national health programs

7/28/2019 National Health Programs

1/19

FAMILY PLANNING

Background

The main thrust of the National Family Planning Program is to expand and sustain adequate qualityfamily planning services to communities through the health service network such as hospitals,

primary health care (PHC) centres, health posts (HP), sub health posts (SHP), primary health care

outreach clinics (PHC/ORC) and mobile voluntary surgical contraception (VSC) camps. The policy also

aims to encourage public private partnership. Female community health volunteers (FCHVs) are

mobilized to promote condom distribution and resupply of oral pills. Awareness on FP is to be

increased through various IEC/BCC intervention as well as active involvement of FCHVs and Mothers

Groups as envisaged by the revised National Strategy for FCHV program.

In this regard, family planning services are designed to provide a constellation of contraceptive

methods/services that reduce fertility, enhance maternal and neonatal health, child survival, and

contribute to bringing about a balance in population growth and socioeconomic development,

resulting in an environment that will help the Nepalese people improve their quality of life.

ObjectivesWithin the context of reproductive health, the main objectives of the Family Planning Program are to

assist individuals and couples to:

Space and/or limit their childrenPrevent unwanted pregnanciesImprove their overall reproductive healthTargetsPeriodic and longterm targets for the Family Planning Program have been established as follows:

To reduce TFR to 2.5 children per woman by 2015To increase the Contraceptive Prevalence Rate (CPR) to 67 percent by 2015StrategiesIn order to achieve the CPR and the TFR targets mentioned above, a total of 2,580,000 couples were

expected to be using modern contraception by the end of the FY 2067/68. Recognizing the

importance of spacing of births, the Family Planning Program has been placing greater emphasis on

promoting temporary methods of contraception. More specifically, the longterm objective is to

reduce the share of permanent sterilization in overall use of family planning methods. However, the

emphasis on VSC services should be continued to address the unmet demand of those who desire to

limit further births.

The Family Planning Program aims to provide a constellation of contraceptive services throughoutthecountry. The strategy to achieve the family planning goals includes the following elements:

Periodic review of policy through national RH steering committee meetings.Coordination of FP program and activities through RH coordination committee networks

including Family Planning SubCommittee.

Institutionalization of policy/operational guidelines and clinical protocols to ensure maximumcoverage and quality of family planning services.

Increasing the knowledge and understanding of the benefits of delayed marriage, birth spacing,and a well planned family norm across the country through integrated RH/FP/IEC/BCC activities.

Increasing accessibility and availability of FP services through a combination of static, outreachand referral services.


2/19

Establish FP service as a part of hospital service and strengthen Institutionalized Family PlanningService Centres (IFPSC).

Expanding regular yearround and mobile VSC outreach services and expanding IUCD services toPHC and HP with special emphasis on thorough counselling and followup services.

Linking FP program with essential Health Care Service.Providing nonclinical methods (condoms, pills, and injectables) through static and outreach

services.

Training of service providers.Improving the quality of care in accordance with the National Medical Standards for contraceptive

services, with special attention on counselling, infection prevention and management of side

effects and complications.

Providing recanalization services in selected hospitals.Establishing postpartum FP services in institutions with a significant caseload of deliveries.Integrating family planning services with post abortion care and safe abortion care.Identifying national requirements and ensuring adequate procurement of contraceptives and

logistic supplies.

Promote wider use of Health Management Information Systems (HMIS) and health systemresearch for better planning and program management.

Ensuring effective monitoring and supervision of FP programs.Increasing free access to condom by having condom boxes at all health institutions andresupplying pills and distributing condom through FCHVs.

Current status:


3/19

SAFE MOTHERHOOD AND NEWBORN HEALTH

BackgroundThe goal of the National Safe Motherhood Program is to reduce maternal and neonatal mortalities

by addressing factors related to various morbidities, death and disability caused by complications ofpregnancy and childbirth. Global evidence shows that all pregnancies are at risk, and complications

during pregnancy, delivery and the postnatal period are difficult to predict. Experience also shows

that three key delays are of critical importance to the outcomes of an obstetric emergency: (i) delay

in seeking care, (ii) delay in reaching care, and (iii) delay in receiving care. To reduce the risks

associated with pregnancy and childbirth and address these delays, three major strategies have been

adopted in Nepal:

Promoting birth preparedness and complication readiness including awareness raising andimproving the availability of funds, transport and blood supplies.

Encouraging for institutional delivery.Expansion of 24hour emergency obstetric care services (basic and comprehensive) at

selected public health facilities in every districtSince its initiation in 1997, the Safe Motherhood Program has made significant progress in terms of

the development of policies and protocols as well as expansion in the role of service providers such

as staff nurses and ANMs in life saving skills. The policy on skilled birth attendants endorsed in 2006

by MoHP specifically identifies the importance of skilled birth attendance at every birth and

embodies the Governments commitment to training and deploying doctors and nurses/ANMs with

the required skills across the country. Similarly, endorsement of revised National Blood Transfusion

Policy 2006 is also a significant step towards ensuring the availability of safe blood supplies in the

event of an emergency. In order to ensure focused and coordinated efforts among the various

stakeholders involved in safe motherhood and neonatal health programming, government and

nongovernment, national andinternational, the National Safe Motherhood Plan (20022017) has

been revised, with wide partner participation. The revised Safe Motherhood and Neonatal HealthLong Term Plan (SMNHLTP 2006 2017) includes recent developments not adequately covered in the

original plan. These include:

recognition of the importance of addressing neonatal health as an integral part of safe motherhood

programming; the policy for skilled birth attendants; health sector reform initiatives; legalisation of

abortion and the integration of safe abortion services under the safe motherhood umbrella;

addressing the increasing problem of mother to child transmission of HIV/AIDS; and recognition of

the importance of equity and access efforts to ensure that most needy women can access the

services they need. The SMNHLTP identifies the following goal, purposes and outputs.

