
100
91
80 99

60 78 61
64 54
48 38
40 53 50 46 39 33
39 32 28
33 25
20 33 33 21
21 12
23
0
90 9 6 0 1 0 6 1 1 14 16 22 30
1 9 19 20 20 20 20 S2 0 2 0 2 0
e S S S S S S G
e lin FH DH DH DH IC DH DH SD
B as N N N N M N N

NMR IMR U5MR

29
National
situation • Annually 13,000 newborn
babies die within the first 28
days of life
• One-third deaths occur in
the first day of life
• 78% of these neonatal
deaths is avertable and can
be prevented through cost-
effective interventions
NDHS 2016
 Causes of under five mortality
Other diseases
(Meningitis, injuries
, pertusis, measles,
non-communicable
diseases)
19%
Other Prematurity
communicable, peri 30%
natal and
nutritional
conditions Sepsis and
8% other infectious
Diarrhoeal diseases conditions of
6% Acute lower the newborn
respiratory 7%
infections
Congenital Birth asphyxia and
anomalies 15% birth trauma
4% 11%
 Causes of Deaths Among Children U-5 Years
31

NDHS, 2016
 Cause of Neonatal Deaths
32

Hypothermia Other
Sudden 4% 7%
neonatal
death
6%
Congenital
malformations
& deforma- Respiratory &
tions cardiovascular
7% disorder of
perinatal period
31%

Infection specific
to perinatal pe-
riod
16% Complications
of pregnancy,
labor &
delivery
31% NDHS, 2016
 Neonatal Deaths
33 Percent distribution of neonatal deaths within 0-28 days of birth

<1 hour
7-28 days 17%
21%

1-7 days
22% 1-23 hours
40%

NDHS, 2016
Globally Moving from Survive to Thrive
Provision & experience of care

2016
Survive and Thrive: Transforming
care for small and sick newborns

2019

Invest in transforming care for 30 million vulnerable newborns

that require quality care in a hospital setting to
achieve SDGS and UHC by 2030
35
Global commitments - ENAP (launched in 2014) and SDG
(launched in 2015)
Every Newborn Action Plan
By 2030:
• All countries will achieve newborn deaths of 12 or less per
1000 life births
• All countries will reduce stillbirths to 12 or less per 1000
total births

Sustainable Development Goal 3.2

By 2030:
• All countries to reduce neonatal mortality as low as 12 per
1000 life births

36
Impact of Packages of Care on Newborn Deaths Averted: Lives
Saved (LiST analysis)
36%

44%
11%

30 million newborns require inpatient care each year – 80% do not receive it 37
Small and / or Sick Newborn Care being prioritized

If the present annual average rate of reduction of NMR persists:

• Southern Asia is predicted to achieve NMR of 12 or less by 2042 and sub-
Saharan Africa by 2050
• Countries in sub-Saharan Africa or Southern Asia need to at least
double their rate of progress to achieve the 2030 national targets

• Estimated 1 million small and sick newborns survive

with long-term disability
38
Every Newborn Action Plan (ENAP) Coverage Indicators
1 2 3 4
Every Pregnant Woman Every Birth Every Woman & Newborn Every Small and / or Sick Newborn

Four or more ANC Births attended by Early routine postnatal care ●80% of countries have an
contacts Skilled Birth (within 2 days) implementation plan
Attendants ● 80% of districts have 1 functional
level 2 in-patient unit to care for
small and sick newborns and
provide CPAP

https://www.unicef.org/media/77166/file/Ending-preventable-newborn-deaths-and-stillbirths-by-2030-universal-health-coverage-in-2020%E2%80%932025.pdf

39
The Dual Path Ahead

Small and / or sick newborn care

Essential Newborn Care &

Newborn Resuscitation

40
Accelerating Focus
on Coverage and
Quality of Small
and / or Sick
Newborn Care

41
 Call for Action

• Support/advocate in choosing
the best, pragmatic
options/alternatives for Nepal
in such pilots/newer
recommendations

42
 Call for Action
• Chlorohexidine use:
– Clean, dry umbilical cord care is
recommended
– Daily application of 4% in the first week
after birth is recommended only in settings
where harmful traditional substances (e.g.
animal dung) are commonly used on the
umbilical cord.

43
Call for Action

44
 Call for Action

• Universal newborn screening for abnormalities of the eye is

recommended
• Universal newborn hearing screening (UNHS) with otoacoustic
emissions (OAE) or automated auditory brainstem response
(AABR) is recommended for early identification of permanent
bilateral hearing loss (PBHL).

45
46

What is being done??

 Child Health Programs in Nepal
Child Health and Immunization Service Section is one of the four sections of Family
Welfare Division, Department of Health Services.

 Plans, executes and monitors several activities of child health and immunization services.

