Neonatal Health Care in Nepal

neonatal wellness CARE in NEPAL 1. BACKGROUND In the mid way of 2000 and 2015, the abbreviation of Millennium Development Goals (MDGs) in developing world shows encouraging come on signs particularly in kidskin wellness, but really less or no notable achievements in neonatal health (WHO, 2009). The pro good deal of neonatal deaths deaths within the graduation 28 days of life is expected to ontogenesis overdue to decline in burden of post-neonatal deaths (UN, 2009 USAID, 2008 WHOSIS, 2010).As per the WHO Statistics (2009), the progress on health-related MDGs shows nigh 37% of under-five (U-5) deathrate rate occurs in the neonatal period, with most deaths within the first week i. e. early neonatal period. Over one million neonates demote within their first 24hours of life due to lack of quality tuition, annually, intercontinental (UNFPA, 2008). In Nepal, neonatal Mortality Rate ( nuclear magnetic resonance) is 32 per 1000 proceed conducts in 2004 (WHO, 2009). Fig 1 Continuum of business concern Source Kerber et al. , 2007 The basic dogma of developing strategies to address Neonatal health anxiety (NHC) revolves round the continuum of business.Throughout the lifecycle as shown in figure 1, including adolescence, pregnancy, nipperbirth and childhood, the c be ought to be provided as a seamless continuum that spans the home, the community and health centre, locally and globally (Save the electric shaverren StC, 2006). Hence, cut back child death rate is more dependent on tackling neonatal death rate or in other words, managing the NHC. 2. KEY CONCEPTS AND ISSUES In Nepal, most of the deliveries seize on place at home with delayed c ar-seeking behavior the NMR form towering in rural areas, frequently associated with cessation of suckling and steepness of breath (Mesko et al. 2003). While the Department for International Development DFID (2009) report reveals that, the factors create unforesightful agnatic outcomes and ultimately resulting high NMR are poor and delayed send offation arrangements, weak financial status, long distance to health centre, and even needing permission to seek business concern. As the survival of the brand-newborns, older than a month is progressing quickly, at that place has been transformed concern in hitchs assumed to meliorate neonatal survival.The questions about the new interventions providing thermal care to the newborn, postnatal care to the mother and newborn, and counseling on infant and maternal health care to mothers has been added in the Demographic Health Surveys (DHS) of Nepal, along with Bangladesh, India, Indonesia, and the Philippines, to address antepartum, intrapartum, and postnatal interventions for the NHC (USAID 2008). Moreover, the address to reduce NMR from 34 to 30 per 1000 live births by 2010 has been set in the new Three Years Interim formulate (TYIP) for health 2008-10 (TYIP 2008-10, 2008).Pertaining to the revised target associated with neonata l mortality and to combat delays in seeking, reaching and receiving care, the Department of Health Services, Nepal (DoHS 2006/07, 2008) has postulated three study strategies * To promote birth preparedness and complication readiness including raising awareness, improving the availability of funds, transport and blood supplies. * To promote use of skilled birth attendants at each birth, either at home or in a health facility. * To make provision of 24-hour emergency obstetrics care services (basic and comprehensive) at selected public health facilities in every district. . STRENGTHS AND WEAKNESSES The strengths and weaknesses of the NHC in Nepal green goddess be reflected in broad spectrum, by analyzing the strengths and weaknesses of the subject field Health Policy and flow rate heath services, in general. 4. 1. Strengths 4. 2. 1. Health as citizens skillful The Ministry of Health and Population (MoHP) aims to create a new healthy Nepali society, operative in alignment with t he prime nonsubjective of bringing about a meaningful change in the overall health as per the guidelines issued by the Government of Nepal (GoN) to establish health as a fundamental human being right of each and every Nepalese. . 2. 2. decentalisation of health policy Decentralization in health policy a starting point for acknowledgment and its implementation is under process, initiated with the coordination between the MoHP and Ministry of Local Development (MoLD). The major intent of the decentralization in health policy is to improve cost dexterity and impellingness of government exertion, and strengthen community approach (DFID, 2003). The respective resolution Development Committee has been handed over the administrative and financial care tasks, initiatives taken from the lowest take, i. . Sub-health Posts (NHSP, 2009). 4. 2. 3. Public Private Partnership The head-to-head empyreans involvement to a considerable extent is noteworthy (TYIP, 2008) in the Public Pri vate Partnership (PPP) which initiated since 1950s (MoHP, 2008). The PPP has created continuous and coherent coordination of interventions such as immunization and pneumonia treatment, epochally trim down children and neonatal mortality (UNDP, 2010). 4. 2. 