GoalSafemotherhood and neonatal health aims at improving maternal and neonatal health and survival,

especially of the poor and excluded. The main indicators for this include reduction in maternalmortality ratio and neonatal mortality rate. The detail indicators are given in Table 3.2.1.


4/19

IMMUNIZATION PROGRAM

The National Immunization Program (NIP) is a high priority program (P1) of Government of Nepal.

Immunization is considered as one of the most costeffective health interventions. NIP has helped in

reducing the burden of vaccine preventable diseases (VPDs) and child mortality and has contributed

in achieving the Millennium Development Goal on child mortality reduction (MDG4).

Currently NIP provides vaccination against TB (BCG), diphtheriapertussistetanushepatitis B and

haemophilus influenza (DPTHepBHiB), poliomyelitis (OPV) and measles throughout the country and

JE vaccine in high risk post campaign districts through routine immunization. TT vaccination is

provided to all pregnant women. The routine immunization services are provided through health

facilities (fixed clinic), private, NGO or INGO clinics, urban clinics, outreach session and mobile team

in geographical inaccessible areas. All vaccines under NIP are provided free of cost. Since the past

decades new vaccines are available in the markets, and the Government is keen to provide all

available vaccines to reduce morbidity and mortality. Since last 10 years several new vaccines

(hepatitisB, Hib and JE) were introduced into routine immunization. In addition to routine

immunization services NIP carries out several supplementary immunization activities either to

eradicate, eliminate or control vaccine preventable diseases (VPDs).

GoalThe goal of National immunization Program is to reduce child morbidity, mortality and disability

associated with vaccinepreventable diseases.

ObjectivesThe objectives of the National Immunization Program are as follows:

Achieve and sustain 90 percent coverage of DPT3 by and of all antigens Maintain polio free status Sustain MNT elimination status Initiate measles elimination Expand vaccine preventable disease (VPDs) surveillance Accelerate control of other vaccine preventable diseases through introduction of new

vaccines

Improve and sustain immunization quality Expand immunization services beyond infancy

targetsNHSP2 targets to achieve 85 percent of children under 12 months of age immunized against DPT3

and measles.

strategies

The key strategies to achieve the above objectives are:1. Strengthen routine immunization through RED strategies

RED micro planning in all districtsSupportive supervision and monitoringIncrease and promote public awareness and demand through social mobilisation forimmunisation services and IEC/BCC interventions

Partnership with private, CBOs, NGOs and others2. Strengthen municipality immunization services

Fulfil vacant post of vaccinatorsEnsure availability of vaccine and other logisticsSupportive supervision and monitoring3. Conduct supplementary immunization activities and surveillance for eradication of

poliomyelitis and control of measles and JE.


5/19

4. Sustain Maternal and Neonatal Tetanus elimination status through expansion of school TT

immunization program and high TT coverage.

5. Strengthen and expand integrated surveillance of VPDs built on AFP Surveillance (AFP, Measles,

Neonatal Tetanus and Japanese Encephalitis) and initiate disease burden study of other vaccine

preventable diseases like Hib and Rubella, Pneumococcal and Rota.

6. Conduct periodic meetings of National Committee for Immunization Practices (NCIP), AdverseEvent Following Immunization (AEFI) and Interagency Coordination Committee (ICC) committee.

7. Conduct capacity building for relevant health staff (MLM, refresher training, cold chain and

vaccine management, maintenance training, incountry observation tour by EPI staff).

8. Control outbreak of VPDs through appropriate reporting, investigation and response.

9. Improve quality of immunization services practicing injection safety policy.

10. Introduction of new and underused vaccines based on disease burden.

Current status

NUTRITION PROGRAM

The National Nutrition Program under Department of Health Services has laid the vision as all

Nepali people living with adequate nutrition, food safety and food security for adequate physical,

mental and social growth and equitable human capital development and survival with the mission

to improve the overall nutritional status of children, women of child bearing age, pregnant women,

and all ages through the control of general malnutrition and the prevention and control of

micronutrient deficiency disorders having a broader inter and intrasectoral collaboration and

coordination, partnership among different stakeholders and high level of awareness and

cooperation of population in general.Malnutrition remains a serious obstacle to child survival, growth and development in Nepal. The

most common form of malnutrition is proteinenergy malnutrition (PEM). The other forms of

malnutrition are iodine, iron and vitamin A deficiency. Each type of malnutrition wrecks its own

particular havoc on the human body, and to make matters worse, they often appear in combination.

Even moderately acute and severely acute malnourished children are more likely to die from

common childhood illness than those adequately nourished. In addition, malnutrition constitutes a

serious threat especially to young child survival and is associated with about one third of child

mortality. Major causes of PEM in Nepal is low birth weight of below 2.5 kg, due to poor maternal

nutrition, inadequate dietary intake, frequent infections, household food insecurity, feeding

behaviour and poor care and practices leading to an intergenerational cycle of malnutrition.

Iodine Deficiency Disorder (IDD) was another endemic problem in Nepal, especially in the western

mountains and mid hills for which Ministry of Health and Population adopted a policy to fortify all

edible common salt with iodine and decided to celebrate February as the month to create general

awareness about the use of adequately iodized salt through mass campaign to contribute in the

prevention of Iodine Deficiency Disorders.

Another problem among schoolaged children and women is the Vitamin A deficiency leading to

night blindness both in children and women. No cases of night blindness are reported so far among

children below 5 years due to a regular semiannual supplementation of high dose Vitamin A

supplementation to preschool children (200,000 I.U.). The National Vitamin A Supplementation

Program with community support is considered as the one of the internationally recognized

successful program. Nepal Government also completed the piloting of newborn Vitamin A dosingprogram in four district of Nepal (Nawalparasi, Tanahun, Bardiya and Sindhuli). A high dose of


6/19

vitamin A supplementation for mother during postpartum period is also ongoing throughout the

country.