Has two programs:

1) National Immunization Program

2) Integrated Management of Neonatal and Childhood Illness(IMNCI) Program

47
 राष्ट्रिय खोप कार्यक्रम (NIP)
• नेपाल सरकारको उच्च प्राथमिकता प्राप्त कार्यक्रम

• २०३४ देखि शुरूवात भएको र हाल १३ थरिका एन्टिजेन १६०००

भन्दा बढि खोप के न्द्रहरू मार्फ त
• १५ महिना मुनिका बालबालिकाहरु,

• गर्भवती महिलाहरु

• सफल र सवै भन्दा लागत प्रभावकारी कार्यक्रम

• बाल मृत्युदर घटाउन प्रमुख भूमिका रहेको

 राष्ट्रिय खोप कार्यक्रमका मूख्य उदेश्यहरु
• खोपबाट बचाउन सकिने रोग नियन्त्रण, अपाङ्गता र मृत्युदरलाई कम गर्नु

• खोपबाट बचाउन सकिने रोगहरुको निवारण र उन्मुलनलाई तिव्रता दिई दिगोपन कायम राख्ने
 पोलियो शुन्य अवस्था (सन् २०१०)
 नवशिशु धनुष्टङ्घार निवारण (सन् २००५)
 दादुरा निवारण गर्ने (सन् २०२३)

• प्रत्येक बालबालिकाले पूर्ण खोप लगाएको सुनिश्चित गर्ने

 राष्ट्रिय खोप कार्यक्रमका मूख्य उदेश्यहरु……….
• आपूर्ति व्यवस्था तथा खोप व्यवस्थापन प्रणालीलाई सुदृढ गर्ने
• खोप कार्यक्रमको लागि दिगो वित्तिय व्यवस्थापनको सुनिश्चित गर्ने ( महामारी व्यवस्थापन, सर्भेलेन्स,
सहलगानी दायीत्व)
• नयाँ तथा कम प्रयोग भएका खोपहरुलाई खोप कार्यक्रममा समावेश गर्दै लैजाने
• खोपबाट बचाउन सकिने रोगहरुको खोजपड्ताल (सर्भिलेन्स) कार्यलाई सुद्दढिकरण र विस्तार गर्ने
• एक बर्षभन्दा बढी उमेर समूहको लागि पनि खोप सेवा विस्तार गर्दै लैजाने
 के ही प्रमुख उपलब्धिहरू….
नियमित खोपमा टाइफाइड
खोपको शुरुवात (दक्षिण
जापानिज बालबालिकामा एसियामा पहिलो)
ईन्सेफलाईटिस रोग पूर्ण खोप सुनिश्चितता खोप ऐन र नियमावली “हेपाटाईटिस बि”
बिफर रोगको उन्मूलन नियन्त्रण घोषणा शरूवात जारी नियन्त्रण

1977 2005 2006 2010 2012 2015 2016 2018 2019 2020 2022

मातृ तथा नवशिशु
धनुष्टङ्कार रोग निवारण
पोलियो रोग शून्य बाल मृत्युदरमा उल्लेख्य रुबेला तथा सि.आर.एस नियमित खोपमा रोटा भाइरस
अवस्था र उन्मूलनको कमि (सहस्राब्दि लक्ष ४ (Congenital खोप तथा सरसफार्इ प्रर्बधन
नजिक र ५ प्राप्त) Rubella
Syndrome) कार्यक्रमको शुरुवात
नियन्त्रण
राष्ट्रिय खोप कार्यक्रमको लागि मार्गदर्शक नीति, रणनीति र कार्यसूचीहरू (Guiding strategy, policy
and agenda for NIP)

• बृहत बहुवर्षीय खोप योजना २०१६ देखि २०२१/नयाँ राष्ट्रिय खोप रणनीति
• खोप कार्यसूची (Immunization Agenda) २०३० (विश्वव्यापी दस्तावेज)
• क्षेत्रीय खोप कार्ययोजना २०२२–२०३० (RVAP)
• WHO दक्षिण–पूर्वी एशिया क्षेत्रमा दादुरा र रुबेला उन्मूलनका लागि क्षेत्रीय रणनीतिक योजना (२०२०–२०२४)
• पोलियो उन्मुलन रणनीति २०२२–२०२६
• गाभी रणनीति ५.० (शून्य मात्राका बालबालिकालाई खोप)
• अन्य राष्ट्रिय नीति, रणनीति र निर्देशिका
 Guiding Instruments for National Immunization Program (NIP)

Public Health
Service Act 2074
National Health
Immunization Act 2072 Policy Nepal Health Sector
& Regulation 2074 Strategy
Other documents related to immunization
 Key Initiatives
Full Immunization Declaration : As of end of FY 2078/79, 70 out of 77 districts have
been declared ‘fully immunized’. Gandaki, Lumbini and Sudurpaschip Province has
declared their province as fully immunized province.

Introduced several new and under-utilized vaccines contributing towards Global

Vaccine Action Plan target achievement.

As per comprehensive Multi-year Plan for Immunization (cMYP) 2017 - 2021, several
other vaccines, including Human Papilloma Virus Vaccine (HPV) and Typhoid
Conjugated Vaccine (TCV) are planned for introduction in Nepal.

55
 Key Initiatives: Immunization Act
First country in the South East Asia Region to have Immunization Act

Immunization Act 2072 published in the Official Gazette on 26 January 2016.

Based on the Act, Nepal has Immunization Regulation 2074, which was published in the
Official Gazette on 6 August 2018.

