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NEONATAL HEALTH CARE in NEPAL 1. BACKGROUND In the mid way of 2000 and 2015, the analysis of Millennium Development Goals (MDGs) in developing world shows encouraging progress signs particularly in child health, but very less or no notable achievements in neonatal health (WHO, 2009). The proportion of neonatal deaths – deaths within the first 28 days of life – is expected to increase due 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 about 37% of under-five (U-5) mortality occurs in the neonatal period, with most deaths within the first week i. e. early neonatal period. Over one million neonates die within their first 24hours of life due to lack of quality care, annually, worldwide (UNFPA, 2008). In Nepal, Neonatal Mortality Rate (NMR) is 32 per 1000 live births in 2004 (WHO, 2009). Fig 1 Continuum of care Source: Kerber et al. , 2007 The basic principle of developing strategies to address Neonatal Health Care (NHC) revolves round the ‘continuum of care’.

Throughout the lifecycle as shown in figure 1, including adolescence, pregnancy, childbirth and childhood, the care ought to be provided as a seamless continuum that spans the home, the community and health centre, locally and globally (Save the Children [StC], 2006). Hence, reducing child mortality is more dependent on tackling neonatal mortality or in other words, managing the NHC. 2. KEY CONCEPTS AND ISSUES In Nepal, most of the deliveries take place at home with delayed care-seeking behavior; the NMR remains high in rural areas, frequently associated with cessation of suckling and shortness of breath (Mesko et al. 2003). While the Department for International Development [DFID] (2009) report reveals that, the factors causing poor maternal outcomes and ultimately resulting high NMR are poor and delayed transportation arrangements, weak financial status, long distance to health centre, and even needing permission to seek care. As the survival of the newborns, older than a month is progressing quickly, there has been transformed concern in interventions assumed to improve 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 target to reduce NMR from 34 to 30 per 1000 live births by 2010 has been set in the new Three Years Interim Plan (TYIP) for health 2008-10 (TYIP 2008-10, 2008).

Pertaining to the revised target associated with neonatal mortality and to combat delays in seeking, reaching and receiving care, the Department of Health Services, Nepal (DoHS 2006/07, 2008) has postulated three major 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 every 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 can be reflected in broad spectrum, by analyzing the strengths and weaknesses of the National Health Policy and current heath services, in general. 4. 1. Strengths 4. 2. 1. Health as citizen’s right The Ministry of Health and Population (MoHP) aims to create a new healthy Nepali society, working in alignment with the prime objective 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 right of each and every Nepalese. . 2. 2. Decentralization of health policy Decentralization in health policy – a starting point for consultation – and its implementation is under process, initiated with the coordination between the MoHP and Ministry of Local Development (MoLD). The major objective of the decentralization in health policy is to improve cost efficiency and effectiveness of government action, and strengthen community approach (DFID, 2003). The respective Village Development Committee has been handed over the administrative and financial management tasks, initiatives taken from the lowest level, i. . Sub-health Posts (NHSP, 2009). 4. 2. 3. Public Private Partnership The private sector’s involvement to a considerable extent is noteworthy (TYIP, 2008) in the Public Private Partnership (PPP) which initiated since 1950s (MoHP, 2008). The PPP has created continuous and uniform coordination of interventions such as immunization and pneumonia treatment, significantly reducing children and neonatal mortality (UNDP, 2010). 4. 2. 4. Community based interventions Fig. 2 Neonatal mortality in past 15 years

Source: DoHS (2006) The development and implementation of community-wide protocols has significantly reduced the NMR in the past 15 years, as shown in figure 2 (DoHS, 2006); and aims to ensure access 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 significant 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 significant in improving the health of the newborn. 4. 2. Weaknesses 4. 3. 5. Weakening and unsafe care The weakly designed system, unable to ensure safety 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 broadening of specialized health care and cutting interest in the disease ontrol programmes, do not realize for the continuity of care. Due to poor and highly 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 people with the most means but with lesser need, while the neonatal health care in the rural areas remain almost 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 accessible 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 supply of equipment and drug, * political interference in management, * weak monitoring and supervision, and lack of physical infrastructure and its inadequate repair and maintenance (TYIP 2008-10, 2008). 4. EFFECTIVENESS The performance of a nation’s health system can be judged against WHO Criteria: health status of the population and inequality, responsiveness and inequality in responsiveness and fair financing (WHO 2000); and Managing Cost, Care and Health Framework. 5. 3. WHO Criteria According to the WHO Report (2000), the health level of Nepal is ranked at 142 with Disability Adjusted Life Expectancy (DALE) of total population at birth 49. years, as shown in table 1. Table 1 Health system attainment and performance in Nepal, ranked by eight measures, estimates for 1997 ATTAINMENT OF GOALS| Health expenditures in international dollars| PERFORMANCE| 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| Uncertainty Interval| Level| Distribution| | | | | | 142| 49. 5| 161| 0. 585| 0. 513-0. 63| 185| 166-167| 186| 160| 170| 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 amenities 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 Health

Going with the global approach, Nepal has also adopted decentralized health care system, attempting “to make providers both independent and more accountable 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 advanced health of the population (Kane and Turnbull, 2003). . 5. 9. Managing Cost The fairly existing systems operated by small number of agencies provide membership to the clients, cost borne by the clients or their employers on installment basis. The employees of government sector and labour organization are supported with healthcare cost borne by social support schemes (WHO, 2003). There has been significant decrease in financial resources in the health sector due to shoot-up of concerns in conflict resolution and internal security (NHSP, 2009). The maximum portion of health financing is from out-of-pocket payment, i. . 85. 20% (WHO 2009), and there has been increased competition among the (private healthcare) providers to deliver the responsive behavior to the care-seekers (patients). But the larger portion of the consumers’ right to have an option of choosing economic and most compatible supplier still remains virgin. The Second Long Term Health Plan (SLTHP) 1997-2017 has emphasized 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 has 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 Delivery

Intermittent 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 down the cost of training, monitoring and evaluation, and facilitate judicious use of the available resources, with greater 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, increasing the met need of emergency obstetric complications by 3% and of caesarean section by 4%, each year (Safe Motherhood 2010).

The Partnership for Maternal, Newborn, and Child Health (PMNCH) formed by merging three separate entities – newborn, maternal and child health partnership – has been established. This joint venture aims “[t]o 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 underweight (38. 6%) are the root causes of perinatal deaths (MoHP, 2007). * The nation wide campaign 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, disparity 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 poverty line with poverty gap ratio declining from 0. 12 to 0. 75, child malnutrition 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 catastrophic 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 modification 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.



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