The prevalence of worm infestation in Nepal remaining still high leading to decreased resistance to

infection and contributing to anaemic status, which in turns induces malnutrition, and also, leads to

anaemia impairing cognitive function in children. Therefore, deworming of children one to five years

of age is incorporated into the national biannual Vitamin A supplementation program which hasbeen implemented in the entire country. Similarly, deworming of all pregnant women with single

dose of albendazole tablet after first trimester of pregnancy is being routinely practiced through all

health facilities in Nepal. In addition, under School Health and Nutrition (SHN) Program biannual

school deworming is also launched to the school students studying at government schools

throughout the country. GoN is planning to upscale deworming chemotherapy to students from

grade 1 to 10 of all public and private schools of the country.

Anaemia caused by iron deficiency is also a major public health problem in Nepal affecting all

segments of the population. As per findings of NDHS 2011, 46 percent of children ages 6 to 59

months are anaemic. The majority of children who suffer from anemia are classified as having mild

or moderate anemia (27 and 19%, respectively) while less than 1 percent are severely anemic.

Anemia is less common among women; 35 percent show evidence of anemia, and the majority ismildly anemic (29%). Anemia among both children and women is especially prevalent in rural areas,

where nearly half of the children (46%) and more than onethird of women (36%) have some degree

of anemia. The NDHS 2011 found more than 70 percent of children aged 6 to 23 months are anaemic

compared with 25 percent of children aged 48 to 59 months. Anaemia is most common among

children less than 5 years in the farwestern terai (60%) compared to central mountain (33%).

Overall, there has been no significant improvement in the anemia status of children and women in

Nepal between 2006 and 2011.

As per the government policy, all pregnant women and postpartum mothers are given iron tablet

starting from second trimester to postpartum period free of cost. In order to increase coverage and

compliance of iron tablets among pregnant and postnatal mothers Intensification of Maternal and

Neonatal Micronutrient Program (IMNMP) is implemented through the existing health facilities andcommunitybased outlets like FCHVs with special emphasis on creating awareness. Awareness

raising activities mainly include advocacy, information through public media and training of health

workers/volunteers at all levels. IEC materials such as flip chart and posters are also being

distributed for this purpose. By the end of fiscal year 2067/68, the program has been introduced in

70 districts (Out of total 75 districts).

According to WHO 2011 guideline, micronutrient powder supplementation is required in the areas

where more than 20 percent under five children population is suffering from any form of anaemia.

In

Nepal, irrespective of geographical regions, the anaemia prevalence is higher than 20 percent in the

under five children and the situation is more critical in under two years children where the

prevalence is as high as 70 percent, according to the Nepal Demographic Health Survey, 2011. To

address the problem, MoHP Nepal has endorsed a permissive policy on home fortification of

micronutrient powder (MNP) in the complementary food in order to correct Anaemia Prevalence in

623 month children. Linking the distribution of MNP to 623 months children with Governments

Infant and Young child Feeding Promotion Program, the MNP distribution program has been

implemented in 6 districts of Nepal viz. Rupandehi, Parsa, Gorkha, Rasuwa, Palpa and Makawanpur.

The plan is to scale up this program all 75 districts by 2015.

ObjectivesGeneral ObjectiveThe general objective of the National Nutrition Program is to enhance nutritional wellbeing, reduce

child and maternal mortality and is to contribute for equitable human development.

Specific Objectives:


7/19

Reduce general malnutrition among women and childrenReduce Iron Deficiency Anaemia among children and pregnant motherMaintain and sustain Iodine Deficiency Disorder (IDD) and Vitamin A Deficiency Disorder (VAD)Improve maternal nutritionAlign with Multisectoral Nutrition InitiativeImprove Nutrition related Behaviour change and communicationImprove Monitoring and Evaluation for Nutrition related Programs/ActivitiesTargetsIn order to improve the overall nutritional status of children and pregnant women, the national

nutrition program has set the following targets:

To reduce PEM in children under 5 years of age and reproductive aged women to half of the2000 level by the year 2017.

To reduce the prevalence of anaemia among women and children to less than 40 percent by2017.

To virtually eliminate IDD and sustain the elimination by 2017.To virtually eliminate vitamin A deficiency and sustain the elimination by 2017.To reduce the infestation of intestinal worms among children and pregnant women to less than10 percent by 2017.

To reduce the prevalence of low birth weight to 12 percent by the year 2017.To improve household food security to ensure that all people can have adequate access,availability and utilization of food needed for healthy life in order to reduce the percentage of

people with inadequate energy intake to 25 percent by 2017.

To improve health and overall nutritional status of school children through the implementationof School Health and Nutrition Program.

To reduce the critical risk of malnutrition and life during exceptionally difficult circumstances.To strengthen the system for analyzing, monitoring and evaluating the nutrition situation.Topromote exclusive breastfeeding till the age of six completed months. Thereafter, introducecomplementary foods along with breast milk till the child completes 2 years or more.

To reduce the Infestation of intestinal worm among Children and Pregnant Women to less than10 percent by 2017.

StrategiesThe following general strategies have been pursued to address the nutritional situation in Nepal:

To reduce proteinenergy malnutrition (PEM) in children less than five years of age andReproductive aged Women to half of the 2000 level by the year 2017 through a multisectoral

approach.

Promote, facilitate and utilize community participation and involvement for all nutritionactivities.

Develop understanding and effective coordination between various concerned Sections,Divisions and Centres within the Department of Health Services.Maintain and strengthen coordination among other agencies involved in nutrition activities, i.e.,the Ministries of Agriculture, Education, Local Development and the National Planning

Commission, as well as with EDPs, NGOs, INGOs and private sector.

Decentralise authority to the region, district, Health Post, Sub Health Post and community forneeds assessment, planning, implementation, and monitoring.

Conduct national advocacy and social mobilization campaigns; Integrate/incorporate activities(such as Expanded Program on Immunization, Integrated Management of Childhood Illness,

Maternal and Family Health and other concern program, etc.) into nutrition plans.

Develop a systematic approach for Monitoring and Evaluation of all nutrition program activities.Celebrate different events related to nutrition program like School Health and Nutrition Week(Jestha 1 to 7), Breast feeding week (August 17), Iodine month (February) to raise awareness


8/19

about the importance of Nutrition.