The Immunization Act of Nepal has Chapter 4 Family Welfare 24 that recognizes immunization
as a right of all children.

In line with this, Gandaki province also has its provincial Immunization Act.
56
 Goal : Reduction of morbidity, mortality and disability
associated with vaccine preventable diseases.
Strategic Objectives
Objective 1. Reach every child for full immunization
Comprehensive Objective 2. Accelerate, achieve and sustain vaccine
Multi-Year Plan preventable diseases control, elimination and eradication
for Objective 3. Strengthen immunization supply chain and
Immunization vaccine management system for quality immunization services
(cMYP)2017- Objective 4. Ensure financial sustainability for immunization
program
2021
Objective 5. Promote innovation, research and social
mobilization activities to enhance best practices

57
 Vaccine Preventable Diseases Surveillance
Strategic approaches within objective 2 of cMYP 2017-21 are :

Sustain polio-free status for the global eradication of the disease

Achieve measles elimination and rubella/CRS control by 2019
Accelerate JE control
Sustain MNT elimination status
Accelerate hepatitis B vaccination
Expand surveillance of other vaccine preventable diseases

Supported by WHO-IPD, surveillance for these diseases are conducted throughout the country
through 699 routine weekly zero reporting sites, 560 case-based measles surveillance sites and 785
informers.
58
 खोप संयन्त्रः सहभागीता र सहजीकरण
 राष्ट्रिय खोप समिती
राष्ट्रिय खोप ऐन
 राष्ट्रिय खोप खोप सल्लाहकार समिती
२०७२
 राष्ट्रिय AEFI अनुसन्धान समिती
 अन्तर संस्था समन्वय समिति (ICC): WHO/SAGE र गाभी
 दादुरा निवारणका लागि राष्ट्रिय प्रमाणीकरण समिति
 पोलियो उन्मूलनको लागि राष्ट्रिय प्रमाणीकरण समिति
 राष्ट्रिय पोलियो भाइरस नियन्त्रण प्रयोगशाला कार्यदल समिति
 तहगत खोप समन्वय समिती (राष्ट्रिय, प्रदेश, जिल्ला, स्थानिय तह, वडा)
 राष्ट्रिय खोप कार्यक्रमको
तुलनात्मक प्रगति अवस्था
 नियमित खोप कभरेज (आ.व. २०७६/७७ – २०७८/७९)
104
99 98
95 94 95 93
91
86 85 88 87 85 87
78 78 80 80 82 81
71
प्रतिसत

la=l;=hL= l8=lk=6L=– l8=lk=6L=– lk=l;=eL= lk=l;=eL= bfb'/f ?a]nf bfb'/f ?a]nf

x]kaL–lxa x]kaL–lxa klxnf] dfqf t]>f] dfqf klxnf] dfqf bf]>f] dfqf
klxnf] dfqf t]>f] dfqf
खोप

Data: iHMIS, MD, DoHS

विगत ४ वर्षको पेन्टा १ को प्रगति अवस्था

2019 2020
86% 78%

2022
2021
98.8%
87%

Data: iHMIS, MD, DoHS

बिगत ४ वर्ष को दादुरा रूबेला दोश्रो मात्राको प्रगति अवस्था

2019 2020
73% 71%

2022
92.8%
2021
81%

Data: iHMIS, MD, DoHS

प्रदेश स्तरिय पेन्टा १ Vs एम्. आर २ खोपको प्रगति २०७८/७९
120

104 103 103 101

98 99 99
100 95 94
93 92 93
87 89 89
86
80

60

40

20

0
Province1 Madhesh Bagmati Gandaki Lumbini Karnali Sudurpaschim NATIONAL

Penta1 MR2
सुन्सरीको पेन्टा १ Vs एम्. आर २ खोपको प्रगति २०७८/७९ सम्मको
120 112 114
111 109
104 108
101 102 101
100 99
92 94 93
89 88 89 89 88 90 89
82 85 83
80

61 61
60 57

40

20

0
C M C R I
SM haM iR a RM ni
M
SM bi
M
iR
M aM aR
M
jR
M RM SA
ra
n ra s h
ra
h
dh
u r i h a dh ru
w
ga
r
gu
n r ju N
a Ba Ko k ha Du G a a a n B a SU
Dh ho
m It a In n a
B Ra ari w
H De

Penta1 MR2
रौतहटको पेन्टा १ Vs एम्. आर २ खोपको प्रगति २०७८/७९ सम्मको
140

120116 115 114

106 105 107 109
105
98 101 9997 98 99
100 95 96
87 90 89
83 82 84 86 85
82 82 74
80 67 69
63 60
57 56 59
60 53
46
39 39
40

20

Penta 1 MR2
काठमाण्डौंको पेन्टा १ Vs एम्. आर २ खोपको प्रगति २०७८/७९ सम्मको
160
134
140 136
122 119
120 107
112 109 110
107 105 104 104107
102101 100
100 97 93
90 91 91
86
80 72 69
60

