Feb ua y 2016 | Volume 4 | A icle 151
Pe sPec i e
published: 11 Feb ua y 2016
doi: 10.3389/ pubh.2016.00015
F on ie s in Public Heal h | www. on ie sin.o g
Edi ed by:
S ephen B adbe y,
Alliance Ins i u e, USA
Re iewed by:
S e en Jaye Sko ,
No he n Te i o y Depa men o
Heal h, Aus alia
Anne e Regan,
Wes e n Aus alia Depa men o
Heal h, Aus alia
*Co espondence:
Resham Bahadu Kha i
[email p o ec ed]
Special y sec ion:
This a icle was submi ed o
Public Heal h Policy,
a sec ion o he jou nal
F on ie s in Public Heal h
Recei ed: 15Augus 2015
Accep ed: 25Janua y2016
Published: 11Feb ua y2016
Ci a ion:
Kha iRB, Mish aSR, KhanalV,
GelalK and NeupaneS (2016)
Newbo n Heal h In e en ions and
Challenges o Implemen a ion
inNepal.
F on . Public Heal h 4:15.
doi: 10.3389/ pubh.2016.00015
Newbo n Heal h in e en ions and
challenges o implemen a ion in
Nepal
Resham Bahadu Kha i1* , Shi a Raj Mish a2 , Vishnu Khanal2,3 , Khageshwo Gelal4 and
Subas Neupane5
1 Sa ing Newbo n Li es P og am, Sa e he Child en, Ka hmandu, Nepal, 2 Nepal De elopmen Socie y, Ka hmandu, Nepal,
3 School o Public Heal h, Cu in Uni e si y, Pe h, Aus alia, 4Child Heal h Di ision, Minis y o Heal h and Popula ion,
Ka hmandu, Nepal, 5 School o Heal h Sciences, Uni e si y o Tampe e, Tampe e, Finland
Neona al mo ali y is a majo challenge in educing child mo ali y a es in Nepal. Despi e
e o s by he Go e nmen o Nepal, da a om he las h ee demog aphic and heal h
su eys show a ise in he con ibu ion o neona al dea hs o in an and child mo ali y.
The Go e nmen o Nepal has implemen ed communi y-based p og ams ha we e
pilo ed and hen scaled up based on lessons lea ned. These p og ams include, bu
a e no limi ed o ensu ing sa e mo he hood, bi h p epa edness package, communi-
y-based newbo n ca e package, and in eg a ed managemen o childhood illnesses.
Despi e he implemen a ion o such p og ams on a la ge scale, hei e ec i e co e age
is ye o be achie ed. Heal h sys em challenges included an inadequa e policy en i on-
men , unding gaps, inadequa e p ocu emen , and insu icien supplies o commodi ies,
while human esou ce managemen has been ound o be impeding se ice deli e y.
Such bo lenecks a policy, ins i u ional and se ice deli e y le el need o be add essed
inco po a ing heal h in o ma ion in decision-making as well as wo king in pa ne ship
wi h communi ies o acili a e he u iliza ion o a ailable se ices.
Keywo ds: in e en ions, challenges, Nepal, neona al mo ali y a e, heal h sys ems
iN ODUc iON
Dispa i y in he unequal dis ibu ion o he neona al mo ali y a e (NMR) has been epo ed among
di e en egions, eligious, and e hnic g oups in Nepal. The e a e highe a es o NMR among poo
socio-economic g oups, Muslims and Dali s, as well as people li ing in emo e a eas such as he mid
and a -wes e n egions o he coun y (1–3). Neona es bo n o olde mo he s and hose wi h high
pa i y ha e been epo ed o be a mo e han ou imes highe isk o neona al dea h (3). Simila ly,
newbo ns o illi e a e mo he s we e wice as likely o su e neona al dea h han hose bo n o women
wi h highe le els o educa ion (1). Impo an ly, ha ing ou an ena al ca e (ANC) isi s o he
childbi h assis ed by a skilled bi h a endan (SBA) hal es he isk o neona al dea h. Howe e ,
u iliza ion o such se ices is e y low in high- isk sub-g oups o women (3, 4). In esponse o hese
issues, many p og ams and newbo n heal h in e en ions a e being implemen ed bu encoun e
a ious heal h sys em challenges. This s udy aims o summa ize he heal h sys em challenges and
possible solu ions o speci ic in e en ions ocused on educing neona al dea hs.
FiGU e 1 | Neona al mo ali y ends in Nepal (Pe 1000 li e bi hs).
Sou ce: MDG Baseline Es ima e 1990, NFHS 1996, NDHS 2001, NDHS
2006, and NDHS 2011.
Feb ua y 2016 | Volume 4 | A icle 152
Kha i e al.
