Child Health Program

Ravi K Mishra
Public Health Officer
Central Regional Health Directorate, Hetauda
 Neonatal mortality
 Low birth weight
Medical  Birth injuries and difficulty in labor
causes of  Congenital anomalies

infant  Hemolytic disease of new born

 Condition of placenta and cord
mortality and
 Diarrhoel disease
morbidity  Acute respiratory infection
 Neonatal tetanus
Post neonatal  Diarrhoel disease
 Acute respiratory infection
and pre school
 Other communicable disease e.g. TB, Measles, whooping cough etc.
children
 Mal nutrition
mortality  Congenital anomalies
 Accidents
  Malnutrition
Causes of child  Infection- diarrhea, diphtheria, tetanus, whooping cough, measles, eye
and skin problems
morbidity  Parasitic infestation
 Accidents cause disability
 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
Identification  Birth weight less than 2.5kg

of “at risk”  Twins

 Birth order 5 and more
babies
 Artificial feeding
 2nd and 3rd degree malnutrition
 Failure to gain weight during three successive months
 Children with PEM, diarrhoea
 Working mother/ one parent
  Immunization
 Nutrition
 Community Based Integrated Management
of Childhood Illness (CB-IMCI) and newborn
care
Child Health
Program of
Nepal
  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
National interventions.
 At present, National immunization Program provides vaccine against 10
Immunization diseases.
Programme  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.
National  Nationwide Surveillance of vaccine preventable diseases (AFP,
Immunization Measles like illnesses, MNT and AES) is conducted through
sentinel network of “Acute Flaccid Paralysis” (AFP) surveillance
Programme system supported by WHO/IPD.
NATIONAL
IMMUNIZATION  NEPAL HEALTH SECTOR SUPPORT PROGRAM- II (NHSP IP II)
PROGRAM IS  Comprehensive Multi Years Plan of Action (2011- 2016)
GUIDED BY:
 GOAL
GOALS
 To reduce child, mortality, morbidity and disability associated with
GOALS, vaccine preventable diseases
OBJECTIVES
AND OBJECTIVES AND STRATEGIES

STRATEGIES Objective 1: Achieve and maintain at least 90% vaccination coverage

for all antigens at national and district level by 2016
Key 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
 Objective 2: Ensure access to vaccines of assured quality and with
appropriate waste management

GOALS, Key strategies:

 Strengthen the vaccine management system at all levels
OBJECTIVES
Objective 3: Achieve and maintain polio free status
AND Key strategies:
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
status
Key strategies:
 Achieve and maintain at least >80% TT2+ coverage for pregnant
GOALS, women in every districts
OBJECTIVES  Conduct Td follow up campaigns in high risk districts
 Expand school based immunization program
AND
 Continue surveillance of NT
STRATEGIES
 Objective 5: Initiate measles elimination
Key strategies:
 Achieve and sustain high population immunity to reduce measles
incidence to elimination level
GOALS,
 Investigate all suspected measles like outbreaks with program response
OBJECTIVES  Use platform of measles elimination for Rubella / CRS control
AND  Continue case-based measles surveillance
STRATEGIES Objective 6: Accelerate control of vaccine-preventable diseases
through 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
 Objective 7: Strengthen and expand VPD surveillance
Key strategies:
 Expand VPD surveillance to include vaccine preventable diseases of
GOALS, public health concern.
OBJECTIVES  Strengthen and expand laboratory support for surveillance.
Objective 8: Continue to expand immunization beyond infancy
AND
Key strategies:
STRATEGIES
 Consider for booster dose of currently used antigen based on evidence
and protection of adult from potential VPDs.
 SN Type of Antigen Against Disease Age

1 BCG TB At Birth

2 DPT Hep B Hib, 1st 2nd 3rd Diptheria, 6 Week

Pertusis,Tetanus, 10 Week
National Hepatitis B 14 week
Hemophilus
Immunization Influenza b
Schedule 3 Oral Polio , 1st 2nd 3rd
IPV
Poliomylitis 6, 10, 14 week
14 week
4 PCV Pneumonia, 6, 14 week
Meningitis 9 month
5 Measles- Rubella Measles, Rubella 9 month

6 JE Japanese 13-23 month

Encephilitis
  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
MAJOR regions
ACTIVITIES  Immunization Performance Review (conducted at all level)
 Internal review of VPD surveillance
CARRIED OUT  Cold chain strategic guideline development and endorsement
IN FY 2069/70  Vaccinators training guideline development
(2012/2013)  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
 1. Mortality and
nutrition status of
children and women
in Nepal
Section I 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
MDG Target:
134/100,000

