Critical Appraisal of Child Health Policies, Programs, Guidelines and Their Implementation Strategies and Review the Current Status of National Context

1. Critical Appraisal of Child Health Policies,
Programs, Guidelines and Their Implementation
Strategies and Review the Current Status of
National Context
Prepared By:
Mohammad Aslam Shaiekh
MPH-3rd Batch
School of Health and Allied Sciences (SHAS)
Pokhara University (P.U)

2. Introduction
Childhood mortality in general and infant mortality in particular is often used
as broad indicators of social development or as specific indicators of health
status.
Childhood mortality therefore contribute to a better understanding of a
country’s changing socioeconomic situation and quality of life.

3. Childhood mortality indicators
1. Perinatal mortality rate
2. Neonatal mortality rate
3. Postnatal mortality rate
4. Infant mortality rate
5. Childhood mortality rate
6. Under 5 year mortality

4. Determinants of Child Health

5. Source: WHO SEAR,MDG progress report 2014

6. Child Mortality rate in Nepal
Source: NDHS 2016

7. NEONATAL MORTALITY IN
SOUTH EAST ASIA 2012
INFANT MORTALITY RATE IN
SOUTH EAST ASIAN REGION 2012
Source: WHO SEAR,MDG progress report 2014

8. Under 5 mortality rate
Source: WHO SEAR,MDG progress report 2014

10. Major causes of Child Morbidity
Malnutrition
Infection- diarrhea, diphtheria, tetanus, whooping cough, measles, eye
and skin problems
 Parasitic infestation
Accidents cause disability

11. Development in Child health policies, plans and programs
in Nepal

12. Child Health Programs of Nepal
 Immunization
 Nutrition
 Community Based Integrated Management of Newborn and
Childhood Illness (CBIMNCI)

13. National Immunization Program
The National Immunization Programme (NIP) is a high priority program
(P1) of Government of Nepal.
Immunization is considered as one of the most cost-effective health
interventions.
At present, National immunization Program provides vaccine against 12
diseases.
 National Immunization Program is guided by Comprehensive multi year
plan of action (CMYP 2017-21)

14. Goal, Objectives and Strategies of CMYP2012-16
Goals:
To reduce child, mortality, morbidity and disability associated with vaccine
preventable diseases
OBJECTIVES AND 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 level
•Strengthen communication, social mobilization, and advocacy activities Strengthen
immunization services in the municipalities.

15. 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

16. 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

17. 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
of measles 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

18. Objective 7: Strengthen and expand VPD 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 potential VPDs.

19. National Immunization Schedule

20. Immunization Coverage

21. District wise Coverage

22. Fully Immunized Districts Declaration

23. Immunization : Proportion of children age 12-23
months who received all
basic vaccinations at any time

24. Problems/Constraints
 Inadequate HRH especially in Metro/Sub – Metropolitan, MCH / Institutional
clinics and ill-defined JD of AHW & ANM (for vaccinations)
 Poor quality immunization data: Under and over reporting
 Poor Inventory keeping and distribution system
Unplanned immunization month celebration
Low achievement of FID as per National target
Poor Cold Chain and Vaccine management
 Inadequate CC Equipment and inadequate repair, maintenance and replacement,
lack of technician
 Inadequate Vaccine Store Capacity specially central level

25. Nutrition Program
Nutrition section under Child Health Division is responsible for national nutrition
program for improving the nutritional status of children, pregnant women and
adolescents.
Goals:
Achieve nutritional 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.

26. MortalitystatusofChildrenand
WomeninNepal
Source:NDHS2016&LancetSeriesonmaternalandChild
undernutrition2013

27. NutritionalstatusofChildrenin
Nepal
Source: NDHS 2016
Stunting in children by Province

28. Source: WHO SEAR,MDG progress report 2014

29. Assessing Severity of Malnutrition by Prevalence among
U5 Children
Indicator Severity of malnutrition by Prevalence Rates (%)
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

30. Prevalence ofAnemia in U5 Children and Women
Source: NDHS 2016

31. InfantYoung and Child Feeding (IYCF) Practice in Nepal
- Breastfeeding
* Predominant breastfeeding includes exclusive breastfeeding, breastfeeding plus water, and
breastfeeding plus non-milk liquids/juice.
**Age appropriate breastfeeding = Children age 0-5 months who are exclusively breastfed +
children age 6-23 months who receive breast milk and complementary foods.
Source: NDHS 2016

32. InfantYoung and Child Feeding (IYCF) Practice in Nepal
– Complementary feeding
.
Source: NDHS 2016

33. Infant andYoung Child Nutrition
Proportion of infants less than age 12 months with
breastfeeding initiated within one hour of birth
Source: WHO SEAR,MDG progress report 2014