Newbo n Heal h in Nepal
F on ie s in Public Heal h | www. on ie sin.o g
eNDs OF cHiLD MO ALi Y iN NePAL
Nepal has been success ul in achie ing millenium de elopmen
goal (MDG) 4 o educing he unde - i e mo ali y a e (U5MR) by
wo- hi ds om he le el in 1990 (2, 5). Du ing he pas 20yea s,
he na ion has wi nessed unequal p og ess in he educ ion o
mo ali ies among child en; wi h a 54% educ ion in U5MR, a 55%
educ ion in pos -neona al mo ali y a e (PNMR) bu wi h a slowe
educ ion in neona al mo ali y a e (NMR) o 34%. The U5MR
declined by 7.6%/yea , while he NMR declined by only 2.6%/yea
o e he pe iod 2000–2010 (6). Du ing he pe iod o 2006–2011,
he p opo ion o NMR in he U5MR and in an mo ali y a e
(IMR) inc eased om 42 o 61% and 63 o 72%, espec i ely, wi h
no change in NMR, which emained he same (33/1000 li e bi hs)
in bo h Nepal Demog aphic and Heal h Su eys (NDHS) (7).
The U5MR and IMR dec eased apidly om 1996 o 2006,
bu he a e o educ ion slowed be ween 2006 and 2011 due
o cons an NMR (7). The a ge o MDG 4 o educe U5MR o
54/1000 li e bi hs has al eady been achie ed, bu educing IMR
o 34/1000 li e bi hs and NMR o 16/1000 li e bi hs by he end
o 2015 has been di icul , al hough o mal s a is ics a e ye o be
eleased (2). Figu e1 shows he end o mo ali y a es among
he unde - i es, in an s, and neona es o e he las 20yea s (2).
Fu he analysis o he 2011 NDHS showed ha abou wo in
i e neona al dea hs occu on he i s day a e bi h wi h mo e
han 8 ou o 10 neona al dea hs occu ing in he i s week o li e
(3). Fu he mo e, he high p opo ion o s illbi hs indica es poo
quali y o ca e du ing he in a-pa um pe iod (8). The e bal
au opsies on he causes o neona al mo ali y in 2014 showed
ha he mos common causes o neona al mo ali y a e neona al
sepsis, bi h asphyxia, low bi h weigh , and p ema u i y- ela ed
condi ions ha occu mos ly wi hin he i s week o li e bu , o en
wi hin he i s 24h ollowing deli e y (8, 9).
POLicies AND P OG AMs FO
NeWBO N HeAL H iN NePAL
Nepal has made signi ican p og ess in he accessibili y o
heal h se ices in he na ion’s u al a eas since he endo semen
and implemen a ion o speci ic heal h policy ini ia i es in he
1990s. (7). Focused ma e nal and child heal h in e en ions
we e implemen ed h ough a ious p og ams such as he
Na ional Sa e Mo he hood P og am (NSMP), Communi y-
Based In eg a ed Managemen o Childhood Illness (CB-IMCI)
(pilo ed in 1997 and wi h he na ionwide oll-ou comple ed
in 2009), bi-annual supplemen a ion o Vi amin A, and he
Na ional P og am on Immuniza ion. These in combina ion
ha e esul ed in a ema kable educ ion in ma e nal and
unde - i e dea hs. In 2004, he Family Heal h Di ision o he
Minis y o Heal h (MOH) de eloped he Na ional Neona al
Heal h S a egy esul ing in newbo n heal h ecei ing app o-
p ia e a en ion (10). By 2007/08, he Child Heal h Di ision
had designed he Communi y-Based Newbo n Ca e P og am
(CB-NCP), which was i s pilo ed in 10 dis ic s wi h scaling-
up ini ia ed in 2010 (11, 12).
The CB-IMCI was ocused on p e en a i e and p omo i e
measu es, and ea men o common childhood illnesses, espe-
cially neona al sepsis, measles, mala ia, pneumonia, dia hea,
and malnu i ion (11). The mo e ecen ly implemen ed CB-NCP
inco po a ed se en speci ic newbo n in e en ions, including,
bu no limi ed o, he p omo ion o essen ial newbo n ca e,
managemen o neona al sepsis, Kanga oo Mo he Ca e (KMC)
o low bi h weigh babies, and esusci a ing non-b ea hing
babies a bi h (12). Female communi y heal h olun ee s and
heal h wo ke s in u al heal h ca e acili ies we e he se ice
p o ide s in bo h o he p og ams. The CB-NCP p og am was
implemen ed in 41 dis ic s ou o 75 up o 2013 (5). Howe e , in
2014, bo h he CB-NCP and CB-IMCI p og ams we e in eg a ed
in o he Communi y-Based In eg a ed Managemen o Neona al
and Childhood Illness (CB-IMNCI) ha has al eady been olled
ou in 30 dis ic s wi hin he i s yea o in eg a ion (as o July
2015) (11, 13).
