Challenges and Strategies to improve Children’s Health in Low-Income Countries

Healthy children become healthy adults: people who create better lives for themselves, their communities, and their countries.

Nepal is a low-income country with a gross domestic product (GDP) per capita (purchasing power parity, PPP, Int $) of US$ 1276 in 2012. The poverty rate has declined from 42% to 25% in the past 15 years, partly owing to the inflow of remittances. Life expectancy has increased steadily in the past 20 to 67 years for males and 69 years for females.
Nepal has made significant progress in improving the health of women and children and is on track in 2013 to achieve MillenniumDevelopment Goals (MDGs) 4 (to reduce child mortality) and 5A (to reduce maternal mortality). Nepal is also on track to achieve MDG 4 having successfully improved coverage of effective interventions to prevent or treat the most important causes of child mortality through a variety of community-based and national campaign approaches. These include high coverage of semiannual vitamin A supplementation and deworming; community-based integrated management of childhood illness (CB-IMCI); high rates of full child immunization; and moderate coverage of exclusive breastfeeding of children under 6 months, among others. However, the newborn mortality rate (NMR) is a serious concern, having remained stagnant at around 33 deaths per 1000 live births (LB), accounting for 61% of child mortality in 2011. This is one of Nepal’s challenges going forward.

Women’s educational status has been inversely linked with maternal and neonatal mortality in Nepal. In recent years, girls’ enrollment in schools has increased, driven partly by targeted free education policies. Access to healthcare has increased through a rapid expansion of the road network, vehicle movement, communication through mobile phones, growing access to clean drinking water and sanitation, especially toilets in rural areas, and construction of health facilities. Recognizing the important contributing factor of undernutrition to child mortality, Nepal has made addressing undernutrition a national priority and has adopted a multi sectoral approach to the challenge.

Nepal has made modest progress in strengthening voice and accountability, but has achieved limited change in terms of rule of law and control of corruption from 2002 to 2011. Social auditing is used to devolve authority and improve accountability to communities served, especially the poor and marginalized. However, governance and leadership within the health system remain a challenge.

In the past two decades, Nepal has made significant progress in improving the health of children and women. The country has been declared polio-free, as no new polio case has been discovered since 2010.
Nepal received the Millennium Development Goal (MDG) award for commitment and progress towards improving maternal health. It is also one of the seven countries in the world currently on track to reduce child mortality, as under-five mortality rate has been reduced by 67 % between 1996 and 2016.

However, there are numerous challenges that the country still needs to deal with.
• The neonatal mortality rate (rate of death during first 28 days after birth) remains as high as 21 deaths per 1000 live birth, whereas under-five mortality is 39 deaths per 1000 live births.
• The neonatal mortality rate is twice as high among the poorest wealth quintile compared with the richest one, and higher among younger mothers.

Improving the health of the world’s children is the core objective. Nepal is also on track to achieve MDG 4, having attained a rate of 54 under 5 child deaths per 1000 LB from 162 in 1991 according to national data. Global estimates indicate that the rate has reduced by 70% from142 to 42 per 1000 live births between1991 and 2013. Nepal has successfully improved coverage of effective interventions to prevent or treat the most important causes of child mortality through a variety of community-based and national campaigns/approaches. These include high coverage of semiannual vitamin A supplementation and deworming; CB-IMCI; high rates of full child immunization; and moderate coverage of exclusive breastfeeding of children under 6 months. However, in the past few years especially between 2006 and 2011, the NMR has remained stagnant at around 33 deaths per 1000 LB. This compares to a rate of 32 in India (2011) and 36 in Pakistan (2011). The NMR is a serious concern in Nepal, accounting for 72% of the infant mortality rate (IMR) and 61% of the under 5 mortality rate (U5MR) in 2011 and is one of its challenges going forward.

Globally, more than 40% of all under-five child deaths occur during the neonatal period. Neonatal mortality in Nepal is 33 per 1,000 live births, eight times that of developed regions.