40

20

0
C U
u rM r aM o rM aM haM or
M
n
M M urM iri
M
li
M
N D
p ha w nt
h k w r ju du p g ka A
ra a h To sh ga n rti ra hi
n
a an ne
s h a
ke a a Ki d
ks HM
kh r i lk a N hm an T
an i M
ka an r
Ka
t C h D a KA
Sh or o dh Ta
G
s hw Bu
age
K
Penta 1 MR2
स्याङ्जाको पेन्टा १ Vs एम्. आर २ खोपको प्रगति २०७८/७९ सम्मको
120

103 104
100 100
100 96 94 94 96
93 92 91 92 89
89
86 85 85 87 82
80 78 81 78
80
72

60

40

20

0
Putalibazar M

Biruwa RM
Phedikhola RM

Aandhikhola RM

Arjun Choupari RM

Bhirkot M

Harinas RM

Chapakot M

Walling M

Galyang M

Kaligandaki RM

SYANGJA
Penta 1 MR2
 बाँके को पेन्टा १ Vs एम्. आर २ खोपको प्रगति २०७८/७९ सम्मको
140
123 121
120 116 115
109 107 107
103 104 102
100 94 95
91 90 92 92
86 86
80

60

40

20

BANKE
Nepalganj SMC

Duduwa RM

Narainapur RM
Rapti Sonari RM

Kohalpur M

Baijanath RM

Khajura RM

Janaki RM
Penta 1 MR2
हुम्लाको पेन्टा १ Vs एम्. आर २ खोपको प्रगति २०७८/७९ सम्मको
120

100 98
95
91
84
80 76
73
65 64 65
62 61
59
60 56

47
43
40 35

20

0
Chankheli RM Kharpunath RM Simkot RM Namkha RM Sarkegad RM Adanchuli RM Tanjakot RM HUMLA

Penta 1 MR2
बाजुराको पेन्टा १ Vs एम्. आर २ खोपको प्रगति २०७८/७९ सम्मको
140

120 118
107
101
100 94 93 91 92
85 85 83 87 85
80 81
80 73 75
71 72
67
59
60

40

20

0
Himali RM Gaumul RM Budhinanda Swami Kartik Jagannath Badimalika Khaptad Budhiganga Tribeni M BAJURA
M RM RM M Chhededaha M
RM

Penta 1 MR2
 पेन्टा पहिलो मात्रा तथा दादुरा दोश्रो मात्रा तुलनात्मक प्रगती संख्या तथा ड्र प आउट २०१९ देखि २०२२ सम्म
600,000 561,346
530,691 546,816
513,744
500,000 482,147 480,032
445,221
426,791
400,000

318,406
300,000

200,000

116,125 103,900
100,000
64,669
33,712
-
2019 2020 2021 2022 Total # of missed
child penta1 vs MR2
(Four Years Cohort)
Penta 1 MR2 Drop -out Penta1 vs MR2
 Quick Immunization Assessment(Independent monitoring ), Jan to Dec 2022
Total
Province Total visits Yes (N) Yes (%)
Communities
Province 1 219 2162 2070 96
Madhesh 226 2154 1687 78
Bagmati Province 365 3070 2955 96
Gandaki Province 182 1842 1795 97
Lumbini Province 81 666 655 98
Karnali Province 51 458 397 87
Sudurpaschhim Province 45 467 462 99
National 1169 10819 10021 93

Less than 70%

70 % - 79 %

80 % - 89 %

90 % and more

No community level monitoring

FWD, DoHS - January 2023

 बिगत ३ वर्षको खोप खेर जाने दर (%)
खोप स्वीकृ त खेर जाने दर
BCG 20 dose 50%
Penta 10 dose 15 %
OPV 10 dose 15%
PCV 4 dose 10 %
fIPV 5 dose 10 %
MR 10 dose 33 %
JE 5 dose 40 %
 प्रगति अवस्था चुनौति
अपेक्षित प्रगति (>९५%) र सबै तहमा एकरूपता नभएको

• National को तुलनामा प्रादेशिक प्रगतिमा एकरूपता नभएको

• प्रदेशको तुलनामा जिल्लाहरूको प्रगति एकरूपता नभएको

• जिल्लाको तुलनामा स्थानिय तहको प्रगतिमा एकरूपता नहुनु

lgoldt vf]k sfo{qmdsf d"Vo
r'gf}lt
Trend of vaccination in Nepal
100

90 83 87
78 80
80

70 66
60

50 43
40

30
20
20

10
1 3 3 1 4
0
NFHS 1996 NDHS 2001 NDHS 2006 NDHS 2011 NDHS 2016 NDHS 2022
Fully vaccinated (Basic Antigens) No vaccination