Nepal’s NSMP was implemen ed a e he endo semen o he
Sa e Mo he hood Policy in he la e 1990s (14). The bi h p e-
pa edness package, a communi y-based ma e nal and newbo n
heal h p og am, was pilo ed in 2003 wi h scale-up comple ed
h oughou he coun y in 2008. This p og am aimed o p epa e
p egnan mo he s o sa e bi h and complica ion eadiness.
NDHS da a show ha ins i u ional deli e y inc eased om
19 o 36% du ing 2006–2011 a e he implemen a ion o he
SBA policy (7, 15, 16). This policy aims o make skilled ca e a
bi h a ailable a all Bi hing Cen e s (BCs), Basic Eme gency
Obs e ic and Neona al Ca e (BEmONC) si es, as well as
Comp ehensi e Eme gency Obs e ic and Neona al Ca e
(CEmONC) si es (16). BCs a e he se ices si es o no mal
labo and deli e y ca e a u al heal h acili ies, BEmONC si es
a e o complica ed cases such as an icipa ed assis ed deli e ies
and manual emo al o e ained placen a, and CEmONC si es
a e o cesa ean deli e ies h ough ad anced SBAs and obs e i-
cians (2, 5, 17).
A u he de elopmen in p o iding skilled ca e du ing
deli e y was he endo semen o he “Na ional Aama P og am,”
a ma e ni y incen i e scheme. This is a condi ional cash ans e
p og am ha aims o lowe inancial ba ie s o use s and aims
o acili a e engagemen wi h, and p o ide access o, ANC isi s
and ins i u ional deli e y.
ABLe 1 | Newbo n in e en ions and hei implemen a ion s a us.
P og ams cu en in e en ions aining packages Main se ice
p o ide s
se ice ou le s sugges ed packaging o
in e en ions
Ma e nal heal h
p og ams
Skilled ca e a bi h
An ena al co icos e oids
Sa e mo he hood, SBA,
Ad anced SBA aining
package
Nu se midwi es and
doc o s
BCs, BEmONCs, and
CEmONCs
Skilled ca e a bi h
An ena al co icos e oids
Essen ial newbo n ca e
Neona al esusci a ion
KMCs
Child heal h
p og ams
Essen ial newbo n ca e CB-IMNCI aining
package
Pa amedical s a s,
nu ses, and doc o s
Pe iphe al le el heal h
acili ies and e e al
hospi als o inpa ien
ca e
Managemen o neona al sepsis
Inpa ien ca e o sick and small
newbo ns
Neona al esusci a ion
KMC se ice
Managemen o neona al sepsis
Inpa ien ca e o sick and small
newbo ns
Feb ua y 2016 | Volume 4 | A icle 153
Kha i e al.
Newbo n Heal h in Nepal
F on ie s in Public Heal h | www. on ie sin.o g
NeWBO N HeAL H iN e eN iONs AND
Hei iMPLeMeN A iON s A Us
The se en newbo n in e en ions implemen ed unde he
umb ella o child and ma e nal heal h p og ams include skilled
ca e du ing labo and deli e y, an ena al co icos e oids o man-
agemen o mo he s a isk o p e e m bi h, basic newbo n ca e,
managing and esusci a ing non-b ea hing babies a bi h ( om
he Helping Babies B ea he ini ia i e), KMC o s able p e e m
and low bi h weigh babies, ea men o neona al sepsis, and
inpa ien suppo i e ca e o sick and small babies (4).
Table1 desc ibes he cu en newbo n in e en ions and hei
implemen a ion s a us. The ecen co e age o skilled ca e a bi h
is abou 56%, p ac ices o basic newbo n ca e, o ins ance, use
o chlo hexidine is a 50% and he use o injec able an ibio ics
(gen amicin) o neona al sepsis is 32% (17), howe e , co e age
da a o o he in e en ions is limi ed (5, 11).
cHALLeNGes iN He iMPLeMeN A iON
OF NeWBO N HeAL H iN e eN iONs
Based on hei implemen a ion s a us, challenges can be di ided
in o wo g oups. Fi s , h ee in e en ions: skilled ca e a bi h,
basic newbo n ca e, and he managemen o neona al sepsis a e in
a mo e ma u e implemen a ion s age. Policy guidelines ha e been
de eloped, heal h wo ke s ha e been ained, a logis ics sys em
has been es ablished, and se ices a e a ailable om se ice
ou le s. Howe e , achie ing high e ec i e co e age is he majo
ba ie wi h hese in e en ions. The equen ly obse ed heal h
sys em challenges in hese in e en ions a e an inadequa e num-
be o skilled se ice p o ide s o se ice p o ide s wi h poo
skills, poo co e age and quali y o ca e in a ailable se ices, and
poo and agile sys em o logis ics p ocu emen and i s supply
chain managemen (4, 18–22).