The literature suggests that the following challenges and their significant improvements/ discussions:
• Antenatal care: Neonatal and maternal mortality are closely linked, and the risk of dying from neonatal conditions can be reduced with quality care provided during pregnancy and childbirth. There is limited awareness of available and required health services. For example, two doses of tetanus toxoid vaccine given to women during pregnancy to prevent deaths from neonatal tetanus is received only by 69.7% mothers, even though provided free of cost at government health centers. For better child survival, preparation for delivery should be made before hand. The challenge of delivering messages to promote maternal and newborn health in the terai region of Nepal was addressed through training Female Community Health Volunteers (FCHVs), who are provided with a pictorial booklet to educate women about frequency and timing of antenatal visits, requirement of tetanus toxoid vaccination, iron tablets, improved diet, avoidance of smoking and alcohol, rest and reduced workload; and help in the recognition of, and appropriate responses to, maternal and newborn danger signs. Arranging for a skilled birth attendant, choice of facility, saving for care in case of emergency and transportation are also important aspect of birth preparedness.
• Delivery practices: Pregnancy is regarded as a fragile, vulnerable state, yet childbirth is considered a natural event with social and religious ramifications, not a medical event. In Nepal, 63% of deliveries take place at home, with 7.5% occurring in the backyard or cow shed, increasing the risk of infection and sepsis. Only in the event of complications are newborns taken to health centers causing a delay in obtaining critical care. In Nepal, only 36% deliveries are attended by a skilled birth attendant, including doctors, nurses, or midwives. The rest have deliveries conducted by those who cannot provide basic resuscitation in asphyxia or manage newborn complications, leading to death, otherwise preventable.
• Limited health infrastructure: Most health posts lack calibrated infant weighing scale and records of low birth weight babies. In most hospitals in villages, there are no incubators or radiant warmers, required especially for preterm and LBW (low-birth weight) babies. Even the government hospitals in urban areas of Nepal can be poorly equipped, discouraging families from using such services. However, though preventive and good curative intervention should be the priority, emergency and critical care facilities should also be developed proportionately. Neonatal mortality could be reduced theoretically by adding Neonatal Intensive Care Units (NICU) at a few key hospitals.
• Transport and communication: Telecommunication problems also exist in many rural areas where there is no telephone service. Mobile phones are often with the head of the family as married women live in extended families, and if in the event of complications, the head of the household is unavailable no one can be called for help. The provision of ambulances by the healthcare sector in Nepal can ensure high-risk deliveries or newborns with complications to be referred to well-equipped facilities in time.
• Affordability: In Nepal, most cannot afford the direct costs needed to pay for the services, investigations, drugs, procedures and transport and indirect costs in the form of the loss of the women’s household duties, reported as lying between 1-5% of annual household expenditures. Medicines should be provided free of cost during postnatal health checks and their subsidization should be ensured as user fees would deter parents from seeking care. This is the biggest challenge as progress is least made in fragile states, where Nepal is a country in transition to democracy post-conflict.
• Political instability: Political conflict impacts negatively on the health of population, however, in Nepal, progress was made as access to health services increased. Thus in spite of the violent conflict, Nepal made progress in 16 out of 19 health indicators over the period 1996-2006 (among them the child and maternal health indicators). Lessons were adopted from the conflict to include marginalized groups (Dalits and women) to increase coverage of the health programs in more remote and underserved areas, emergency funds and community drugs schemes. It was during the conflict that the government implemented the community-based newborn care package.
• Health promotion is one of the most cost effective health interventions. It is important to increase awareness among the general public as well as among primary care health workers that deliveries are best conducted by skilled health personnel in a hygienic environment. Health promotion should focus on raising awareness among the general public regarding potentially harmful cultural practices and the danger signs during pregnancy, delivery, and child care. Evidence shows that informing women about the benefits of antenatal and postnatal care, danger signs/symptoms during pregnancy and in neonates, and advice to seek emergency care when needed, is essential.

• Establish intensive care units for newborns and relevant referral systems to increase access to quality services for mothers and newborns.
• Strengthen early detection of developmental delays, impairments, and disabilities among high-risk newborn babies.
• Promote positive care seeking behavior to address practices that harm the care of mothers and newborns.
• Sustain high-level immunization coverage by strengthening the immunization supply chain system.
• Strengthen capacity of female community health volunteers (FCHV) and health workers to improve access to gender and adolescent-sensitive health services.
• Promote healthy behavior by adolescents, using direct outreach, mass, and social media and e-health platforms.
• Develop a strategy to prevent pneumonia through multi-sectoral collaboration to reduce indoor and outdoor pollution and to improve care for pneumonia through improved diagnostic aids and treatment methods.
• Address adolescent health issues, including teenage pregnancy, mental health through the implementation of the National Adolescent Health and Development Strategy.



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