Implement School Health and Nutrition Program as per National Strategy.Growth monitoring will be used as a screening tool to assess the general malnutrition status ofchildren under less than five years.

Specific Strategies

1. Control of Protein Energy Malnutrition (PEM)Promotion of IYCF through creating awareness regarding the importance of growth monitoringand exclusive Breast Feeding up to 6 month of age and timely introduction of complementary

foods.

Provide growthmonitoring services, ANC checkups, deworming during Pregnancy throughoutreach clinics, Sub Health Posts, Health Posts/PHC in food insecure districts.

Protect, Promote & Support Optimal Feeding Practice for Infant & Young Children.Increase awareness among medical professionals through advocacy efforts, such as by includingsessions on breastfeeding on seminars/workshops held by various associations.

BCC for Changing the Dietary Practices.Celebrate Breastfeeding Week (August 17) as an advocacy for the protection and promotion ofbreastfeeding.Strengthen Nutrition Rehabilitation Home and community based management of acutemalnutrition (CMAM).

Improve Maternal and Adolescent Nutrition & Low Birth Weight Baby Through improvedMaternal Nutrition Practices.

2. Control of IDD

Strengthen the implementation of Iodized Salt Act, 2055 for regulation and monitoring ofiodized salt trade to ensure that all edible salt is iodized.

Increase the accessibility and market share of iodized packet salt with twochild logo.Create awareness about the importance of use of iodized salt for the control of IDD; throughSocial Marketing Campaign.

Celebrate month of February as an iodine month.3. Control of Vitamin A Deficiency (VAD)

Distribute highdose vitamin A capsules to children between 6 and 59 months biannuallythrough FCHVs.

Advocate for increased home production, consumption and preservation of Vitamin A rich foodsat the community level.

Explore the fortification of suitable foods (such as sugar and cooking oil) with Vitamin A.Strengthen the usage of Vitamin A Treatment protocol.Supplementation of Vitamin A capsule (200,000 IU) to postpartum mothers through healthcarefacilities and community volunteers.

4. Control of Anaemia

Increase coverage and compliance of iron/folate supplementation for pregnant women.Reduce the burden of parasitic infestations (helminths, malaria and Kalazar).Identify and implement food fortification to increase the dietary iron intake focusing oncommercial as well as smallscale community based fortification initiatives.

Promote dietary diversification to improve the quality of food consumed with an emphasis onbioavailable iron.

Promote maternal care practices and services to improve health and nutritional status of motherand babies.

Identify and implement the effective modalities to address iron deficiency in adolescents andnonpregnant women of reproductive age.5. Deworming


9/19

Deworming of pregnant women through health facilities with single dose tablet (Albendazole400 mg) starting from 2nd trimester (4 months) of the pregnancy.

Distribute Biannual deworming tablet to Primary School Children in 75 districts (Governmentschools).

Follow up the comprehensive deworming work plan.Current status:

IMCI PROGRAM

Community Based Integrated Management of Childhood Illness (CBIMCI) Program is an integrated

package of childsurvival interventions and addresses major childhood killer diseases like

Pneumonia, Diarrhoea, Malaria, Measles, and Malnutrition in 2 months to 5 year children in a

holistic way. CBIMCI also includes management of infection, Jaundice, Hyperthermia and counselling

on breastfeeding for young infants less than 2 months of age. With the implementation of this

package children are diagnosed early and treated appropriately for major childhood diseases at the

health facility and community level. At the community level FCHVs are the main vehicle of service

delivery and also plays key role to increase community participation.

In 1997, the program was initiated in Mahottari as a piloting district for IMCI. Based on the

recommendations it was decided to include a community component, enabling mobilisation of

community health workers (VHWs and MCHWs) and FCHVs to provide CDD, ARI, Nutrition and

Immunisation services to the community. As a result the Community based ARI and CDD (CBAC)

program was merged into IMCI in 1999 and is now called the Community Based IMCI (CBIMCI). At

the end of fiscal year 2066/67 (2009/2010) CBIMCI Program has covered 75 districts. I n 2004,

Newborn component was added to CBIMCI.

Vision

Contribute to survival, healthy growth and development of under five children of Nepal.Achieve MDG Goal 4 by 2015.GoalTo reduce morbidity and mortality among children underfive due to pneumonia, diarrhoea,

malnutrition, measles and malaria.

Targets

To reduce neonatal mortality from the current rate of 33/1,000 live births to 17/1,000 live birthsby 2015.

To reduce neonatal morbidity among infants less than 2 months of age.Objectives

Reduce frequency and severity of illness and death related to ARI, Diarrhoea, Malnutrition,Measles and Malaria.

Contribute to improved growth and development.StrategyThe following strategies have been adopted by CBIMCI program: 1. Improving knowledge and

case management skills of healthcare staffCBIMCI aims to improve the skills of healthcare staff through

training to all health workers on CBIMCI including zinc treatment for diarrhoea;regular integrated review and refresher trainings to health service providers;inclusion of CBIMCI in the curriculum of preservice medical and paramedical schools;technical support visits should include visits from the central and regional level to districts,DHO to all HFs; HFs to FCHVs; and

capacity building training to the CBIMCI focal persons of the districts.2. Improving overall health systems


10/19

Carry out CBIMCI Program maintenance activities as per the recommendations made by IMCIworking group and global context.

Improve logistic supply.Regularize mothers group meeting.Strengthen reporting system at all levels.Strengthen supervision and monitoring.3. Improving family and community practicesDisseminating key behavioural message through FCHVs to families and communities usingrelevant IEC materials.

Reaching the disadvantaged and hardtoreach communities through reactivated mothersgroup meeting.

Dissemination of key family practice messages through interpersonal communication.Current status:

MALARIA

Malaria control project was first initiated in Nepal in 1954 with the suppot from USAID (then USOM).