Despi e his, he ou o he in e en ions o new-
bo ns – adminis a ion o an ena al co icos e oids o he
managemen o mo he s a isk o p e e m bi h, managing non-
b ea hing babies a bi h, p o iding KMC se ices o p e e m
and low bi h weigh babies, and inpa ien ca e o e y small
and sick babies – ace mo e c i ical heal h sys em challenges
(18). Fu he de elopmen o app op ia e policy guidelines o
an ena al co icos e oids, KMC se ices and neona al inpa ien
ca e is equi ed (4, 20, 23, 24). The MOH has no ye issued any
guidelines o he managemen o p e e m babies (18). Also,
na ional guidelines o he managemen o low bi h weigh
babies and na ional s anda d inpa ien ea men guidelines o
se e ely sick newbo ns a e se iously lacking (18). P ope logis ics
supply o key i ems, such as d ugs, and bags and masks, is a majo
ba ie in all in e en ions. The quali y o se ices, and o da a use
in decision-making and ac ion a e u he heal h sys em chal-
lenges. Also, he unding gap in inpa ien ca e se ices esul s in
inadequa e se ice a ailabili y ou side he me opoli an a eas. All
in all, lack o app op ia e policies and s a egic guidelines, und-
ing gaps, poo in as uc u e, and logis ics as well as inadequa e
in o ma ion a e he c i ical challenges in hese newbo n heal h
in e en ions (4, 18).
Table 2 desc ibes newbo n in e en ions and heal h sys em
challenges o implemen a ion, including possible esponses.
Ensu ing ecommended newbo n ca e is challenging in Nepal
o a numbe o easons (25). Ru al BC unc ion is poo due
o acu e sho ages o SBAs as well as he necessa y medicines
and p og am commodi ies. The ins i u ional deli e y se ices
p o ided in he u al BCs a e bypassed by women due o pe -
cei ed poo quali y o ca e and inadequa e e e al links (26).
Bu o e c owding o he zonal and egional hospi als (26–28),
poo in ec ion p e en ion in BCs and e e al hospi als as
well as lowe o inapp op ia e use o pa og aphs in he in a-
pa um pe iod a e he g ea es challenges o he p o ision o
quali y ma e nal and newbo n heal h se ices in Nepal (4, 8).
Compounding challenges a e he socio-cul u al di e ences and
p ac ices ha may c ea e di icul ies in ega d o pos na al ca e
(PNC). In addi ion, adop ing he cu en p o ocol o PNC isi s
o heal h ca e acili ies is challenging in a eas whe e pos pa um
mo he s do no lea e hei homes un il 10days a e he deli e y
(7). Mo e han hal o all newbo n dea hs epo edly occu due
o pe ina al complica ions (29), bu in he gi en con ex , quali y
in a-pa um ca e se ices is no being p ope ly deli e ed (27).
Fu he mo e, e y ew e ia y hospi als o e KMC se ices
because o inadequa ely skilled heal h ca e p o ide s and space
in hose acili ies (30, 31). Inadequa e BEmONC and CEmONC
si es in emo e dis ic s ha e esul ed in poo co e age o se ices
ABLe 2 | Newbo n in e en ions and heal h sys em implemen a ion challenges.
ca ego ies o
newbo ns
Newbo n heal h
in e en ions
( ime o ca e)
se ice ou le s se ice p o ide s
(cu en ly a ailable
se ices)
Policies, s a egies,
p og ams, and aining
packages
Heal h sys em challenges Possible ac ions
Ca e o all
newbo ns
Skilled ca e du ing labo
and deli e y (du ing labo
and deli e y)
BCs, BEmONCs,
and CEmONCs
SBAs (sa e and
clean bi h, use o
pa og aph)
doc o s (assis ed
deli e y)
Ad anced SBA
and obs e icians
(c-sec ion)
Policies and p og am on
sa e mo he hood and
skilled bi h a endance,
ma e ni y incen i e
scheme p og am,
CB-IMNCI p og am, and
SBA package
Inequi y o ins i u ional deli e y se ices
especially among poo , disad an aged
and emo e communi ies
Quali y o ca e du ing labo and deli e y
Inadequa e supply o medical supplies
Low co e age o BEmONC and
CEmONC se ices
Poo da a quali y, insu icien men o ing
and onsi e coaching suppo
Low o no use o pa og aph
Inadequa e numbe o SBA and hei
unequal dis ibu ion
De elop and implemen he emo e a ea s a egy
Use quali y o ca e guideline o ensu e op imal
s anda d o ca e
Ensu e quali y o ca e audi
Pe ina al and neona al dea h audi
T ain adequa e numbe o SBAs and deployed in