34. Nutrition Program Implemented by CHD’s Nutrition
Section (1993 – 2016)
Nationwide programmes:
• Growth monitoring and counselling
• Prevention and control of iron
deficiency anaemia (IDA)
• Prevention, control and treatment of
vitamin A deficiency (VAD)
• Prevention of iodine deficiency
disorders (IDD)
• Control of parasitic infestation by
deworming
• Mandatory flour fortification
Scale-up programmes:
• Maternal, Infant, and Young Children
Nutrition (MIYCN) programme
• Integrated Management of Acute
Malnutrition (IMAM)
• Micronutrient Powder (MNP)
distribution linked with infant and
young child feeding(IYCF)
• School Health and Nutrition
Programme
• Vitamin A supplementation to address
the low coverage in 6–11 month olds
• Multi-sector Nutrition Plan (MSNP)

35. Objectives and Strategies of National Nutrition Program
The overall objective is to enhance nutritional well-being, reduce child and maternal
mortality and contribute to equitable human development.
Specific Objectives:
To reduce protein-energy malnutrition in children under 5 years of age and women
of reproductive age
 To improve maternal nutrition
 To reduce the prevalence of anemia among adolescent girls, women and children
 To eliminate iodine deficiency disorders and vitamin A deficiency and sustain
elimination
 To reduce the infestation of intestinal worms among children and pregnant women
To reduce the prevalence of low birth weight
 To improve household food security to ensure that all people can have adequate
access, availability and use of food needed for a healthy life

36. Objectives and Strategies of National Nutrition Program
To promote the practice of good dietary habits to improve the nutritional status of all
people
 To prevent and control infectious diseases to improve nutritional status and reduce
child mortality
 To control lifestyle related diseases including coronary disease, hypertension, tobacco
related diseases, cancer and diabetes
 To improve the health and nutritional status of schoolchildren
 To reduce the critical risk of malnutrition and life during very difficult circumstances
To strengthen the system for analyzing, monitoring and evaluating the nutrition
situation
 Behavior change communication and nutrition education at community levels
 To align health sector programes on nutrition with the Multi-Sectoral Nutrition
Initiative.

37. Objectives and Strategies of National Nutrition Program
Strategies:
The overall strategies for improving nutrition are:
The promotion of a food based-approach
Food fortification
The supplementation of foods and
The promotion of public health measures

38. Adopting Multi - Sectoral Nutrition Plan (MSNP)
framework

39. Community Based Integrated Management of Newborn
and Childhood Illness (CBIMNCI)
CB-IMNCI is an integration of CB-IMCI and CB-NCP Programs. This integrated
package of child-survival intervention addresses the major problems of sick newborn
such as birth asphyxia, bacterial infection, jaundice, hypothermia, low birth-weight,
counseling of breastfeeding.
It also maintains its aim to address major childhood illnesses like Pneumonia,
Diarrhea, Malaria, Measles and Malnutrition among under 5 year’s children in a
holistic way.

40. Goals, targets, objectives, strategies, interventions and
activities of CBIMNCI program
Goal:
Improve newborn and child survival and healthy growth and development.
Targets of Nepal Health Sector Strategy (2015-2020):
 Reduction of Under-five mortality rate (per 1,000 live births) to 28 by 2020
 Reduction of Neonatal mortality rate (per 1,000 live births) to 17.5 by 2020
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 children

41. Goals, targets, objectives, strategies, interventions and
activities of CBIMNCI program
Strategies:
 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

42. Interventions of CBIMNCI
Newborn Specific Interventions:
Promotion of birth preparedness plan
 Promotion of essential newborn care practice sand postnatal care to mothers and
newborns
 Identification and management of non-breathing babies at birth
 Identification and management of preterm and low birth weight babies
 Management of sepsis among young infants (0-59days) including diarrhea
Child Specific Interventions
 Case management of children aged between 2-59 months for 5 major childhood
killer diseases.
(Pneumonia, Diarrhea, Malnutrition, Measles and Malaria)

43. Interventions of CBIMNCI
Cross -Cutting Interventions
 Behaviors change communications for healthy pregnancy, safe delivery and
promote personal hygiene and sanitation
 Improved knowledge related to Immunization and Nutrition and care of sick
children
 Improved interpersonal communication skills of HWs and FCHVs

44. Vision 90 by 20

45. Classification of cases as per CB-IMNCI protocol by province
(FY2073/74)

46. Problems in CB-IMNCI
No sanctioned position for CB-IMNCI focal persons at district and regional levels
Unclarity in roles of staffs (including CBIMNCI focal person) in the new federal
context
Unable to implement free new-born care guideline since last FY as expected.
Frequent stock outs of essential commodities in districts and communities.
Poor service data quality
Poor quality of care

47. Conclusion
 The program achievements are important to understand progress in child health
status. Even though we have achieved tremendous progress in decreasing child
mortality. Now, large proportion of babies dies before completing their first month of
their life as we can see the number of neonatal death remaining stagnant and poses
challenge to the current health system.
To understand child health status, it is equally crucial to evaluate the children, who
are survived. Their survival should be accompanied by healthy childhood and better
future. Thus the aim of child health programme should not be limited to decreasing
deaths but the well being of the children and better opportunity in a safe, secure
world.

48. THANK YOU