The objective of the project was to control malaria mainly in southern Terai belt of central Nepal. In

1958, national malaria eradication program, the first national public health program in the country

was launched with the objective of eradicating malaria from the country within a limited time

period. Due to various reasons the eradication concept was reverted to control program in 1978.

Following the call of WHO to revamp the malaria control programs in 1998, Roll Back Malaria (RBM)

initiative was launched to address the perennial problem of malaria in hardcore forested, foot hills,

inner Terai and valley areas of the hills, where more than 70 percent of the total malaria cases of the

country prevail. The high risk of getting the disease is attributed to the abundance of vector

mosquitoes, mobile and vulnerable population, relative inaccessibility of the area, suitable

temperature, environmental and socioeconomic factors. Currently malaria control activities are

carried out in 65 districts at risk of malaria. The districts are divided into four different categories as

follows:

High risk districts (13): Ilam, Jhapa, Morang, Sindhuli, Dhanusa, Mahottari, Kavre, Nawalparasi,Banke, Bardiya, Kailali, Kanchanpur, Dadeldhura

Moderate risk districts (18): Panchthar, Dhankuta, Sunsari, Saptari, Siraha, Udayapur, Sarlahi,Rautahat, Bara, Parsa, Makawanpur, Chitwan, Sindhupalchowk, Rupandehi, Kapilvastu, Dang,

Surkhet, Doti

Low risk 34 Districts (Minimal transmission) (34)No risk Districts (10)The Global Fund is supporting malaria control program in the high risk 13 endemic districts and

moderate risk 18 endemic districts.

Objective

Overall incidence of (probable and confirmed) malaria in population at risk brought below 2cases per 1,000 by 2011. (2005 baseline: 4.1 cases per 1,000)

Hospitalbased severe malaria case fatality rate reduced to below 15% by 2010.By 2010, weekly incidence of malaria (probable and confirmed) in all outbreak wards broughtbelow outbreak threshold level within 6 weeks of detection.

Community mobilization and community partnership in malaria control.Targets


11/19

80 percent of people in high risk areas (stratum 1 VDCs) sleeping under LLIN (last night) by 2011. 80 percent of malaria cases reported by public sector health facilities in high risk areas (stratum 1)

confirmed by microscopy or RDT by 2011.

80 percent of care providers at rural public sector health facilities providing appropriate treatmentfor malaria by 2011.

StrategiesVector Control and Personal Protection

Two rounds of routine indoor residual spraying (IRS) will be carried out annually in each high riskVDCs unless LLIN population coverage in that VDC exceeds 80%

In the event of limited insecticide stocks round 2 of the IRS campaign may be withheld and targetVDCs will be prioritized according to malaria burden.

Insecticides for IRS will be WHOPES approved and will be selected by the insecticide TechnicalWorking Group (TWG) on the basis of likely cost effectiveness (insecticide resistance profiles for

primary vectors will be taken into consideration).

IRS operations will aim to cover at least 80 percent of households in target VDCs.WHOPES approved longlasting insecticide treated bed nets (LLINs) will be provided free of chargeto all people living in high risk VDCs (1 LLIN per 2 people every three years assuming a three year life for the LLIN).

LLIN delivery campaigns will take place in one third of targeted VDCs in each district each year sothat total coverage of the target population is achieved by year 3 and maintained thereafter.

Additional WHOPES approved LLINs will be provided to all pregnant women attending ANC checkups

in high risk VDCs (one LLIN per pregnancy).

Early Diagnosis and Appropriate Treatment

Diagnostic services for malaria will be provided free of charge at all public sector health facilities.Microscopy will form the diagnostic method of choice at hospital and primary health care centrelevel and some selected health posts and subhealth posts.

Below primary health care centre level falciparum specific and RDTs will form the diagnosticmethod of choice in high and moderate risk areas. To minimize wastage, use of RDTs will bestrictly limited to diagnosing clinically suspected cases only.

EDCD will implement a comprehensive quality assurance system for malaria microscopy and RDTsthrough the referral laboratory network (District, Regional and Central). This will be linked to

needsbased refresher training.

Antimalarial drugs will be provided free of charge from all public sector health facilities.Antimalarial drugs will be provided free of charge through the Female Community HealthVolunteer (FCHV) network in high risk area according to national treatment guidelines.

Artemisininbased combination therapy (ACT) will be provided for confirmed falciparum malariacases throughout the country as per national treatment guidelines.

Chloroquine will be provided for confirmed vivax cases and suspected malaria cases as pernational treatment guidelines.

Primaquine will be provided for the radical cure of confirmed vivax cases as per nationaltreatment guidelines.

National malaria treatment guidelines will be reviewed regularly and revised as appropriate basedon the findings of drug resistance surveillance.

National malaria treatment guidelines (and any revisions to them) will be implemented at allpublic sector health facilities throughout the country within one year of ratification by the

Regional Technical Advisory Group on Malaria (RTAGM). Recommended antimalarials,

includingACT, will be incorporated into the essential drug list. Malaria Surveillance and

Epidemic Preparedness

A simple malaria outbreak early warning system will be established in selected public healthfacilities (one sentinel site/endemic district). This will be complimentary to existing surveillance


12/19

networks.

Technical and operational linkages between EDCD and epidemic prone districts will bestrengthened for an effective coordinated action in response to outbreaks.

In the event of an outbreak, focal IRS will be carried out in the ward(s) where the outbreak wasdetected and in all adjacent wards.

In the event of an outbreak, districtlevel teams will carry out RDTbased active case detection inthe outbreak ward(s) and in all adjacent wards. Confirmed cases will be treated according to

national treatment guidelines.

Behaviour Change Communication (BCC)

Carefully tailored locally appropriate malaria related IEC/BCC will be delivered through 5methodologies: interpersonal communication (health workers, religious and community

members); primary and secondary education (malaria incorporated into vector borne disease

control module); mass media (electronic and print); special events (malaria day); and, high level

advocacy.