ha d- o- each heal h acili ies
Male in ol emen in suppo p egnancy and
deli e y ca e
App op ia e logis ics supplies
Technical suppo isi s, onsi e coaching and
men o ing
Educa ional campaigns and mobile apps on
impo ance o skilled ca e a bi h
An ena al co icos e oids
o managemen o mo he s
a isk o p e e m bi h
(du ing labo )
Specialized
hospi als
Obs e icians (an ena al
co icos e oids o e al
lung ma u a ion)
Na ional medical
s anda ds
Lacking policy guideline o implemen
in BEmONC
P esc ip ion au ho i y is no o SBAs
Indica o s lacking in ou ine in o ma ion
sys em
Inadequa e amily and communi y
awa eness on p e e m labo
Ensu e se ice a ailable a BEmONC si es and
expand such se ices in emo e dis ic s
Task shi ing o SBAs
Include in ou ine in o ma ion sys em
Communi y mobiliza ion on complica ion o
p e e m labo
Include an ena al co icos e oids in essen ial
d ugs lis
Basic newbo n ca e
(immedia e a e labo )
Heal h acili ies,
communi ies, and
home
SBAs, pa amedics, and
doc o s (cleanliness,
he mal ca e-d ying
and w apping, skin-
o-skin con ac , and
delaying ba hing, co d
ca e wi h chlo hexidine,
and immedia e
b eas eeding)
CB-IMNCI p og am, SBA
package
Poo adhe ences o essen ial newbo n
ca e s anda ds
Low p og amma ic p io i y o bi h
p epa ed package
Low co e age o ENCs se ices
Inadequa e compe ency o se ice
p o ide s on ENCs
Poo Da a quali y o ENCs
Poo communi y awa eness
Poo supply chain managemen
Implemen beha io change communica ion
ac i i ies o educe ha m ul p ac ices
Onsi e coaching and men o ing o imp o e skills
o se ice p o ide s
Conduc p og am pe o mance e iews mee ings
Imp o e amily and communi y p ac ices h ough
mass media mobiliza ion
Inc ease male in ol emen in basic newbo n ca e
Ensu e p ope supplies especially chlo hexidine gel
Ca e o all
newbo ns who
a e a isks –
small and sick
newbo ns
Managing non-b ea hing
babies a bi h-neona al
esusci a ion (immedia e
a e labo )
BCs, BEmONC,
and CEmONC
SBAs (neona al
esusci a ion using bag
and mask)
CB-IMNCI p og am, SBA
aining package
Poo compe ency o SBAs o manage
he bi h asphyxia
Inadequa e supply o bag and mask
SBAs eluc ance o handle bi h
asphyxia condi ions
Da a a e no cap u ed in heal h
in o ma ion sys em
Inadequa e ha moniza ion in p e-se ice
cu icula
Onsi e coaching and men o ing o SBAs
Ensu e he a ailabili y o esusci a ion
commodi ies
Ensu e newbo n esusci a ion se ice da a in
heal h in o ma ion managemen sys em (HMIS)
C ea e awa eness on complica ion o bi h
asphyxia
Include p e-se ice aining packages and ain
medical and nu sing s uden s
(Con inued)
Feb ua y 2016 | Volume 4 | A icle 154
Kha i e al.
Newbo n Heal h in Nepal
F on ie s in Public Heal h | www. on ie sin.o g
ca ego ies o
newbo ns
Newbo n heal h
in e en ions
( ime o ca e)
se ice ou le s se ice p o ide s
(cu en ly a ailable
se ices)
Policies, s a egies,
p og ams, and aining
packages
Heal h sys em challenges Possible ac ions
KMC o s able p e e m
and low bi h weigh babies
(pos na al)
BCs, BEmONC,
and CEmONC
SBAs (kanga oo
mo he ca e o s able
newbo n who a e
p e e m and low bi h
weigh s
SBA package, CB-IMNCI
p og am
Lack o s anda d na ional p o ocol
Poo supply o logis ics o pe o m
KMC
Poo communi y pe cep ion o KMC
Inadequa e space in HFs o KMC
se ices on ENCs
Lack o pos na al ca e guideline o
newbo n bo n a home
Inadequa e in o ma ion on KMC
se ices
P omo e KMC p ac ices a heal h acili ies
Ensu e pos na al ca e o all newbo ns
Es ablish KMC co ne s in each bi hing cen e s
Ensu e KMC se ice da a in HMIS
Mobilize communi y and inc ease on bene i s o
KMC
Inc ease he demand o KMC se ices
In ol e male in KMC se ices
T ain heal h se ices p o ide s
Poo skills o heal h wo ke s
T ea men o neona al
sepsis (0-59days)
Pe iphe al le el
heal h acili ies and
communi y
Pa amedics, SBAs,
and doc o s (injec able
an ibio ics-gen amicin)
CB-IMNCI p og am Poo adhe ence o na ional p o ocol
especially in p i a e sec o
Lack o in o ma ion se ices ecei ed
om p i a e sec o
Poo skills and compe ency o heal h