NDHS @)@@
!^Ü afnaflnsf k"0f{ vf]kaf6 al~rt 5g\ eg] $ Ü jRrf
z'Go 8f]h
 Child Survival Program: Major Milestones
77 1
9 • National Immunization Program (EPI)
7
1
9
9 • Diarrhea Control Program
8
1
3
9 • ARI Control Program
8
71 • Community Based Integrated Management of
9 Childhood Illness Program- CBIMCI
9
2
8 • Morang Innovative Neonatal Intervention pilot(MINI)
0 • Zinc + Low osmolar ORS for diarrhea treatment
0
5
 Child Survival Program: Major Milestones
78 2
0 • Community Based Newborn Care Program
0
9
2 • Use of Chlorhexidine for cord care
01
1
2 • Community Based Integrated Management of
0 Neonatal and Childhood Illnesses- CBIMNCI
1
2
4
0 • Facility based IMNCI and free newborn care
1
2
5
0 • Nepal Every Newborn Action Plan
1
6
 Government of Nepal’s Initiative to Improve Outcomes for
Newborns
• National Neonatal Health Strategy – 2004
• Initiate use of Chlorohexidine (CHX) for cord care-2011
• Community based Newborn Care Program integrated in IMNCI program –
2014
•Nepal Every New-born Action Plan, Free new born care Program &Facility
Based IMNCI Program -2015
• Comprehensive New-born Care Training (Level II) package -2017
• Initiate guideline on Kangaroo Mother Care
• Initiate development of guideline on Early Child Development

79
 Cont…
• Nation-wide scale up of SNCU and NICU
– 13 level III NICUs
– 61 level II SNCUs
• Dedicated government funds for SNCUs and NICUs.
• Health workforce – capacity building
– 6 day CBIMNCI Training for Health workers & 3 day FBIMNCI ToT
– 6 day FBIMNCI ToT for Medical Officers
– Onsite Coaching & Mentoring
• Commodities Supply – included in LMIS for procurement and distribution
• SSNB indicators included in HMIS; additional SNCU & NICU data collection
to track progress
80
 Global Every Newborn Action Plan’s Vision
81

 The action plan envisages a world in which

there are no preventable deaths of newborns
or stillbirths, where every pregnancy is
wanted, every birth is celebrated, and
mothers, babies and children thrive and reach
their social and economic potential.
 Goal of NENAP
82
Reduce Neonatal Mortality Rate (NMR) less than 11/1000
live births and Still Birth Rate (SBR) less than 13/1000
total births by 2035
 Opportunities to accelerate progress in
83
newborn and child health
1. Free Newborn Care in National Health Sector Strategy
2. Newborn services and care prioritized in CB-IMNCI
program
3. Facility based-IMNCI (FB-IMNCI) initiated
4. Training to para-medics, nurses and doctors on facility
based newborn care and FBIMNCI
5. Strengthening of health facility to develop newborn
corner, special newborn care unit (SNCU) and newborn
intensive care unit (NICU)
 Goal, objectives and targets of IMNCI
84
Goal program
 Improve newborn and child survival and healthy growth and development.
Objectives
 To reduce neonatal morbidity and mortality by promoting essential newborn care
services
 To reduce neonatal morbidity and mortality by managing major causes of illness
 To reduce morbidity and mortality by managing major causes of illness among
under 5 years
Targets
 To reduce the NMR to 12 per 1000 live birth
 To reduce the U5MR to 25 per 1000 live birth
85 Strategies of IMNCI
 Quality of care through system strengthening and
referral services for specialized care
 Ensure universal access to health care services for
new born and young infant
 Capacity building of frontline health workers and
volunteers
 Increase service utilization through demand
generation activities
 Promote decentralized and evidence-based
planning and programming
 Proposed Newborn and Child Health Services Structure
86
Child Health
Programs

Newborn
Care IMNCI
Services

Level I Level III CB- FB-

Level II Referral
(Newborn (NICU) IMNCI IMNCI
(SNCU)
corner)

HP/PHCC/ Province
District HP/PHCC/DH DH/PH
Hospital Hospital and
Hospitals
above
87 FB-IMNCI package

 Integration of the existing IMNCI package and

the facility based care package into one package.
 Provides a continuum of quality care for severely
ill newborns and children referred from the
community
FB-IMNCI Package contd..

 Focuses on providing appropriate inpatient management

of major causes of neonatal and childhood mortality
 asphyxia, sepsis, and low birth
weight among neonates;
 pneumonia, diarrhoea, malaria,
meningitis, malnutrition among
children
Linkages Between CB and FB-IMNCI
CB-IMNCI FB-IMNCI
“Red”
PRE-
REFERRA
L
TREATME
NT AND
REFERRA
L
Nutrition Programs in Nepal

91
 Nutrition Programs in Nepal
Goal : “to achieve well‐being of all people to maintain a healthy life to contribute in the
socio‐economic development of the country, through improved nutrition program
implementation in collaboration with relevant sectors".
Responsible for national nutrition specific interventions to improve the nutritional status of
children, pregnant and lactating women and adolescents.
The Scaling-Up-Nutrition (SUN) initiative calls for multi-sectoral actions for improved
nutrition during the first 1,000 days of life.
Nepal joined SUN movement in 2011 and adopted the Multi-sector Nutrition Plan (MSNP)
in 2012 with 10 years vision (2013-2022) and five-year plan (2013-2018) to reduce chronic
under nutrition.