Final development and production of BCC materials will be outsourced to private/INGO/NGOsector specialists.

Maximum use will be made of free promotional opportunities such as articles in newspapers, andnews bulletins, and dramas on television and radio.

Program Management

Capacity building: A holistic package of carefully tailored technical and management training willbe developed and will be implemented through central and district level staff in order to

strengthen the functionality of service provision in the periphery.

Planning: Technical Working Groups (TWGs) will be established and maintained for all keytechnical areas including: diagnostics; case management; vector control; IEC/BCC; monitoring &

evaluation; and operational research.

Existing technical guidelines, including guidelines on case management, vector control, epidemicpreparedness and control, monitoring drug and insecticide resistance will be updated by the

TWGs/TA and disseminated.Policies, strategies and guidelines will be reviewed regularly by TWGs in light of findings fromperiodic evaluations and in view of recommendations resulting from surveillance and operational

research activities.

To ensure equitable and evidencebased distribution of services, allocation of all programcommodities will be carried out by the relevant TWG.

A National Technical Advisory Group for Malaria (NTAGM) will be established. The group will haverepresentation from MoHP, EDCD, NPHL, NHEIC, VBDRTC, DHOs, the INGO/NGO sector and WHO

(and other key agencies as appropriate). This committee will meet annually in order to review

programmatic progress and to ratify any policy/strategy changes.

Operational Research

The program will implement a modest needsbased package of operational research in associationwith implementing partners and national and international research institutes.

Research priorities will be reviewed annually by a TWG and the resulting research agenda will beratified by the NTAG Malaria.

Community Participation

Enhance community participation and partnership building in malaria control through theprogressive expansion of Roll Back Malaria (RBM) initiative.

Current status:


13/19

TUBERCULOSIS

Tuberculosis (TB) is a major public health problem in Nepal. About 45 percent of the total population

is infected with TB, of which 60 percent are adult. Every year, 40,000 people develop active TB, of

whom 20,000 have infectious pulmonary disease. These 20,000 are able to spread the disease to

others. Treatment by Directly Observed Treatment Short course (DOTS) has reduced the number of

deaths; however 5,0007,000 people still die per year from TB. Expansion of this cost effective and

highly successful treatment strategy has proven its efficacy in reducing the mortality and morbidity

in Nepal. By achieving the global targets of diagnosing 70 percent of new infectious cases and curing

85 percent of these patients will prevent 30,000 deaths over the next five years. High cure rates and

Sputum conversion rate will reduce the transmission of TB and lead to a decline in the incidence of

this disease, which will ultimately help to achieve the goal and objectives of TB control.

DOTS have been successfully implemented throughout the country since April 2001. The NTP has

coordinated with the public sectors, private sectors, local government bodies, I/NGOs, social

workers, educational sectors and other sectors of society in order to expand DOTS and sustain the

present significant results achieved by NTP. By 16th July 2011 NTP has 1,118 DOTS treatment centres

with 3,103 sub centres. The treatment success rate stands at 90 percent and case finding rate of 73

percent. At the national level 36,951 TB patients have been registered of whom 15,000 infectious

(sputum smear positive new cases) and are being treated under the DOTS strategy in NTP during the

FY 2067/68 (2010/2011).

VisionThe NTPs vision is TB free Nepal.

Mission

To ensure that every TB patient has access to effective diagnosis, treatment and cureTo stop transmission of TBTo prevent development of multi drug resistant TBTo reduce the social and economic toll of TBGoal

To reduce the mortality, morbidity and transmission of tuberculosis until it is no longer a publichealth problem in Nepal.

Objectives

Achieve universal access to highquality diagnosis and patientcentred treatmentReduce the human suffering and socioeconomic burden associated with TBProtect poor and vulnerable populations from TB, TB/HIV and multidrugresistant TBSupport development of new tools and enable their timely and effective useTargetsTargets linked to the MDGs and endorsed by the Stop TB Partnership:

by 2005: detect at least 70 percent of new sputum smearpositive TB cases and cure at least 85percent of these cases

by 2015: reduce prevalence of and death due to TB by 50 percent relative to 1990by 2050: eliminate TB as a public health problem (


14/19

Case detection through quality-assured bacteriology Standardized treatment with supervision and patient support An effective drug supply and management system Monitoring and evaluation system, and impact measurement

2. Address TB/HIV, MDR-TB and other challenges

Implement collaborative TB/HIV activities Prevent and control multi-drug-resistant TB Address prisoners, refugees and other high-risk groups and special situations

3. Contribute to health system strengthening Actively participate in efforts to improve system-wide policy, human resources, financing,management, service delivery, and information systems Share innovations that strengthen systems, including the Practical Approach to Lung Health(PAL) Adapt innovations from other fieldsDoHS, Annual Report 2066/67 (2009/2010) (page 161)

4. Engage all care providers

Public-Public, and Public-Private Mix (PPM) approaches

International Standards for Tuberculosis Care (ISTC)5. Empower people with TB, and communities Advocacy, communication and social mobilization Community participation in TB care Patients' Charter for Tuberculosis Care

6. Enable and promote research

Programme-based operational research

The National Tuberculosis ProgrammeThe National Tuberculosis Programme (NTP) is an approach within the national health system forcontrol of tuberculosis (TB). NTP has specific policies, plans and activities to achieve its goals,objectives and targets. NTP is countrywide, continuous, and permanent and fully integrated within thegeneral health services. NTP policies are in accordance with the national health plan, WHO Stop TB

Strategy and the Global Plan to Stop TB (2006-2015).Current status

LEPROSY

Leprosy has existed in Nepal since time immemorial and was recognized as a major Public Health

problem as early as 1950. Khokana Leprosarium near Kathmandu was established more than 160

years ago to provide services to the leprosy patients.

For ages, leprosy has been a disease causing public health problem and has been a priority of the

government of Nepal. Thousands of people have been affected by this disease and many of them

had to live with physical deformities and disabilities.

Activities to control leprosy in an organized and planned manner were initiated only from 1960.

