Despite political turmoil and power struggle in the center, surprisingly Nepal has been progressive in reforming parts of its health sector. The country is on track for achieving the targets for the United Nations Millennium Development Goals – reduce under-five mortality by two-thirds and maternal mortality ratio by three-quarters between 1990 and 2015. While improved government policies have helped to materialize these goals, the community’s role should also be underscored. For them, these targets are much more than reducing the numbers and getting a “pass/fail” remark on the global report card – every mother and newborn saved, like for everyone else, is a story of joy and celebration, a memory that will live with their generations to come.
During the past two weeks, I have had a chance to learn about some of the researches that have helped save thousands of lives and the programs followed thereafter, which have been a basis for formulating national health policies. The policies that led to national programs have massively helped reducing neonatal, child and maternal mortality in Nepal. Meanwhile, it was also interesting to see how the ongoing researches are incorporating innovative and easy solutions that could further help save more mothers and newborns.
The following innovations and success stories listed below were highlighted in an event during the visit of Dr. Rajiv Shah, Administrator of the United States Agency for International Development (USAID). The first high-level US official to visit Nepal since 2002, Shah was in the country to award the Government of Nepal, Ministry of Health and Population, for its Chlorhexidine Program.
Chlorhexidine Cord Care Program
In 2011, Nepal’s Ministry of Health and Population became a global pioneer to scale up the use of Chlorhexidine for newborn cord care at national level through the Chlorhexidine Navi Care Program and other partners. For this significant march toward improved neonatal health care, the program has been awarded one of the Grand Prizes of USAID’s 2013 Science and Technology Pioneers Prize that commemorates the use of science, technology and innovation to solve development challenges.
A majority of Nepal’s population, especially in remote parts of the nation, still prefer traditional remedies for cord care to modern-day medicines. The latest Demographic and Health Survey estimates more than 41 percent of babies had materials such as mustard oil, turmeric, ash etc. used in their umbilical cord.
Such practices may contribute to Nepal’s neonatal mortality rate of 33 deaths per 1,000 live births. With about two-third of deliveries conducted at home, mostly in unhygienic conditions, newborns are vulnerable to neonatal infections, which is a leading cause of neonatal deaths in Nepal.
But Chlorhexidine, locally known as Navi Malam, is an antiseptic gel that reduces bacterial colonization on the skin and umbilical stump of newborns.
A pooled analysis of three randomized controlled trials of use of Chlorhexidine immediately after cord cutting done in Nepal, Bangladesh and Pakistan shows that the application of Chlorhexidine reduces neonatal mortality by 23 percent and reduces serious infections by 68 percent.
The intervention that has reached 41 of the 75 districts started as a pilot project in 2009 using the antiseptic manufactured by a Nepali company, Lomus Pharmaceuticals, along with technical support through USAID and Nepal Family Health Program/JSI. Female Community Health Volunteers, the backbone of Nepal’s public health system, are the main channel to counsel pregnant women and distribute Chlorhexidine tube during the eighth month of pregnancy.
When the program is scaled up and implemented nationally through the public health system, Lomus estimates Nepal would require about 800,000 tubes annually – one for each birth. Currently, the pharmaceutical company produces around 20,000 tubes per day, which cost Rs. 18 (approximately $0.18) apiece.
Since 2009 Lomus has delivered more than 775,000 tubes within Nepal. The company has also exported 240,000 tubes to countries like Nigeria, Madagascar and Liberia within the last two years.
One-cent test for pre-eclampsia/eclampsia
At a time when most public health facilities are lacking standardized testing tools for pre-eclampsia and eclampsia, Jhpiego is in a developing phase to innovate and improve the screening of the disease, which is the leading cause of maternal mortality in Nepal. Though it can be detected early during antenatal visits to a health facility, about 50 percent of women do not fulfil this routine.
This new technique to test pre-eclampsia and eclampsia involves a device (currently a dropper) to dispense a color-changing reagent on paper. Similar to a pregnancy test kit, a pregnant woman urinates on the paper and finds out the result instantaneously. While yellow signifies a negative result, green is a warning that they should visit the health facility.
In this developmental phase, Jhpiego, an affiliate of John Hopkins University in the US, is also training the Female Community Health Volunteers who take this testing to the would-be mothers.
The Maternal Mortality and Morbidity Study 2009 suggests that 21 percent of deaths are attributed to eclampsia.
In course of time, with results from the research that would meet the Gold Standard, Jhpiego plans to develop a standardized design for manufacturing, get a regulatory approval and conduct nationwide pilot studies.