wo ke s
Weak e e al mechanism
Delay p ocu emen and poo supply
chain managemen
Poo quali y o se ices
Poo ca e seeking beha io o
communi ies
Men o heal h wo ke s p o ide echnical skills o
heal h wo ke s
De elop app op ia e s a egy o engage p i a e
sec o
Ensu e he da a quali y by pe o mance e iew
mee ing and moni o ing
Include ea men p o ocol in p e-se ice aining
cou se and in ol e academias
Ensu e yea ound a ailabili y o essen ial d ugs o
ea neona al sepsis
De elop con ex ual IEC ma e ials o educa e
communi ies
Inpa ien suppo i e ca e
o sick and small babies
(0–59days)
Seconda y and
e ia y e e al
hospi als, special
newbo n ca e uni
Doc o s, pedia icians
(in a enous luids,
al e na i e eeding
suppo s, and oxygen
suppo )
Guideline is ye o be
de eloped
Lack o s anda d p o ocols P epa e and implemen inpa ien ca e guideline o
e y small and se e ely sick neona esFunding gaps in inpa ien ca e
Una ailabili y o Inpa ien ca e se ices
o newbo n a inpa ien uni o all
dis ic hospi al
Poo supply o essen ial commodi ies
o inpa ien ca e o newbo n
Poo documen a ion o se ice s a is ics
Lack o neona al nu se and o he skilled
human esou ces
Inadequa e budge o upg ading HFs
o Special ca e Neona al Uni (SCNU)
and es ablishing Neona al In ensi e
Ca e Uni (NICU) se ices a e e al
hospi als
Weak e e al sys em due o
anspo a ion and inancial ba ie s
De elop NICU in e e al hospi al and special
newbo n ca e uni a dis ic hospi als
P o ide ee newbo n ca e o all e e ed
newbo ns who need inpa ien ca e se ices
including anspo a ion cos
Ensu e unds o NICU and SCNU de elopmen
and ope a ion
Use quali y o ca e guideline
De elop local anspo a ion sys em
De elop inno a i e inancial mechanism ( ouche
sys em, insu ance o incen i e sys em)
ABLe 2 | con inued
Feb ua y 2016 | Volume 4 | A icle 155
Kha i e al.
Newbo n Heal h in Nepal
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Feb ua y 2016 | Volume 4 | A icle 156
Kha i e al.
Newbo n Heal h in Nepal
F on ie s in Public Heal h | www. on ie sin.o g
eFe eNces
1. Neupane S, Doku DT. Neona al mo ali y in Nepal: a mul ile el analysis o
a na ionally ep esen a i e. J Epidemiol Glob Heal h (2014) 4(3):213–22.
doi:10.1016/j.jegh.2014.02.001
2. Paudel D, Sh es ha IB, Siebeck M, Reh uess EA. Neona al heal h in Nepal:
analysis o absolu e and ela i e inequali ies and impac o cu en e o s
o educe neona al mo ali y. BMC Public Heal h (2013) 13(1):1239.
doi:10.1186/1471-2458-13-1239
3. Paudel D, Thapa A, Shedain P, Paudel B. T ends and De e minan s o Neona al
Mo ali y in Nepal: Fu he Analysis o he Nepal Demog aphic and Heal h
Su eys, 2001-2011. Ka hmandu; Cal e on, MD: Nepal Minis y o Heal h
and Popula ion, New ERA; ICF In e na ional (2013).
4. MoHP; UNICEF; Sa e he Child en; WHO; USAID. E e y Newbo n Ac ion
Plan-Repo on Na ional Consul a i e Wo kshop–Nepal (D a ). Ka hmandu:
Minis y o Heal h and Popula ion, UNICEF, Sa e he Child en, WHO and
USAID (2013).
5. Child Heal h Di ision; Family Heal h Di ision; Sa e he Child en. A Syn hesis
o Recen S udies on Ma e nal and Newbo n Su i al In e en ions in Nepal.
Ka hmandu: Child Heal h Di ision and Family Heal h Di ision, Minis y o
Heal h and Popula ion (2014).
6. P adhan YV, Up e i SR, Kc NP, Ashish KC, Khadka N, Syed U, e al. Newbo n
su i al in Nepal: a decade o change and u u e implica ions. Heal h Policy
Plan (2012) 27(Suppl 3):iii57–71. doi:10.1093/heapol/czs052
7. Minis y o Heal h and Popula ion (MOHP) [Nepal]; New ERA; ICF
In e na ional Inc. Nepal Demog aphic and Heal h Su ey 2011. Ka hmandu;
Cal e on, MD: Minis y o Heal h and Popula ion, New ERA; ICF
In e na ional (2012).
8. Minis y o Heal h and Popula ion; USAID; IRHDTC Nepal. A Repo
on Ve bal Au opsy o Asce ain he Causes o Neona al Dea hs in Nepal.
Ka hmandu: Minis y o Heal h and Popula ion, USAID, IRHDTC Nepal
(2014).
9. Khanal S, Gc VS, Dawson P, Hous on R. Ve bal au opsy o asce ain causes o
neona al dea hs in a communi y se ing: a s udy om Mo ang, Nepal. JNMA
J Nepal Med Assoc (2011) 51(181):21–7.