92
 Nutritional status Trend
Targets
80 100
90
90 85
70
70 80
66 80

70
60 57
60
53 53
50 49 48 50
46
43 40
41 41
40 39
30 28 28
36 36 35 24 24
20 20 20
20 15 15
30 29
27 10 10
10 7
24 4
0 00 0 0
0
20

n
n

)
n

BW

49
tfe
re

re

re
14

re
13

5-
ild
ild

ild

ild

as
L
12

(1
ch

ch

ch
of
11 11 10

e
ch

br

en
e

U5
U5

U5

U5

ag
10

m
siv
nt
g

wo
g

on
on

on

cl u
on

ce
am

am

am

g
m

Ex

on
Pe
ta

am
ia
g

g
tin

tin

gh

ia
un

as

ae
i
0

we

m
W

An
St
Stunting Wasting Underweight Percentage Exclusive Anaemia Anaemia

ae
de

An
among U5 among U5 among U5 of LBW breastfed among U5 among

Un
children children children children women (15- MSNP 2022 WHA 2025 SDG 2030
NDHS 2001 NDHS 2006 NDHS 2011 NDHS 2016 49)
93
 Nutrition programs being implemented in Nepal
Nationwide Programs
• MIYCN
• Growth Monitoring and
Promotion
• Prevention and control of Iron
Deficiency Anemia (IDA)
• Prevention, Control and
Treatment of Vitamin A
deficiency (VAD)
• Prevention of Iodine Deficiency
Disorders (IDD)
• Control of Parasitic Infestation
by deworming
• Flour fortification via larger
roller mills
• Adolescent IFA
Scaling Up Programs Pilot Programs
• Integrated Management of • MAM management Program
Acute Malnutrition (IMAM): : 2 districts
56 Districts
• Family MUAC : 8 districts
• IYCF and Baal-vita
community Promotion (IYCF-
MNP): 45 Districts
• Integrated Program Maternal
and Child Health Nutrition
(MCHN) Program–6 districts
94
 Nutrition Program Strategies
1. Control of protein energy malnutrition (PEM)
2. Household food security
3. Improved dietary practices
4. Infectious disease prevention and control
5. Control of iron deficiency anemia (IDA)
6. Control of iodine deficiency disorders
7. Control of vitamin A deficiency
8. Integrated management of acute malnutrition
9. School Health and Nutrition Program

95
Programs under Nutrition

96
 1. Growth monitoring and promotion
Health worker at all public health facilities monitor the growth of children once a month
using the growth monitoring card that is based on WHO’s new growth standards.

Helps to prevent Protein Energy Malnutrition.

97
 2. Infant and young child feeding
Include early initiation of breast feeding within an hour of childbirth.

Exclusive breastfeeding for six months

 Providing nutritionally adequate and appropriate complementary feeding starting from

six months with continued breastfeeding up to two years of age or beyond.

The IYCF program has been ongoing to all 77 districts from FY 2072/73.

Distribution of micro-nutrient powder (Baal Vita) to 6-23 months children in 46

districts and child cash grants (CCG) in 14 districts (CCG program scaled up in 11 more
districts)
98
 3. Integrated Infant and Young Child Feeding
and Micro-Nutrient Powder Community
Promotion Program
The promotion and supplementation of MNPs is linked with improving complementary
feeding practices.

 Mothers and caregivers are counselled to introduce complementary foods at six months of
age focusing on age-appropriate feeding frequency, improving dietary quality of
complementary foods by making them nutrient and calorie dense

Hand washing with soap before handling the food and feeding the child.

99
 4. Integrated management of acute
malnutrition
Provides the treatment of the children with Severe Acute Malnutrition (SAM) aged 0-59
months through inpatient and outpatient treatment services at facility and community levels.
Four components of IMAM
Community Outreach/mobilization
Outpatient treatment of SAM without complication i.e. treatment of SAM children under
supervision of health worker but not admitting in the health facility
In-patient treatment of SAM with complication i.e. treatment of SAM patient by admitting in
the health facility (hospital/stabilization center)
Management of Moderate Acute Malnutrition

100
 5.Nutrition rehabilitation homes
Facility based management of severe acute malnutrition integrating with hospital services.
Associated with primary, secondary and tertiary level hospitals.
Treat and manage severe acute malnutrition with inpatient service
 Provide nutrition education and counselling to the guardians/parents for the management
of moderate acute malnutrition as well as good nutrition and health care of their children.
Counselled on the dietary management for young children and maintain the enhanced
nutrition status of SAM children at home.
1671 children with severe acute malnutrition were admitted in the 21 NRH and among
them 1,679 were recovered discharged.

101
102
Major Nutrition Program Status
Indicators
Province wise IMAM performance

103
Safe motherhood and Newborn Health
Program

104
 Maternal health and Safe motherhood
Maternal health refers to the health of women during pregnancy, childbirth and the
postnatal period. - (WHO)

Safe motherhood encompasses a series of initiatives, practices, protocols and service

delivery guidelines designed to ensure that women receive high-quality gynecological,
family planning, prenatal, delivery and postpartum care, in order to achieve optimal health
for the mother, fetus and infant during pregnancy, childbirth and postpartum.

Safe motherhood decreases maternal and infant mortality and morbidity.