Without improvement in Nutrition, further

Sources: Nepal Demographic an Health Survey 2006 & 2011 child mortality reduction is less likely

The Lancet Series on Maternal and Child Undernutrition 2013

 Nutrition
status of
children and
women

Source: Nepal Demographic an Health Survey 2011

 Indicator Severity of malnutrition by prevalence
ranges (%)
Classification
Low Medium High Very high
for assessing
Stunting <20 20-29 30-39 >=40*
severity of
Underweight <10 10-19 20-29* >=30
malnutrition
by prevalence Wasting <5 5-9 10-14* >=15
ranges among
* Nepal
children under
5 years of age

Source: http://www.who.int/nutgrowthdb/about/introduction/en/index5.html
 Prevalence of anemia in under 5 years children
90 NATIONAL
80 AVERAGE
70
60
50 46%
40
30
20

Problem of 10
0

micro-nutrient 6-8 9-11 12-17 18-23 24-35 36-47 48-59

Age in months
Mountain Hill Terai Total

deficiencies is 67.7
70
still serious 60
Prevalence of anemia in women (15-49 years)
47.6 49
50 44.9 42.6 41.9
38.9
36.2 35 36.2 33 35.9
40 33.1 32.7
27.6 26.5 28.8
30 26.1
22.5
19.2 19.5
20

10

Source: Nepal Demographic an Health Survey 2011

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

Source: Nepal Demographic an Health Survey 2011

 Initiating Partners

Global
initiatives in
nutrition –
SUN and Scaling up of evidence-based-cost-
effective interventions to prevent and
REACH treat under-nutrition with special focus
on 1000 days “window of opportunity’
Adopting multi-sector approach which
includes integrating nutrition in relevant
sectors
REACH focuses on scaling-up
nutrition (SUN) actions
 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
National  Reduce Iron Deficiency Anemia among children, children under age 2 year
nutrition and pregnant women
 Maintain and sustain Iodine Deficiency Disorders and Vitamin A Deficiency
policy and control activities
strategy  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
 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
Strategies  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
 National
nutrition
programmes

Section II
 Infant and Young Child
Feeding (IYCF) programme
1. Basic IYCF package training to HWs
and FCHVs (7)
2. Integrated IYCF and Baal Vita
Community Promotion Programme
National (15)
3. IYCF linked with Child Cash Grant
nutrition Programme (5)
programmes 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

Age specific
A = Amount
T = Texture
V = Variety
A = Active feeding
H = Hygiene
 IMAM manages
acute
2. Integrated malnutrition in
Management children age 6-59
months through
of Acute inpatient and
Malnutrition outpatient
services at the
(IMAM) community level.
programme
Previously 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.
 Recording & reporting
IMAM programme service model in district SHP / HP
Hospital
Region / Centre

Ilaka HF / PHC

DHO / DPHO
Hospital / SC &/ OTP

Community SHP / HP
FCHV
Ilaka HF / PHC
PHC

Supply
Recording of new
cases, referral,
follow up
(6-59 months)
3. Nutrition
Rehabilitation
Homes (NRHs)
Management of
acute malnutrition
in the facility
Hospital
NRH
 1. National Vitamin A
Programme
2. Intensification of Maternal
4. & Neonatal Micronutrient
Programme (IMNMP)
Micronutrient 3. Iodine Deficiency Disorder
deficiencies (IDD) Control Programme
control 4. IYCF and Baal Vita
programmes Community Promotion
Programme
5. Flour fortification
Programme
6. Fortified flour distribution
programme
 12-23 months: ½ tab i.e. 200 mg
24-59 months: 1 tab i.e. 400 mg
Health
Facility DHO / DPHO
1. National Vitamin A Programme

VAS piloting
Region / Centre to reach the
unreached:

Reporting
Supply
6-11 months
De-worming tablet
Vitamin A capsule

Vitamin A: 6-59 months

De-worming: 12-59 months

Recording

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

12-59 months: 1 capsule i.e. 2,00,000 IU
 Dose: 1 capsule = 2,00,000 IU
Postpartum Vitamin A

House

Within 6 weeks of delivery

 DHO / DPHO
2. Intensification of Maternal & Neonatal
Supply
Micronutrient Programme (IMNMP)
Recording & reporting