10. Khadka N, Moo e J, Vicke y J. Nepal’s Neona al Heal h S a egy: A Policy
F amewo k o P og am De elopmen . Ma yland: JPHIEGO (2003).
11. Child Heal h Di ision. CB-IMNCI Repo 2015-D a . Ka hmandu Nepal:
Child Heal h Di ision (2015).
12. Child Heal h Di ision. Assessmen o he Communi y Based Newbo n
Ca e Package. Ka hmandu: Child Heal h Di ision, Minis y o Heal h and
Popula ion (2012).
13. Bhanda i N, Mazumde S, Taneja S, Somme el H, S and TA. E ec o
implemen a ion o in eg a ed managemen o neona al and childhood illness
(IMNCI) p og amme on neona al and in an mo ali y: clus e andomised
con olled ial. BMJ (2012) 344:e1634. doi:10.1136/bmj.e1634
14. Bhanda i A, P adhan YN, Kc NP, Up e i SR, Thapa K, Sha ma G, e al. S a e
o ma e nal, newbo n and child heal h p og ammes in Nepal: wha may a
as well as poo p ac ices in managemen o complica ions (4).
The poo in as uc u e de elopmen o Neona al In ensi e Ca e
Uni s (NICU), combined wi h limi ed access o hese se ices,
a e he signi ican heal h sys em issues in he deli e y o e ec i e
ma e nal and newbo n se ices (4). While he MOH has imple-
men ed ee deli e y ca e se ices in public hospi als, o a ious
easons, people epo edly ha e o pay o inpa ien newbo n ca e
se ices in all hospi als (32).
In u al a eas, some BCs ace inadequacy and incompe ence
among SBAs o p o ide neona al esusci a ion se ices (33).
Also, an unequal dis ibu ion o ca e p o ide s has esul ed in
lowe a es o ins i u ional deli e y, al hough Nepal had aimed o
achie e a a e o 60% ins i u ional deli e y by SBAs by 2015 (4). In
many ma e nal and newbo n heal h aining p og ams and pack-
ages and in p e- and in-se ice aining, newbo n componen s
and skills a e no emphasized. Ve ical p og am planning and
implemen a ion a di e en le els, inadequa e da a use wi hin
p og am managemen , poo supe ision, and p og am moni o -
ing a e some o he heal h sys em inadequacies in newbo n heal h
ca e (5).
In ecen yea s, p o isions o unding and in e es ha e
inc eased and some in e en ions ha e been mains eamed
in ma e nal and child heal h p og ams. The inclusion o he
newbo n componen s in NSMP was also ini ia ed, bu newbo n
heal h in e en ions we e ei he dilu ed in he sa e mo he -
hood p og am o ha e ecei ed less a en ion du ing p og am
implemen a ion (5). Un o una ely, s a egies, guidelines, and
p o ocols on sa e mo he hood and newbo n heal h a e no
aligned (4). F agmen a ion o newbo n heal h in e en ions
om ma e nal heal h p og ams also clea ly shows he di icul ies
in se ice deli e y and has u he compounded he challenges.
Fo example, mos o he in e en ions o he CB-NCP ha e been
me ged wi h IMCI bu hey ough o be in eg a ed wi h NSMP
as SBAs a e he p ima y se ice p o ide s o skilled ca e a bi h
(11, 14) (Table1).
cONcLUsiON
The heal h o he newbo n is an impo an componen o ma e nal
ca e. The e o e he s a egic in eg a ion o all in e en ions is s ongly
ecommended, no only a he implemen a ion le el bu also a he
policy le el. Equal access o and u iliza ion o quali y an epa um,
in a-pa um, pos pa um, and inpa ien ca e a e essen ial o sa e
he li es o newbo ns. The c ucial heal h sys em challenges such as
poo and inadequa e skills in p e en ing, iden i ying, and manag-
ing newbo n complica ions, inadequa e in as uc u e, un a o able
wo king en i onmen s and poo supply o essen ial newbo n
commodi ies, ine ec i e clinical supe ision, and men o ship o
se ice p o ide s all need o be add essed and imp o ed o ensu e
e ec i e co e age o newbo n in e en ions. Heal h acili y-based
in e en ions should ocus on quali y o ca e in newbo n se ices; in
pa icula , inpa ien ca e se ices o sick and low bi h weigh new-
bo ns should be made a ailable in each dis ic hospi al. In es men
and in e en ions should be a ge ed a emo e and ha d- o- each
u al heal h acili ies. The combina ion o hese in e en ions will
con ibu e o u he lowe ing Nepal’s NMR.
AU HO cON iBU iONs
All au ho s lis ed, ha e made subs an ial, di ec and in ellec ual
con ibu ion o he wo k, and app o ed i o publica ion.