According to a survey conducted in 1966, an estimated 100,000 leprosy cases were present in Nepal.

Dapsone monotherapy treatment was introduced as a Pilot Project in the Leprosy Control Program.

Nepal Leprosy Control Program was started in the country in 1966. Multi Drug Therapy (MDT) was

introduced in 1982 in few selected areas and hospitals of the country. By this time, the number of

registered leprosy cases had reached 21,537 with a Prevalence Rate (PR) of 21 per 10,000

population. Sixtytwo districts of the country had PR of over 5, while only three districts had PR less

than 1 per 10,000 inhabitants.

The program was integrated into the general health services in 1987. By 1996 MDT was expanded to

all 75 districts. The country conducted Leprosy Elimination Campaign in 1999 (LEC1) and again in


15/19

2001 (LEC2) which was an active case detection activity. In high endemic pockets special

interventions were undertaken for case finding. Community mobilization and participation during

LEC contributed to voluntary case reporting due to reduction of stigma and discrimination against

leprosy affected persons. High cure rates through flexible and patientfriendly drug delivery systems

were ensured. Monitoring and supervision of the activities were undertaken to keep track of

progress towards elimination.All initiatives were coordinated amongstthe national, international and local

nongovernmental organizations.

Specialized care for leprosy affected

persons was provided in Leprosy

hospitals and referral clinics run by

NGOs and the government. WHO and

other major partners supporting the

program are Sasakawa Memorial

Health Foundation, The Nippon

Foundation, Netherlands LeprosyRelief, The Leprosy Mission,

International Nepal Fellowship and

Nepal Leprosy Trust.

Leprosy Control Division, the guiding body for leprosy control activity in Nepal, functions in close

coordination with the Regional Health Directorate, District Health System, donor agencies and all the

supporting partners. Regional Health Directorate (RHD) supervises and monitors the program in all

districts within the region. Disease control activities including leprosy control activities are headedby

respective officer as appointed by Regional Director in RHD. Regional Tuberculosis and Leprosy

Officer/Assistant (RTLO) is the focal person of leprosy in RHD. In addition, District TB & Leprosy

Officer/Assistant (DTLO), implement the program in respective district.

MDT service is being delivered through all the public health facilities (Primary Health Centres, HealthPosts and Sub Health Posts) in Nepal. Majority of health care providers serving at community based

health facilities have undergone Comprehensive Leprosy Training (CLT) and are effectively providing

MDT service. In addition more than 90 percent Female Community Health Volunteers (FCHVs) have

received orientation on leprosy and are suspecting and referring cases to the nearest HF for

confirmation of diagnosis and treatment. Capacity building is a key intervention area and is

conducted with support from the WHO and INGOs mentioned above. In addition to capacity building

INGO supported referral centres also provide primary, secondary and tertiary level care to leprosy

patients.

VisionTo usher in a leprosy free society where there are no new leprosy cases and all the needs of existing

leprosy affected persons having been fully met.

MissionTo provide accessible and acceptable cost effective quality leprosy services including rehabilitation

and continue to provide such services as long as and wherever needed.

GoalReduce further the burden of leprosy and to break channel of transmission of leprosy from person to

persons by providing quality service to all affected community.

Objectives

To eliminate leprosy (Prevalence Rate below 1 per 10,000 population) and further reducedisease burden at district level;

To reduce disability due to leprosy;To reduce stigma in the community against leprosy; andProvide high quality service for all persons affected by leprosy.Strategies

Evolution of Leprosy Control Program1960 Leprosy survey in collaboration with WHO

1966 Pilot Project launched with Dapsone therapy

1982 Introduction of Multi Drug Therapy

1987 Integration of vertical program into general basic

health services

1991 National leprosy elimination goal was set

1995 Focal persons (TLAs) appointed for districts & regions


16/19

Early case detection and prompt treatment of cases.Enable all general health facilities to diagnose and treat leprosy.Ensure high MDT treatment completion rate.Prevent and limit disability by early diagnosis and correct treatment.Reducing stigma through information, education, and advocacy by achieving communityempowerment through partnership with media and community.Sustain quality of leprosy service in the integrated set up.Targets

Reduce NCDR by 25 percent at national level by the end of 2015 in comparison to 2010. Reduce PR by 35 percent at national level by the end of 2015 in comparison to 2010.Reduce by 35 percent GII disability amongst newly detected cases per 100,000 population by

the end of 2015 in comparison to 2010.

Additional deformity during treatment


17/19

National HIV/AIDS Policy, a multisector

National AIDS Coordinating Committee

(NACC) chaired by the Minister of Health,

with representation from different

ministries, civil society, and privatesector was established at centre to build

the coordination mechanism to support

and monitor the activities implemented

through NCASC. Similarly, DACC was

established to coordinate and monitor

the activities at district level.

In 2002 a National AIDS Council (NAC)

was established, chaired by the Prime

Minister, to raise the profile of HIV/AIDS.

The NAC was intended to set overall

policy, lead high level advocacy, andprovide overall guidance and direction to

the national response to AIDS in Nepal.

The latest national policy on HIV and AIDS (2010) have envisioned a more concrete policy framework

for making AIDS free society with the overall policy aim of reducing impact of HIV among people by

reducing new HIV infections.

Recently Nepal has expressed its high level political commitment to Political Declaration on

HIV/AIDS: Intensifying our Efforts to Eliminate HIV/AIDS June 2011. The 2011 declaration builds on

two previous political declarations: the 2001 Declaration of Commitment on HIV/AIDS and the 2006

Political Declaration on HIV/AIDS. At UNGASS, in 2001, Member States unanimously adopted the

Declaration of Commitment on HIV/AIDS. This declaration reflected global consensus on a

comprehensive framework to achieve Millennium Development Goal Six: halting and beginning toreverse the HIV epidemic by 2015.