105
Trends and targets of MMR

106
History of Nepal’s Safe Motherhood Program
1988 • Commencement of FCHVs program

1991 • National Health policy cited safe motherhood as a priority

1992 • Formulation of Task Force on SM

1994 • SM plan of action (1994-97) prepared

1996 • Maternity care guidelines finalized

1997 • Second long Term Health plan prepared and ninth five year plan executed

1998 • Safe motherhood policy and the national RH strategy finalized.

1999 • Clinical protocols for various cadres of health workers was developed.

• National safe mother Training strategy prepared

2001 • Safe motherhood plan

107
 Contd..
2002 • Legalization of Abortion

2005 • The Safe Delivery Incentive Program (SDIP) was introduced in 2005

2006 • Policy on SBAs endorsed

• SDIP evolved into the Aama Program in 2009 and was extended to provide
2009 free delivery care at public and some private facilities.
• Nepal’s Every Newborn Action Plan (NeNAP) 2016 set a vision ‘in which
there are no preventable deaths of newborns or stillbirths, where every
2016 pregnancy is wanted, every birth celebrated, and women, babies and
children survive, thrive and reach their full potential.’

2016/17 • Free newborn care was added in the Aama Program

108
Safe Motherhood Program : Goal
The goal of the National Safe Motherhood Program is

to reduce maternal and neonatal morbidity and mortality and

to improve the maternal and neonatal health through

preventive and promotive activities and by

addressing avoidable factors that cause death during pregnancy, childbirth and
postpartum period.
109
110
 Main Strategies
1. Promoting inter-sectoral coordination and collaboration at Federal, Provincial,
districts and Local levels to ensure commitment and action for promoting safe
motherhood with a focus on poor and excluded groups.
2. Strengthening community-based awareness on birth preparedness and
complication readiness through FCHVs and increasing access to maternal health
information and services.
3. Supporting activities that raise the status of women in society.
4. Promoting research on safe motherhood to contribute to improved planning,
higher quality services and more cost-effective interventions.

111
 Contd…
5.Strengthening and expanding delivery by skilled birth attendants and providing basic and
comprehensive obstetric care services at all levels.
Interventions include:
Developing the infrastructure for delivery and emergency obstetric care;
Standardizing basic maternity care and emergency obstetric care at appropriate levels of the
health care system;
Strengthening human resource management :training and deployment of advanced skilled
birth attendant (ASBA), SBA, anesthesia assistant and contracting short-term human
resources for expansion of services sites;
Establishing a functional referral system with airlifting for emergency referrals from remote
areas, the provision of stretchers in Palika wards and emergency referral funds in all remote
districts;

112
Programs under Safe Motherhood

113
 1. Birth Preparedness Package and MNH
Activities at Community Level

Birth Preparedness Package (jeevansuraksha flipchart and card) and distribution of Matri
SurakshaChakki (misoprostol) and complication readiness
 Key ANC/PNC services (Iron, Td, Albendazole, etc)
Self-care
 Essential new born care
Identification and prompt care seeking for danger signs during pregnancy, delivery, post-
partum and newborn period

114
 2. Rural Ultrasound Program
Initiated under the “IMCCR” project (“Improvement of Maternal and Child Care in
Remote Areas”).

 Co-designed by the German Development Cooperation and Nepalese Ministry of Health

and Population, and is being implemented through KfW Development Bank.

Now, all municipalities of FW Province have at least one Health Facility with available
ultrasound services for the examination of pregnant women.

115
 Aama and New Born Program Provision
Recipients Incentives
Incentives to Women  Cash payment after delivery at a facility NRs.3000 (mountain), NRs.2000 (hill)
and Rs.1000 (terai).
 Incentive to pregnant woman who completes 4 focused ANC visits, institutional
delivery and post natal care--NRs 800

Incentive to Health Facility as Reimbursement to institution for free delivery care:

Institutional Cost
 Normal Delivery NRs. 1000 (if <25 bedded HF)
 NRs 1500 (if > 25 bedded HF)
 Complication NRs. 3,000
 C-Section NRs. 7000

(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. 300 from institutional cost
 Health workers need to submit the birth certificate for this payment

116
 3. Nyano Jhola Programme

Two sets of clothes (bhoto, daura, napkin and cap) for newborns and mothers, and
one set of wrapper, mat for baby and gown for mother are provided for women who
give birth at birthing centres and district hospitals.

Was implemented in all 75 districts in 2072/73.

117
 4. Emergency Referral Fund

Supports emergency referral transport to women from poor, Dalit, Janajati,

geographically disadvantaged, and socially and economically disadvantaged
communities who need emergency caesarean sections or complication management
during pregnancy or child birth.

118
5. Reproductive Health Morbidity Prevention and
Management Program
Management of Pelvic Organ Prolapse(POP): Allocated funds to manage POP
including free screening, providing silicon ring pessaries, Kegell exercise training and
free surgical services at designated hospitals.

Cervical cancer screening and prevention training: Recommended screening of at

least 50 percent of women aged 30–60 years every five years and for reducing the
mortality due to cervical cancer by 10 percent among this group

Obstetric Fistula management :Affects many women from poorer communities

and significantly impairs their quality of life due to the social stigma attached to this
condition and their physical suffering.