180
tablets
Recording & reporting

Region / Centre
Supply

45 Once 1 tab
tablets i.e. 400 mg
of de-
worming
table to
pregnant
Dose: 1 IFA tab i.e. 60 mg iron + 400 µg folic acid women after
1st trimester
3. Iodine Deficiency Disorder (IDD) Control World fit for children target on micronutrients
Programme • 90% HH use adequately iodized salt

Iodized Salt Social Marketing Campaign – ISSMaC approach

4. IYCF and Baal Vita Community Promotion Supply
DHO / DPHO

Recording & reporting

Recording &
Programme

reporting
Community
Supply
Region / Centre

6-23 months 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. Flour fortification Programme

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. Fortified flour distribution programme

Karnali &
Solukhumbu
6-23 months
 Growth monitoring in
health facility

Monthly growth monitoring

combined with IYCF

Growth monitoring
from 0-23 months
5. Community
based growth
monitoring
programme Growth monitoring in
outreach clinic

Operational feasibility of new CH card:

Dang, Jumla, Rukum and Udayapur
6. School
health and
nutrition
programme
(SHNP) – a
joint
programme of
MoHP & MoE
 Supply during orientation (Public only; 1 First
Aid Kit box/school)
School health and nutrition programme
Refilling by HF & SMC

Private & Public

Grade 1 - 10
Adolescent
iron

Region / Centre

Recording &
reporting

Supply
Private & Public
Grade 1 - 10

Recording
& Private & Public

Grade 1 - 10
Supply reporting
RC
Supply Supply

Recording & reporting Recording & reporting

EMIS
Recording & reporting
School health
and nutrition
programme
(SHNP)
coverage
COMMUNITY BASED INTREGRATED
MANAGEMENT OF CHILDHOOD ILLNESS
(CB IMCI) AND NEONATE CARE
 An integrated package of child-survival
COMMUNITY interventions and addresses major childhood killer
BASED diseases like Pneumonia, Diarrhoea, Malaria,
INTEGRATED Measles and Malnutrition in 2 months to 5 years
MANAGEMENT children in a holistic way.
OF CHILDHOOD
ILLNESSES CB-IMCI also includes management of infection,
(CB‐IMCI) 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.
COMMUNITY Based on the recommendations it was decided to include a
BASED community component, enabling mobilization of
community health workers (VHWs and MCHWs) and
INTEGRATED FCHVs to provide CDD, ARI, Nutrition and Immunization
MANAGEMENT services to the community
OF CHILDHOOD As a result the Community based ARI and CDD (CBAC)
ILLNESSES program was merged into IMCI in 1999 and is now called
(CB‐IMCI) 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.
 Vision
Contribute to survival, healthy growth and
development of under five years children of Nepal.

VISION AND Achieve MDG 4 by 2015.

GOALS Goal
To reduce morbidity and mortality among children
under-five due to pneumonia, diarrhoea, malnutrition,
measles and malaria.
 To reduce under five mortality from the current rate of
54/1,000 live births to 38/1,000 live births and infant
TARGETS 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.
 Reduce frequency and severity of illness and death
related to ARI, Diarrhoea, Malnutrition, Measles and
OBJECTIVES Malaria.
Contribute to improved growth and development.
 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;
STRATEGIES 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
 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.

STRATEGIES Improve logistic supply.

Regularize mother’s group meeting.
Strengthen reporting system at all levels.
Strengthen supervision and monitoring.
 3. Improving family and community practices
Disseminating key behavioral message through FCHVs
to families and communities using relevant IEC
materials.
STRATEGIES Reaching the disadvantaged and hard-to-reach
communities through reactivated mother’s group
meeting.
Dissemination of key family practice messages through
interpersonal communication.
 1. Management of sick children below 2 months of age
COMPONENTS
2. Management of sick children 2 months to 5 years of age
OF CB‐IMCI
 Management of Diarrhoeal Diseases
 Zinc Supplementation
 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.
MAJOR CB-IMCI training to newly recruited medical doctors and
ACTIVITIES 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.
 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
Community deaths.

Based The major causes of neonatal deaths in Nepal are infection, birth
asphyxia, preterm birth, and hypothermia.
Newborn Care Hence, reduction of high neonatal mortality is an urgent priority
Program for achieving MDG 4.
(CB‐NCP) 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
GOAL AND babies
OBJECTIVE OF  To manage post-delivery asphyxia, and
CB‐NCP  To develop an effective system of referral of
sick newborns
 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
MAJOR service providers (30 persons)
ACTIVITIES 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
Thank you