Exploration and innovation in addressing maternal, infant and neonatal mortality.

The Government of Nepal has been remarkably progressive in introducing innovative community-based maternal newborn and child health interventions in an effort to address the major causes of maternal and child mortality in the country. This article describes the introduction of innovative interventions, including a review of the landmark research that precipitated the discussion and provided evidence of practical feasibility, the acceptance of the intervention concept and validity, the approval process and the introduction and results from the pilot interventions. These interventions, which include the use of misoprostol to prevent post partum haemorrhage during homebirths, Morang Innovative Neonatal Intervention, gentamicin in Uniject and for the management of neonatal sepsis and newborn vitamin A supplementation, are in various stages and demonstrate the responsiveness of the Government to new approaches that address the major causes of maternal and child mortality.

Impact evaluation of uterine prolapse surgery in Nepalese women.

BACKGROUND: The problem of uterine prolapse exists throughout Nepal and negatively affects women's health and quality of life (QOL). The Government of Nepal recognizes it as a priority problem. METHODS: This study was conducted in eight districts to examine the status and problems of women who have undergone prolapse surgery. Qualitative and quantitative methods were used to examine the issues of prolapse. Survey method was used to administer the questionnaire. RESULTS: Sixty-six percent women reported pelvic organ prolapse at an early age. The mean age of its occurrence was 28 years. In the hill/mountain districts, 52% women among the non-poor and 72% among the poor went to health camps for surgery indicating that the camps were fulfilling the demands of the poor. Majority (>75%) of them from remote districts went to health camps for surgery indicating the camps were more beneficial to women in remote areas. Counseling was weak in the health camps and the use of IEC materials was minimal. Majority had improved health status after surgery. The incidence of post-surgery problems were as follows: 10.1% in government hospitals, 11.1% in non-government hospitals and 15.1% in health camps. CONCLUSIONS: Despite improved performance of health camps, the program for prolapse management still seems weak due to lack of ownership of local health institutions and lack of proper coordination among the stakeholders/ partners. However, these camps need to be scaled up for the benefit of the unreached population.

State of maternal, newborn and child health programmes in Nepal: what may a continuum of care model mean for more effective and efficient service delivery?

The cost-effective interventions exist across the continuum of maternal to child survival at each level of the health system that can contribute to achieve the Millennium Development Goals 4 and 5. However, implementation inefficiency, low coverage and equity gaps along this continuum remain a serious challenge to Nepal's efforts to achieve these goals. This paper proposes a continuum of care model; discusses the readiness of policy and programs to provide high impact interventions across the continuum; identifies existing gaps in MNCHN programs; and recommends policy and program actions to improve coverage, equity, effectiveness and efficiency along the continuum of MNCHN service delivery in Nepal. The literature review includes systematic desk review, followed by discussions and deliberations amongst a group of professionals and MNCH experts in Nepal. Within the government health system in Nepal, a continuum of care approach is feasible, as policies and plans exist to ensure an integrated approach across the maternal to child care continuum. However, health programs largely remain vertically oriented. Achieving integration across the maternal to child continuum of care remains a challenge at each level of health system. An integrated system of program management for maternal, newborn and child health would be a feasible solution to enable an efficient and effective delivery of intervention packages. A collaborative and partnership approach to strengthen health systems, building managerial capacity, improving governance and engaging the private and civil sectors remains vital to achieve effective coverage and improve equity across the continuum of care.

Developing community-based intervention strategies and package to save newborns in Nepal.

