Newborn health interventions and challenges for implementation in Nepal

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 F on ie s in Public Heal h | www. on ie sin.o g 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. doi:10.1186/1471-2393-15-S2-S5 24. Liu G, Seg è J, Gülmezoglu AM, Ma hai M, Smi h JM, He mida J, e  al. An ena al co icos e oids o managemen o p e e m 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):S3. doi:10.1186/1471-2393-15-S2-S3 25. Na anee ham K, Dha malingam A. Demog aphy and de elopmen : p elimina y in e p e a ions o he 2011 census. Econ Poli Wkly (2013) 46(16):13. 26. Ka kee R, Binns CW, Lee AH. De e minan s o acili y deli e y a e implemen a ion o sa e mo he p og amme in Nepal: a p o- spec i e coho s udy. BMC P egnancy Childbi h (2013) 13(1):193. doi:10.1186/1471-2393-13-193 27. Ka kee R, Lee AH, Binns CW. Bypassing bi h cen es o childbi h: an analysis o da a om a communi y-based p ospec i e coho s udy in Nepal. Heal h Policy Plan (2015) 30(1):1–7. doi:10.1093/heapol/cz 090 28. Ka kee R, Lee AH, Pokha el PK. Women’s pe cep ion o quali y o ma e ni y se ices: a longi udinal su ey in Nepal. BMC P egnancy Childbi h (2014) 14(1):45. doi:10.1186/1471-2393-14-45 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 s illbi hs, and a wha cos ? Lance (2014) 384(9940):347–70. doi:10.1016/ 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 weigh babies: a p ospec i e obse a ional s udy. J Nepal Paedia Soc (2009) 29(1):6–9. doi:10.3126/jnps. 29i1.1593 31. Acha ya N, Singh RR, Bha a NK, Poudel P. Randomized con ol ial o kanga oo mo he ca e in low bi h weigh babies a a e ia y le el hospi al. J Nepal Paedia Soc (2014) 34(1):18–23. doi:10.3126/jnps. 34i1.8960 32. Up e i S, Ba al S, Lamichhane P, Khanal M, Tiwa i S, Tandan M, e  al. 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 Heal h and Popula ion, Nepal Heal h Sec o Suppo P og amme and Heal h 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- ci a ion: 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):S4. 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 . Copy igh © 2016 Kha i, Mish a, Khanal, Gelal and Neupane. This is an open-ac- cess a icle dis ibu ed unde he e ms o he C ea i e Commons A ibu ion License (CC BY). 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