4. Community based interventions Fig. 2 Neonatal mortality in former(prenominal) 15 geezerhoodSource DoHS (2006) The development and implementation of community-wide protocols has substantially cut the NMR in the past 15 years, as shown in figure 2 (DoHS, 2006) and aims to get word entryway to effective healthcare focusing the neonates, in a sustainable and equitable manner. A study conducted by Dutta (2009) reveals that home-based newborn care has been signifi finisht in about one-third to two-third reduction in neonatal mortality after home based care interventions. Whilst, a study conducted by Haines et al. (2007) reveals that the mobilization of local women through community based participatory intervention can be sig nificant in improving the health of the newborn. 4. 2. Weaknesses 4. 3. 5. modify and unsafe care The weakly designed system, unable to ensure recourse and hygiene standards has been enforcing high rates of acquired infection during the birth, along with medication errors and other avoidable adverse effects (IDA and IMF, 2007). 4. 3. 6. Uneven and fragmenting health care The widen of specialized health care and cutting interest in the infirmity ontrol programmes, do not realize for the continuity of care. Due to poor and extremely under-resourced infrastructure, the health services for poor and marginalized group of Nepalese is highly uneven, aiding fragmentation of development (WHO Report, 2008). 4. 3. 7. Inequity Equity in health care as a basic need to ensure highest possible minimum standards, has not been attainable. The majority of the care is redeemed by the battalion with the most content but with lesser need, while the neonatal health care in the rural areas remain most virgin, with no redistribution of resources (WHO, 2008). . 3. 8. Others According to TYIP for health 2008-10 (2008), there are some general weaknesses largely affecting the novel objective of providing quality health care service that are easily social by all the citizens, also influencing the target of reducing the NMR in Nepal, such as * lack of skilled human resources and problems in their mobilization to rural areas, * very slow pace of decentralization process, * inadequate bring home the bacon of equipment and drug, * political interference in management, * weak monitoring and supervision, and lack of somatogenic infrastructure and its inadequate repair and maintenance (TYIP 2008-10, 2008). 4. EFFECTIVENESS The cognitive operation of a nations health system can be judged against WHO Criteria health status of the population and difference, responsiveness and inequality in responsiveness and honorable financing (WHO 2000) and Managing Cost, Care and Health Frame surve y. 5. 3. WHO Criteria According to the WHO Report (2000), the health level of Nepal is be at 142 with Disability Adjusted Life Expectancy (DALE) of get population at birth 49. years, as shown in table 1. tabular array 1 Health system attainment and performance in Nepal, ranked by eight measures, estimates for 1997 ATTAINMENT OF GOALS Health uses in international dollars exploit Health level Health Distribution Responsiveness Fairness in financial contribution Overall goal attainment DALE (in years) Equality of child survival Level of health Overall health system performance Rank Total Pop. at birth Rank Index unbelief Interval Level Distribution 142 49. 5 161 0. 585 0. 513-0. 63 185 166-167 186 160 clxx 98 150 There remains possibility of large inequality in the care provided at the rural and urban settings due to very poor health settings of workforce (DoHS, 2006). The inequality in responsiveness with very low respect profile for others and very poor quality of conveniences has placed Nepal at 185 level, and the rank of 186 (sixth from the bottom) shows that each household faces very high financial risk and spend largely for healthcare, thus purchase of needed care enforces into poverty (WHO, 2000). 5. 4. Managing Cost, Care and HealthGoing with the global approach, Nepal has also adopted decentralised health care system, attempting to make providers both independent and more responsible for the cost and quality of the healthcare services (Kane and Turnbull, 2003). The supplier and consumer approach can hardly be realized in the health service provided by the government effectiveness of the NHC dominantly under the control of government can be evaluated against the framework of managing costs at affordable levels, improved quality and access, and move health of the population (Kane and Turnbull, 2003). . 5. 9. Managing Cost The fairly existing systems operated by piddling number of agencies provide membership to the clients, cost bor ne by the clients or their employers on installment basis. The employees of government sector and labour organization are support with healthcare cost borne by social support schemes (WHO, 2003). There has been significant strike in financial resources in the health sector due to shoot-up of concerns in conflict resolution and internal gage (NHSP, 2009). The maximum portion of health financing is from out-of-pocket payment, i. . 85. 