119
 6.Safe Abortion Services
Comprehensive abortion care services are available in all 77 district
hospitals and majority of PHCCs.

Abortion rate in Nepal : MA sites

• 1833 ANMs
912 MA
42 per 1000 WRA (15-49 )
MA and MVA sites
Central region : • 743 nurses
604 MA/MVA and 1853
59 per 1000 WRA (Highest) doctors
Safe Abortion in/after second Safe Abortion
Far western region : trimester in/after • 92 MDGP
Second and OBGYN
21 per 1000 WRA (Lowest) 22 trimester

120
 Contd…
Medical
abortion
Comprehensive (60,338)
Abortion Care Surgical
Safe Abortion
Abortion
Services Post Abortion (9,166)
Contraception
(11,460)

Safe motherhood services

121
 7.Onsite clinical coaching and mentoring
To enhance knowledge and skill of SBA and non-SBA nursing staffs providing delivery services at
BC/BEONC and CEONC service sites.

This guideline has included mainly three parts : Clinical coaching/mentoring for MNH service
providers (SBA and non-SBA), Infection prevention and MNH readiness ,QI self-assessment.

FWD and NHTC started to develop district clinical mentors through mentor training since FY
2073/2074.
Implemented in
210 SBA clinical
528 municipals
mentors trained
of 51 districts

122
 Other activities under safe motherhood
1. Human resources
2. Expansion and quality improvement of service delivery sites
3. MNH readiness Hospital and BEONC/CEONC Quality Improvement
4. PNC home visit(microplanning for PNC)
5. Obstetric first aid orientations

123
 Antenatal care
Recommended minimum of four antenatal check-ups at regular intervals to all pregnant
women. (at the fourth, sixth, eighth and ninth months of pregnancy).

Blood pressure, weight and foetal heart rate monitoring.

Provision of tetanus toxoid nd diphtheria (Td) immunization, iron folic acid tablets
and deworming tablets to all pregnant women, and malaria prophylaxis where
necessary.
Early detection and management of complications during pregnancy.

Information on danger signs during pregnancy, childbirth and in the postpartum

period, and timely referral to appropriate health facilities.

IEC and BCC on pregnancy, childbirth and early new born care and family planning.

Services provided during ANC

124
 Delivery care

Skilled birth attendance at home and facility-based deliveries

Early detection of complicated cases and management or referral (after providing

obstetric first aid) to an appropriate health facility where 24 hours’ emergency
obstetric services are available

Registration of births and maternal and neonatal deaths.

Delivery care Services

125
 Postnatal care
Recommended three postnatal check-ups the first in 24 hours of delivery, the second on the
third day and the third on the seventh day after delivery.

The identification and management of complications of mothers and newborns

and referrals to appropriate health facilities

The promotion of exclusive breastfeeding. Personal hygiene and nutrition

education, and postnatal vitamin A and iron supplementation for mothers

The immunization of newborns.

Postnatal family planning counselling and services.

Services provided during PNC

126
 Maternal and Perinatal Death Surveillance
and Response (MPDSR)
Designed to measure and track all maternal deaths in real time with the objective to understand the
underlying factors contributing to mortality and to provide guidance for how to respond to and
prevent future deaths.
Community-based MDSR: At present, community based MDSR program is being implemented
at 12 districts. In the community-based MDSR program, only maternal deaths are reviewed and
responses are planned.
Hospital-based MPDSR: At present, 77 hospitals are implementing MPDSR program. In the
hospitals, every maternal death is reviewed individually and perinatal deaths are reviewed on a
monthly basis and responses are planned.

Formation of MPDSR Committees at different levels :There are MPDSR committees at health
facility level and Local level with separate Verbal Autopsy and cause of death assignment teams
for community MDSR.

127
Status of Major Safe Motherhood
program Indicators

128
Pregnant women with four ANC visits (as per
protocol) among expected live births

129
Percentage institutional deliveries among
expected live births

130
Delivery attended by Skilled Birth Attendants
(SBA)

All deliveries attended by SBAs

and at institutions

Target for SDG target:

2020 : 70 % 90%

131
132
 Female Community Health Volunteers (FCHV)
All together there are 51,416 FCHVs in the country.

They are provided 18 days basic training in two phases (9+9 days) on selected primary health care
components.

Key services provided by FCHVs:

Distribution of the family planning commodities (pills and condoms)
Distribution of the iron tablet to pregnant and lactating mothers
Oral rehydration solution distribution
Health education, communication and community outreach
Act as linkage between the health facility and the community
Provided support in home delivery cases mainly focused on initiating skin to skin contact after birth,
uptake of misoprostol, and application of chlorhexidine in cord after delivery
 Primary Health Care Outreach Clinics
(PHC/ORC)
The aim of these clinics is to improve access to basic health services including family
planning, child health and safe motherhood.

These clinics are service extension sites of PHCCs and health posts.

The primary responsibility for conducting outreach clinics is of ANM and paramedics.

FCHVs and local NGOs and community based organizations (CBOs) support health
workers to conduct clinics including recording and reporting.
Services provided by PHC/ORC
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