AcKNOWLeDGMeN s
We acknowledge Bha a Ban (Sa e he Child en), D K ishna
P asad Paudel and Chuda Mani Bhanda i (Child Heal h Di ision)
o hei encou agemen o w i e his pape . We a e indeb ed o
Shelley Pa ke o he suppo in he inal edi ing o his pape . The
iews exp essed in his pape a e he pe spec i e o he au ho s
and do no necessa ily e lec he iews o he o ganiza ions wi h
which hey a e associa ed.
Feb ua y 2016 | Volume 4 | A icle 157
Kha i e al.
Newbo n Heal h in Nepal
F on ie s in Public Heal h | www. on ie sin.o g
con inuum o ca e model mean o mo e e ec i e and e icien se ice deli -
e y? J Nepal Heal h Res Counc (2011) 9(2):92–100.
15. Minis y o Heal h and Popula ion (MOHP) [Nepal]; New ERA; ICF
In e na ional Inc. Nepal Demog aphic Heal h Su ey 2006. Ka hmandu;
Ca e on, MD: Minis y o Heal h and Popula ion, New ERA; ICF
In e na ional (2007).
16. Family Heal h Di ision. Na ional Policy on Skilled Bi h A endan s.
Ka hmandu: Family Heal h Di ision, Minis y o Heal h and Popula ion
(2006).
17. Minis y o Heal h and Popula ion. Annual Repo . Nepal: Managemen
Di ision, Minis y o Heal h and Popula ion (2012/13).
18. Dickson KE, Kinney MV, Moxon SG, Ash on J, Zaka N, Simen-Kapeu A,
e  al. Scaling up quali y ca e o mo he s and newbo ns a ound he ime
o bi h: an o e iew o me hods and analyses o in e en ion-speci ic
bo lenecks and solu ions. BMC P egnancy Childbi h (2015) 15(Suppl 2):S1.
doi:10.1186/1471-2393-15-S2-S1
19. Heal h o Li e (H4L); ICF In e na ional Inc.; New ERA. Moni o ing he
P og ess o he Bi hing Cen e s in Nepal. Ka hmandu: Heal h o Li e (H4L),
ICF In e na ional Inc.,& New ERA (2014).
20. Moxon SG, Lawn JE, Dickson KE, Simen-Kapeu A, Gup a G, Deo a i A, e al.
Inpa ien ca e o small and sick newbo ns: a mul i-coun y analysis o heal h
sys em bo lenecks and po en ial solu ions. BMC P egnancy Childbi h (2015)
15(Suppl 2):S7. doi:10.1186/1471-2393-15-S2-S7
21. Simen-Kapeu A, Seale AC, Wall S, Nyange C, Qazi SA, Moxon SG, e al.
T ea men o neona al in ec ions: a mul i-coun y analysis o heal h sys em
bo lenecks and po en ial solu ions. BMC P egnancy Childbi h (2015)
15(Suppl 2):S6. doi:10.1186/1471-2393-15-S2-S6
22. Sha ma G, Ma hai M, Dickson KE, Weeks A, Ho mey GJ, La ende T, e al.
Quali y ca e du ing labou and bi h: a mul i-coun y analysis o heal h
sys em bo lenecks and po en ial solu ions. BMC P egnancy Childbi h (2015)
15(Suppl 2):S2. doi:10.1186/1471-2393-15-S2-S2
23. Vesel L, Be gh A-M, Ke be KJ, Valsangka B, Mazia G, Moxon SG, e al.
Kanga oo mo he ca e: a mul i-coun y analysis o heal h sys em bo lenecks
and po en ial solu ions. BMC P egnancy Childbi h (2015) 15(Suppl 2):S5.
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24. Liu G, Seg è J, Gülmezoglu AM, Ma hai M, Smi h JM, He mida J, e  al.
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analysis o heal h sys em bo lenecks and po en ial solu ions. BMC P egnancy
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26. Ka kee R, Binns CW, Lee AH. De e minan s o acili y deli e y
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29. Bhu a ZA, Das JK, Bahl R, Lawn JE, Salam RA, Paul VK, e al. Can a ailable
in e en ions end p e en able dea hs in mo he s, newbo n babies, and
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S0140-6736(14)60792-3
30. Subedi K, A yal DR, Gu ubacha ya SM. Kanga oo mo he ca e o low bi h
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Rapid Assessmen o he Demand Side Financing Schemes: Aama and 4ANC
P og ammes (The Se en h Rapid Assessmen ). Ka hmandu: Minis y o
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Resea ch and Social De elopmen Fo um (2013).
33. Enwe onu-La yea C, Dickson KE, Moxon SG, Simen-Kapeu A,
Nyange C, Nie meye S, e  al. Basic newbo n ca e and neona al esus-
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doi:10.1186/1471-2393-15-S2-S4
Con lic o In e es S a emen : The au ho s decla e ha he esea ch was con-
duc ed in he absence o any comme cial o inancial ela ionships ha could be
cons ued as a po en ial con lic o in e es .
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License (CC BY). The use, dis ibu ion o ep oduc ion in o he o ums is pe mi -
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e ms.