20% (WHO 2009), and there has been increased contender among the (private healthcare) providers to deliver the responsive behavior to the care-seekers ( diligents). But the larger portion of the consumers right to have an option of choosing economic and most compatible supplier static remains virgin. The Second Long Term Health Plan (SLTHP) 1997-2017 has emphasised the importance of restructuring healthcare and health insurance options, which has already been introduced but is almost non-existent.Delayed acknowledgement of managing insurance risk ha s lit some hope of effective healthcare, while managing utilization of services, and managing provider and supplier prices are just unimaginable. 5. 5. 10. Managing Care Fig 3 Neonatal Mortality factors and interventions to reduce it Source USAID 2008 NEONATAL MORTALITY Strengthening of Health Care System Ante-natal Care Neonatal Resuscitation Breast-feeding Clean pitch shotIntermittent preventive treatment for malaria Micronutrient supplementation Health Education Delivery by a Skilled Birth Attendant INTERVENTIONS The factors associated with neonatal mortality (as in figure 2) suggests that managing care can be improved and millions of new born be saved by approaching health issues of maternal care, neonatal care and child health, under the same umbrella and interventions can be operated with lower cost (StC, 2006).The policies and programmes in packages can cut conquer the cost of training, monitoring and evaluation, and facilitate judicious use of the available resources, with great efficiency and more effective coverage of the beneficiaries. 5. 5. 11. Managing Health Despite reduced neonatal mortality trends in Nepal over the past 15 years (NDHS, 2006), the neonatal morbidity and mortality still represents major proportion of U-5 child mortality principally due to the lack of SBAs, poor referral systems and lack of access to life-saving emergency obstetric care when complications occur (Safe Motherhood 2010).The revised National Safe Motherhood Health Long Term Plan 2006-2017 in accordance with SLTHP 1997-2017 focuses on improving maternal and neonatal health, and has aimed to reduce NMR to 15 per 1,000 live births by 2017 targeting to increase deliveries attended by SBAs to 60% and deliveries in a health facility to 40%, by 2017, change magnitude the met need of emergency obstetric complications by 3% and of caesarean contribution by 4%, each year (Safe Motherhood 2010).The Partnership for Maternal, Newborn, and Child Health (PMNCH) formed by mergin g three separate entities newborn, maternal and child health partnership has been established. This joint venture aims to create a more unified voice and facilitate creation of a continuum of care, work for achievement of maternal and child health-related MDGs by strengthening and coordinating action at all levels promoting rapid scale-up of proven, cost-effective interventions aligning the resources with the objectives, more efficiently and effectively (StC, 2006). 5.CHALLENGES and PRACTICALITIES 6. 5. Contextual Challenges * Low birth weight (14. 3%) and tight-fitting (38. 6%) are the root causes of perinatal deaths (MoHP, 2007). * The nation wide grounds of polio (78%), measles (81%) and tetanus (83%) immunisation by 2007, had immense significance in reducing the child deaths (WHO 2009). Despite having 60% children fully immunized, discrepancy remains in service coverage as 8% of U-5C are not immunized at all (MDG 2005). * Though the poor people have moved closer to the po verty line with poverty cranny ratio declining from 0. 12 to 0. 75, child mal maintenance still remains another major challenge for Nepal, which is the underlying cause for 50% of children deaths. Though, improved health and nutrition of the mother and availability of the SBAs can play role in reducing the NMR, it seems devastating to maintain the coverage rates with ongoing political conflicts and security problems. Hence, revisited strategies to combat this challenge will be more effective in reducing NMR due to the above contextual challenges. 6. 6. Leadership Challenges 6. 7. 12. Level of system funding With total expenditure on health 5. 1% of the GDP, and 30. % share of governments expenditure on health the shortfall met by private spending (WHO, 2009) reflects low political will and ability to invest in managerial and administrative infrastructure (Kane and Turnbull, 2003). This condition is prone to inhibit pooling of risks and the citizens are always prone to catastrophi c payments, further aggravating the poverty in the poorer community like Nepal (WHO, 2009). There is an alarming need of allocating financial resources for patient registration, disseminating information, monitoring and follow-up activities, and any other active management of the health services. 6. 7. 13.Provider market structure Nepal health market has countable specialists, very few care practitioners and poorly developed communication among the suppliers lacking primary care capacity. As the large multispecialty of the provider market structure with influential medical leadership facilitates the success of managed healthcare mechanisms, there remains huge alteration in the provider market structure. 6. 7. 14. Proportion of the population covered by health insurance In the span of six years, from 2000 to 2006, there has been decrease in out-of pocket expenditure from 91. 2% to 85. 2% of private expenditure on health.