Thus, to ensure the effective response to the HIV epidemic in Nepal and so to fulfil the accountability

of the response, Nepal has already implemented three rounds national HIV/AIDS strategic plan. The

recent National HIV/AIDS Strategy 20112016 has laid a concrete road map in planning,

programming and reviewing of the national response to the epidemic.

National HIV/AIDS Strategy (20112016)VisionNepal will become a place where new HIV

infection are rare and when they do occur, every

person will have access to high quality, life

extending care without any form of

discrimination.

GoalTo achieve universal access to HIV prevention,

Box 4.7.1: Milestones in Response to HIV/AIDS1988 Launched the first National AIDS Prevention

and Control Program (short term)

19901992 First Medium Term Plan

19931997 Second Medium Term Plan

1993 National Policy on Blood safety1995 National Policy on HIV/AIDS

19972001 Strategic Plan for HIV/AIDS Prevention

2000 Situation Analysis of HIV/AIDSNepal

20022006 National HIV/AIDS Strategic Plan

20032007 National HIV/AIDS Operational Plan

20062011 National HIV/AIDS Strategic Plan

20082011 National HIV/AIDS Action Plan

2007 National HIV/AIDS and STD Control Board

established

2008 National HIV/AIDS Action Plan

2010 New National Policy on HIV/AIDS20112016 New National HIV/AIDS Strategic Plan


18/19

treatment, care and support.

Objectives

Reduce new HIV infections by 50 percent by 2016, compared to 2010;Reduce HIVrelated deaths by 25 percent by 2016 (compared with a 2010 baseline) throughuniversal access on treatment and care services; and

Reduce new HIV infections in children by 90 percent by 2016 (compared with a 2010 baseline)The National HIV/AIDS Strategy is a national guiding document and a road map for the next fiveyears for all sectors, institutions and partners involved in the response to HIV and AIDS in Nepal to

meet the national goal; to achieve universal access to HIV prevention, treatment, care and support

with two major programmatic objectives (i) reduce new HIV infections by 50 percent, and (ii) reduce

HIV related deaths by 25 percent, by 2016. The strategy delineates the central role of the health

sector and the essential roles the other sectors play, in response to the HIV epidemic.

The current national HIV/AIDS Strategy,

therefore, builds on two critical program

strategies: (i) HIV prevention, and (ii) treatment

care and support of infected and affected. To

ensure the achievements of program outcomes,crosscutting strategies are devised to supports (i)

creating enabling environment: health system

strengthening, legal reform and human rights and

community system strengthening (ii) strategic

information (HIV and STI surveillance, program

monitoring and evaluation and research).

Building on the achievements, lessons and experiences of the past five years, the strategy (2011

2016) will focus on the following key points:

Addressing the all dimensions of continuum of care from prevention to treatment care andsupport

Effective coverage of quality interventions based on the epidemic situation and geographicalprioritization

Health system and community system strengtheningIntegration of HIV services into public health system in a balanced way to meet the specificneeds of target populations

Strong accountability framework with robust HIV surveillance, program monitoring andevaluation to reflect the results into NHSPII and National Plan.

Strategy components1: Prevention

2: Treatment, Care & Support

3: Advocacy, Policy & Legal reform

4: Leadership & Management

5: Strategic Information6: Finance & Resource mobilization

expansion and scaling up of the programs for safe migration and mobility; STIs, VCT, PMTCT

services, prevention among health care delivery settings, workplace programs etc.

Six key programs areas and strategic outcomes have been identified within the strategy as follows:1.2.1 Preventionimproved knowledge and safe behavioral practices of all target groups (safer sex and injecting


19/19

practices),increased availability and access to appropriate and differentiated prevention services,increased acceptance of HIV/AIDS and enhance non-discriminatory practices affectingmarginalized and most at risk populations,Reduced risk and vulnerability to HIV infection of all target populations.

1.2.2 Treatment care and support

increased national capacity to provide quality diagnostic, treatment and care services,increased availability of appropriate and differentiated care and support services to infected,affected and vulnerable populations,increased involvement of private sectors, civil societies, communities and family for treatment,care and support to infected, affected and vulnerable groups,increased importance of the role of support groups of infected, affected and vulnerable peoplein treatment, care and support,established and monitored continuum of prevention to treatment, care and support,standardized clinical care, ART, Oise and PEP services both in the public and the privatesectors,Impact mitigation strategies and programs in place, adequately resourced and accessed equitably

by the infected, affected and vulnerable groups.1.2.3 Advocacy, policy and legal reformHIV/AIDS prioritized as national development agenda and included in 11th Five Year Plan asprogram under the social sector,rights of infected, affected and vulnerable groups insured through an effective legislativeframework,networks of PLHA and most at risk populations operational,

HIV/AIDS response decentralized and coordinated,Multi-sectoral response to HIV/AIDS strengthened and expanded.

1.2.4 Leadership and management

operationalized national strategy through the National Action Plan,active champions and leaders at the societal, institutional and individual levels for the

HIV/AIDS response,mainstreamed HIV/AIDS programs in all development sectors,

enhanced social inclusion, equitable access and gender equality to AIDS services,co-ordinated and decentralized response to HIV/AIDS.

1.2.5 Strategic information

trends and changes in HIV prevalence and HIV and STI related risk behaviours among differentrisk groups tracked over time and across regions in Nepal;

effectiveness of HIV prevention and care interventions and activities monitored and evaluated;all aspects of key programme service delivery areas effectively monitored and evaluated;programme coverage and service delivery assessed by target group;DoHS, Annual Report 2066/67 (2009/2010) (page 191)

resources inputs and outputs contributing to the programme monitored.

1.2.6 Finance and resource mobilisation100% of funding mobilized for the implementation of the multi-year National Action Plan fromthe Government, development partners, NGOs and private sector organizations,by 2009, government investment in AIDS activities be at least 5% of the total HIV/AIDSprogram budget, and by 2011, at least 10%,

appropriate multi-sectoral resource allocation under the relevant line ministries,an efficient and coordinated financial management system,timely and improved resource flow,improved accountability at all levels.

national health programs

Documents