In Nepal, the proportion of under 5 deaths that are neonatal (0-28 days) has been increasing in the last decade, due to faster declines in infant and child mortality than in neonatal mortality. This trend is likely due to a focus on maternal and child survival programs that did not adequately address newborn health needs. Policy and actions to save newborn lives resulted from increased attention to newborn deaths in 2001, culminating in the endorsement of the National Neonatal Health Strategy in 2004, a milestone that established newborn health and survival as a national priority. Operationalization of the National Neonatal Health Strategy took place in 2007 with the development of the Community-Based Newborn Care Package (CB-NCP). This paper describes how national stakeholders used global, regional and in-country research and policies to develop the CB-NCP, thus outlining key ingredients to make newborn health programming a reality in Nepal. A technical working group was constituted to review existing evidence on interventions to improve newborn survival, develop a tool to prioritize neonatal interventions, and conduct program learning visits to identify key components appropriate to the Nepal context that should be included in the Community Based Integrated Newborn Care Package. The group identified interventions based on the evidence of impact on newborn survival, potential mechanisms within the existing health system to deliver the interventions, and linkages with existing programs and different tiers of the health system. Not only was Nepal one of the first countries in south-east Asia where government adopted a national strategy to reduce neonatal deaths, but it was also one of the first to endorse a package of neonatal interventions for pilot testing and scaling up through existing community-based health systems that provide basic health services throughout the country. CB-NCP was designed to be gradually scaled up throughout the country by integration with Safe Motherhood and Child survival programs that are currently operating at scale. Under Ministry of health and Population leadership, a network of academia, professional bodies and partners developed a common vision for improving newborn health and survival, and launched district-level pilot programs to demonstrate and learn how newborn health interventions could be effectively and efficiently delivered and scaled up in Nepal.

Fitting Community Based Newborn Care Package into the health systems of Nepal.

Community-based strategies for delivering effective newborn interventions are an essential step to avert newborn death, in settings where the health facilities are unable to effectively deliver the interventions and reach their population. Effective implementation of community-based interventions as a large scale program and within the existing health system depends on the appropriate design and planning, monitoring and support systems. This article provides an overview of implementation design of Community-Based Newborn Care Package (CB-NCP) program, its setup within the health system, and early results of the implementation from one of the pilot districts. The evaluation of CB-NCP in one of the pilot districts shows significant improvement in antenatal, intrapartum and post natal care. The implementation design of the CB-NCP has six different health system management functions: i) district planning and orientation, ii) training/human resource development, iii) monitoring and evaluation, iv) logistics and supply chain management, v) communication strategy, and vi) pay for performance. The CB-NCP program embraced the existing system of monitoring with some additional components for the pilot phase to test implementation feasibility, and aligns with existing safe motherhood and child health programs. Though CB-NCP interventions are proven independently in different local and global contexts, they are piloted in 10 districts as a "package" within the national health system settings of Nepal.

Biodegradation of diesel fuel-contaminated wastewater using a three-phase fluidized bed reactor.

Aerobic biodegradation of diesel fuel (DF)-contaminated wastewater is carried out in a three-phase fluidized bed reactor under unsteady and steady state conditions. The solid phase lava rock particles, which act as the support for the biomass, are fluidized by the upward flows of influent wastewater, and air. The results show that the reactor under unsteady state operation achieved 100% DF removal from synthetic wastewater loaded with 0.43-1.03 kg/m3 day of DF. An average of over 97% of the influent chemical oxygen demand (COD) was also removed from the wastewater with COD concentrations in the range, 547-4025 mg/L. For influent COD concentrations up to 1345 mg/L, the removal is greater than 90%. Under steady state operation, the reactor was able to remove 100% of the DF, and an average of 96% of the COD from the wastewater. It had approximately 200 mg/L of DF, and 1237 mg/L of COD at a low hydraulic residence time of 4 h. In general, the results demonstrate that the reactor is very efficient, and requires short residence times to remove both DF and COD from heavily contaminated wastewater.

Anaerobic biodegradation of diesel fuel-contaminated wastewater in a fluidized bed reactor.

Diesel fuel spills have a major impact on the quality of groundwater. In this work, the performance of an Anaerobic Fluidized Bed Reactor (AFBR) treating synthetic wastewater is experimentally evaluated. The wastewater comprises tap water containing 100, 200 and 300 mg/L of diesel fuel and nutrients. Granular, inert, activated carbon particles are employed to provide support for biomass inside the reactor where diesel fuel is the sole source of carbon for anaerobic microorganisms. For different rates of organic loading, the AFBR performance is evaluated in terms of the removal of diesel fuel as well as chemical oxygen demand (COD) from wastewater. For the aforementioned diesel fuel concentrations and a wastewater flow rate of 1,200 L/day, the COD removal ranges between 61.9 and 84.1%. The concentration of diesel fuel in the effluent is less than 50 mg/L, and meets the Level II groundwater standards of the MUST guidelines of Alberta.