The cost of this innovation would drastically bring down the testing cost. The current retail price for manufacturing and distribution is estimated between $4 to $5 per device for 500 tests; high quality dipsticks cost between 25 cents to 40 cents per test.
GIS Mapping System
A work-in-progress digital mapping of Nepal’s health system is said to be the most advanced in South Asia.
The highly interactive map will also provide scientific data on roads, locations of health services and workers in relationship with population and health service centers.
According to the Ministry of Health and Population, GIS has been incepted and is in the process of institutionalization in the health system. This adoption is also reinforced by e-health, Health GIS and need for integration of information systems.
The Health Facility Mapping Survey has been carried out in 57 districts with technical and financial support from World Health Organization and further processing for remaining 18 districts started in 2013 with the assistance of SAIPAL with support from USAID.
Once compiled the entire database can be linked and accessed according to the user requirement, without the need of studying data table or reports, making GIS the ultimate tool for decision makers in analyzing data by visual means. It would help in answering key questions related to the health sector that would further improve and enhance the country’s health system.
Regarded as Nepal’s “Health Atlas,” the project, once completed, will have the most cutting-edge, geo-enabled data on infrastructure, location and equipment of all health facilities in the region to improve data for decision-making.
Nepal Nutrition Intervention Project – Sarlahi (NNIPS)
For the past 25 years, NNIPS, which is being carried out by Johns Hopkins University (JHU) Bloomberg School of Public Health in collaboration with the Nepal Netra Jyoti Sangh, has been a leader in researching life-saving innovations.
The years of collaborative work, conducting large community trials in the Sarlahi district of Nepal, have contributed significantly to the establishment of programs responsible for reducing maternal, child, and neonatal deaths.
From the vitamin A revolution to umbilical cord cleansing with Chlorhexidine, NNIPS has produced noteworthy health discoveries that have become the basis for establishment of new national health policies and the launching of programs both nationally and globally.
In Nepal, during the 1990s, 2 to 8 percent of preschool-aged Nepali children experienced severe vitamin A deficiency, with a much larger percentage experiencing moderate and sub-clinical deficiencies and the concomitant health and mortality risks associated with them.
During NNIPS’ first large study conducted from 1989 through 1991, it was demonstrated that with periodic high-dose vitamin A supplementation a 30 percent reduction in child mortality in children between six months to five years of age can be achieved. Encouraged by this and similar results from large trials in India and Africa, the Government of Nepal initiated the Nepal National Vitamin A Program in 1993.
The vitamin A campaign now reaches nearly 1 billion children in over 50 countries around the world.
The results of NNIPS’ randomized controlled community trial of umbilical cord cleansing with Chlorhexidine on neonatal mortality and infection in Sarlahi have showed that if applied within 24 hours of birth, chlorhexidine can produce a 34 percent reduction in neonatal mortality.
This research result encouraged the government to implement the Nepal National Chlorhexidine Navi Care Program in 2011. This program, that has the potential to save thousands of lives in Nepal, has now been expanded to 41 districts, with all 75 districts to be eventually included. Many African and Asian countries have either already started or are interested in starting their own national Chlorhexidine cord care programs as well.
Female Community Health Volunteers
Dressed in their blue saree uniform patterned with concentric circles, a striking uniform that makes them stand out, Nepal’s cadre of 52,000 Female Community Health Volunteers have been an instrumental force in promoting safer motherhood and institutional deliveries, encouraging contraceptive use among women and men and administering various government-led health campaigns to effectively using a timer to diagnose respiratory illness in children.
The Government of Nepal started the program in 1988 with support from USAID, UNICEF, UNFPA and local non-governmental organizations. In its 25 years now, these women have been play a key role in helping in strengthen the country’s health system from a grassroots level on a voluntary basis. – what started as a community-based project is a public health sector’s national pride now.
During these years, the FCHVs have also played an integral role in scaling up innovations that have put Nepal in the global spotlight. They are at the forefront of promoting the use of Chlorhexidine to prevent umbilical cord infection in newborn, one of the major causes of neonatal deaths in Nepal.
They are also responsible for promoting community-based health interventions, which include distribution of Oral Rehydration Salt for diarrhoea, Vitamin A and pneumonia treatment, have helped to reduce under-fiver mortality by more than 50 percent in the last 15 years.
Along with the responsibilities, being an FCHV also comes with a reputation – they’re the trusted members who are well recognized in their communities, which motivates most of them to continue doing what they’re doing best.
(The following write-up is partially extracted from a special USAID publication for Dr. Rajiv Shah’s visit to Nepal. With inputs from Alok Thapa for GIS and NNIPS, editing by Jane Silcock, and design by Swapnil Acharya.)