This is useful for those those who are interested on Child Health Program in Nepal.

1. Child Health Program
Ravi K Mishra
Public Health Officer
Central Regional Health Directorate, Hetauda

2. 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

3. 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

4. Causes of child
morbidity
Malnutrition
 Infection- diarrhea, diphtheria, tetanus, whooping cough, measles, eye
and skin problems
 Parasitic infestation
Accidents cause disability

5. 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

6. Child Health
Program of
Nepal
Immunization
Nutrition
Community Based Integrated Management
of Childhood Illness (CB-IMCI) and newborn
care

7. 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 Programprovides 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 andmedical colleges especially inmunicipalities.

8.  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 byWHO/IPD.
National
Immunization
Programme

9. NATIONAL
IMMUNIZATION
PROGRAM IS
GUIDED BY:
NEPAL HEALTH SECTOR SUPPORT PROGRAM- II (NHSP IP II)
Comprehensive Multi Years Plan of Action (2011- 2016)

10. GOAL
GOALS
To reduce child, mortality, morbidity and disability associated with
vaccine preventable diseases
OBJECTIVESANDSTRATEGIES
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 themunicipalities
GOALS,
OBJECTIVES
AND
STRATEGIES

11. Objective 2: Ensure access to vaccines of assured quality and with
appropriate 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 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
GOALS,
OBJECTIVES
AND
STRATEGIES

12. Objective 4: Maintain maternal and neonatal tetanus elimination
status
Key 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
GOALS,
OBJECTIVES
AND
STRATEGIES

13. Objective 5: Initiate measles elimination
Key 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 ofmeasles elimination for Rubella / CRS control
 Continue case-based measles surveillance
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
GOALS,
OBJECTIVES
AND
STRATEGIES

14. Objective 7: Strengthen and expandVPD surveillance
Key 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 infancy
Key strategies:
Consider for booster dose of currently used antigen based on evidence
and protection of adult from potentialVPDs.
GOALS,
OBJECTIVES
AND
STRATEGIES

15. 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 B
Hemophilus
Influenza b
6 Week
10 Week
14 week
3 Oral Polio , 1st 2nd 3rd
IPV
Poliomylitis 6, 10, 14 week
14 week
4 PCV Pneumonia,
Meningitis
6, 14 week
9 month
5 Measles- Rubella Measles, Rubella 9 month
6 JE Japanese
Encephilitis
13-23 month

16. 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

17. Nutrition

18. 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

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

20. Mortality
status of
children and
women
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
MDG Target:
134/100,000

21. Nutrition
status of
children and
women
Source: Nepal Demographic an Health Survey 2011

22. 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
* Nepal
Source: http://www.who.int/nutgrowthdb/about/introduction/en/index5.html

23. Problem of
micro-nutrient
deficiencies is
still serious
46%
90
80
70
60
50
40
30
20
10
0
Prevalence of anemia in under 5 years children
6-8 9-11 12-17 18-23 24-35 36-47 48-59 Mountain Hill Terai Total
Age in months
NATIONAL
AVERAGE
70
60
50
40
30
20
10
0
67.7
36.2 35
27.6
36.2
47.6
38.9
33
26.5
19.2
33.1
26.1
19.5
35.9
22.5
28.8
44.9 42.6
32.7
49
41.9
Prevalence of anemia in women (15-49 years)
Source: Nepal Demographic an Health Survey 2011

24. Infant &
Young Child
Feeding (IYCF)
practices in
Nepal –
Breastfeeding
45% of newborns are breastfed within the first hour of life, and 85% within the first day.
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

25. Infant & Young
Child Feeding
(IYCF) practices
in Nepal –
Complementary
feeding
Source: Nepal Demographic an Health Survey 2011

26. 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

27. 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

28. 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

29. Adopting the
multi-sector
approach for
nutrition
 Need of multi-sector
approach
 Need of a nutrition
architecture
 Identify information and
HR gaps

30. Multi-Sector
Nutrition Plan
Framework

31. Section II
National
nutrition
programmes

32. National
nutrition
programmes
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
(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)

33. 1. IYCF
practices:
Breastfeeding
and
Complementary
feeding F = Frequency
A = Amount
T = Texture
V = Variety
A = Active feeding
H = Hygiene
Age specific

34. 2. Integrated
Management
of Acute
Malnutrition
(IMAM)
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.
IMAM manages
acute
malnutrition in
children age 6-59
months through
inpatient and
outpatient
services at the
community level.

35. IMAM programme service model in district
Ilaka HF / PHC
DHO / DPHO
Hospital / SC &/ OTP
Community SHP / HP
Ilaka HF / PHC
Hospital
PHC
FCHV
Region / Centre
SHP / HP
Recording of new
cases, referral,
follow up
(6-59 months)
Recording & reporting
Supply

36. 3. Nutrition
Rehabilitation
Homes (NRHs)
Hospital
NRH
Management of
acute malnutrition
in the facility

37. 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

38. 1. National Vitamin A Programme
DHO / DPHO
Health
Facility
Region / Centre
Vitamin A: 6-59 months
De-worming: 12-59 months
Vitamin A capsule
De-worming tablet
Reporting
Recording
VAS piloting
to reach the
unreached:
6-11 months
Supply
6-11 months: ½ capsule i.e. 1,00,000 IU
12-59 months: 1 capsule i.e. 2,00,000 IU
12-23 months: ½ tab i.e. 200 mg
24-59 months: 1 tab i.e. 400 mg

39. Postpartum Vitamin A
House
Within 6 weeks of delivery
Dose: 1 capsule = 2,00,000 IU

40. 2. Intensification of Maternal & Neonatal
Micronutrient Programme (IMNMP)
DHO / DPHO
180
tablets
45
tablets
Supply
Recording & reporting
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

41. 3. Iodine Deficiency Disorder (IDD) Control
Programme
World fit for children target on micronutrients
• 90% HH use adequately iodized salt
Iodized Salt Social Marketing Campaign – ISSMaC approach

42. 4. IYCF and Baal Vita Community Promotion
Programme
Community
6-23 months
Supply
Recording &
reporting
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

43. 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.

44. 6. Fortified flour distribution programme
Karnali &
Solukhumbu
6-23 months

45. Growth monitoring in
health facility
5. Community
based growth
monitoring
programme Growth monitoring in
outreach clinic
Monthly growth monitoring
from 0-23 months
Growth monitoring
combined with IYCF
Operational feasibility of new CH card:
Dang, Jumla, Rukum and Udayapur

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

47. School health and nutrition programme
Supply
Supply
Recording & reporting
Supply during orientation (Public only; 1 First
Aid Kit box/school)
Private & Public
Grade 1 - 10
EMIS
Adolescent
iron
Region / Centre
Refilling by HF & SMC
Private & Public
Grade 1 - 10
Private & Public
Grade 1 - 10
RC
Supply
Supply
Recording &
reporting
Recording & reporting
Recording
&
reporting
Recording & reporting

48. School health
and nutrition
programme
(SHNP)
coverage

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

50. 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.

51. 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)

52. 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

53. 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

54. Reduce frequency and severity of illness and death
related to ARI, Diarrhoea, Malnutrition, Measles and
Malaria.
Contribute to improved growth and development.
OBJECTIVES

55. 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

56. 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

57. 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

58. 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

59. 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

60. 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.

61. 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

62. 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

63. Thank you