Child health program in Nepal
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Transcript of Child health program in Nepal
Child Health Program
Ravi K Mishra
Public 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 priorityprogramme (P1) of Government of Nepal.
Immunization is considered as one of the most cost-effective healthinterventions.
At present, National immunization Program provides vaccine against 10diseases.
An immunization service is provided through static clinic at healthfacilities, 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 throughsentinel network of “Acute Flaccid Paralysis” (AFP) surveillancesystem 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)
GOAL
GOALS
To reduce child, mortality, morbidity and disability associated withvaccine preventable diseases
OBJECTIVES AND STRATEGIES
Objective 1: Achieve and maintain at least 90% vaccination coveragefor all antigens at national and district level by 2016
Key strategies:
Increase access and utilization to vaccination by implementing REDstrategies 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 withappropriate waste management
Key strategies:
Strengthen the vaccine management system at all levels
Objective 3: Achieve and maintain polio free status
Key strategies:
Achieve and maintain high immunity levels against Polio bystrengthening routine immunization and conducting high qualitynational polio immunization campaigns.
Respond adequately and timely to outbreak of poliomyelitis withappropriate vaccine
Achieve and maintain certification standard AFP surveillance
GOALS, OBJECTIVES AND STRATEGIES
Objective 4: Maintain maternal and neonatal tetanus eliminationstatus
Key strategies:
Achieve and maintain at least >80% TT2+ coverage for pregnantwomen in every districts
Conduct Td follow up campaigns in high risk districts
Expand school based immunization program
Continue surveillance of NT
GOALS, OBJECTIVES AND STRATEGIES
Objective 5: Initiate measles elimination
Key strategies:
Achieve and sustain high population immunity to reduce measlesincidence 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 surveillance
Objective 6: Accelerate control of vaccine-preventable diseasesthrough introduction of new and underused vaccines
Key strategies:
Introduction of new and under-used vaccines (rubella, pneumococcal,typhoid, rota) based on disease burden and financial sustainability
GOALS, OBJECTIVES AND STRATEGIES
Objective 7: Strengthen and expand VPD surveillance
Key strategies:
Expand VPD surveillance to include vaccine preventable diseases ofpublic health concern.
Strengthen and expand laboratory support for surveillance.
Objective 8: Continue to expand immunization beyond infancy
Key strategies:
Consider for booster dose of currently used antigen based on evidenceand protection of adult from potential VPDs.
GOALS, OBJECTIVES AND STRATEGIES
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 BHemophilusInfluenza b
6 Week10 Week14 week
3 Oral Polio , 1st 2nd 3rd
IPVPoliomylitis 6, 10, 14 week
14 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 & 2011
The 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
46%
0
10
20
30
40
50
60
70
80
90
6-8 9-11 12-17 18-23 24-35 36-47 48-59 Mountain Hill Terai Total
Age in months
NATIONAL AVERAGE
Prevalence of anemia in under 5 years children
0
10
20
30
40
50
60
7067.7
36.2 35
27.6
36.2
47.638.9
33
26.5
19.2
33.1
26.1
19.5
35.9
22.5
28.8
44.9 42.6
32.7
4941.9
Prevalence of anemia in women (15-49 years)
Source: Nepal Demographic an Health Survey 2011
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
Source: Nepal Demographic an Health Survey 2011
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
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 childrenthrough 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 packetsalt
Bi-annual mass supplementation of VA to under 5 years children
Gradual expansion of the School Health and Nutrition activities in alldistricts
BCC for changing dietary practices for improved maternal and childnutrition practices
Expansion of Community as well as facility based Management of AcuteMalnutrition 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 = HygieneA
ge
sp
eci
fic
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.
IMA
M p
rog
ram
me
se
rvic
e m
od
el i
n d
istr
ict
Ilaka HF / PHC
DHO / DPHOHospital / SC &/ OTP
SHP / HPCommunity
Ilaka HF / PHC
Hospital
PHC
FCHV
Region / Centre
SHP / HP
Recording of new cases, referral,
follow up (6-59 months)
Recording & reporting
Su
pp
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
Vit
amin
A P
rog
ram
me
DHO / DPHOHealth Facility
Region / Centre
Vitamin A: 6-59 monthsDe-worming: 12-59 months
Vit
amin
A c
apsu
leD
e-w
orm
ing
tab
let
Re
po
rtin
g
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
on
ths:
½ t
ab i.
e. 2
00
mg
24-5
9 m
on
ths:
1 t
ab i.
e. 4
00
mg
Po
stp
artu
m V
itam
in A House
Within 6 weeks of delivery
Dose: 1 capsule = 2,00,000 IU
2. In
ten
sifi
cati
on
of
Mat
ern
al &
Ne
on
atal
M
icro
nu
trie
nt
Pro
gra
mm
e (
IMN
MP
)DHO / DPHO
180 tablets
45 tablets
Su
pp
ly
Re
cord
ing
& r
ep
ort
ing
Recording & reporting
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
din
e D
efi
cie
ncy
Dis
ord
er
(ID
D)
Co
ntr
ol
Pro
gra
mm
eWorld fit for children target on micronutrients
• 90% HH use adequately iodized salt
Iodized Salt Social Marketing Campaign – ISSMaC approach
4. I
YC
F an
d B
aal V
ita
Co
mm
un
ity
Pro
mo
tio
n
Pro
gra
mm
e Community
6-23 months
Su
pp
ly
Re
cord
ing
&
rep
ort
ing
DHO / DPHO
Recording & 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
lou
r fo
rtif
icat
ion
Pro
gra
mm
e
Government of Nepal adopted wheat flourfortification as one of the nationalstrategies to reduce iron deficiency anemiain Nepal.
Nepal Government made flour fortificationat roller mills mandatory in August 2011based on satisfactory voluntaryfortification experience.
Nepal has become the first country inSouth Asia to have mandatory legislationfor fortification at roller mills.
6. F
ort
ifie
d f
lou
r d
istr
ibu
tio
n p
rog
ram
me
Karnali & Solukhumbu
6-23 months
5. Community based growth monitoring programme
Growth monitoring in outreach clinic
Growth monitoring in health facility
Mo
nth
ly g
row
th m
on
ito
rin
g
fro
m 0
-23
mo
nth
s
Gro
wth
mo
nit
ori
ng
co
mb
ine
d w
ith
IYC
F
Operational feasibility of new CH card: Dang, Jumla, Rukum and Udayapur
6. School health and nutrition programme (SHNP) – a joint programme of MoHP & MoE
Sch
oo
l he
alth
an
d n
utr
itio
n p
rog
ram
me
Supply
Supply
Recording & reporting
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
Su
pp
ly
Supply
Re
cord
ing
&
rep
ort
ing
Recording & reporting
Recording &
reporting
Supply during orientation (Public only; 1 First Aid Kit box/school)
Recording & reporting
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 Mahottaridistrict 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 providers
CB-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 haveshown that neonatal mortality in Nepal has been stagnant at 33deaths per 1,000 live births which account for 61 percent of under 5deaths.
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