Cookies

We use cookies on our site to analyze traffic, enhance your experience, and provide you with tailored content. For more information, visit our privacy policy. By clicking “accept" or continuing to browse this website without disabling cookies, you consent to the use of cookies.

Detailed findings

Diarrhea, pneumonia, and malaria

15% of the reduction in under-five mortality between 2000 and 2017

Per IHME estimates

 

Quantitative modeling results 

DECOMPOSITION METHOD

1% of the reduction in under-five mortality between 2000 and 2017 attributed to oral antibiotics, oral rehydration salts (ORS), zinc treatment, and artemisinin-based combination therapies (ACTs).24

LIVES SAVED TOOL

35,000 lives saved and 22% of total lives saved from 2000 to 2016 attributed to oral antibiotics, ORS, zinc treatment, and ACTs (the majority attributed to antibiotics for pneumonia).25

 

Synthesis of research evidence

ACCEPTABILITY

 A 2017 assessment of IMCI programs in Nepal by WHO found that facilities have far fewer cases than expected for their catchment population, mostly because parents prefer to take their children to private clinics.1

FEASIBILITY

 IMCI was implemented in all 75 districts by 2009.

FIDELITY

 A 2017 assessment of the IMCI program reported that 30% of facilities experienced stockouts in the previous 3 months.1

 The same assessment found that only 65% of facility health workers had been trained in IMCI.1

EFFECTIVENESS/REACH

 Care seeking for children under 5 with diarrhea increased from 14% in 1996 to 47% in 2014; for pneumonia it increased from 18% in 1996 to 50% in 2014; for fever it increased from 15% in 1996 to 46% in 2014.

Synthesis of research evidence

ACCEPTABILITY

  “The most important thing behind FCHVs are that they are selected by the local community … They are regularly in touch and are the bridge between the health system and the community.” (KI 3) See issues in Fidelity section

FEASIBILITY

 Implementation plan able to be followed including training and supervision and reduced costs by using existing female community health volunteers (FCHVs), scaled up over 10 years nationally.

FIDELITY

  According to the 2015 report, although FCHVs fulfilled their role of promoting health behaviors, they performed poorly in service delivery; problems with frequent stockouts; poor data quality; and poor referral mechanisms.2 These findings were supported by a qualitative study in one area citing lack of community trust and satisfaction in the quality of care as challenging access and uptake.

  Multiple key informants expressed concerns about the quality of the CB-IMCI program, as FCHVs are given an increasing number of responsibilities.

  A 2017 assessment of CB-IMCI programs reported that 30% of facilities experienced stockouts of essential IMCI medications in previous 3 months.1 92% of FCHVs offered community treatment for diarrhea, but only 42% for ARI.1

EFFECTIVENESS / REACH

Full effectiveness cannot be determined because no impact evaluation has been completed.

  In 2009–2010, over 50% of children under 5 received treatment for pneumonia or diarrhea from FCHVs.3

  CB-IMCI expanded to all 75 districts across Nepal by 2009.

Synthesis of research evidence

FEASIBILITY

 In 2006, diarrhea was treated with ORT in 88% of cases seen by FCHVs.

FIDELITY

 In the 2016 Demographic and Health Survey (DHS), caregivers reported that only 37% of children with diarrhea were treated with ORT packets, although Health Management Information System (HMIS) data from the same year reported that 92% of children with diarrhea were treated with ORT and zinc.4 HMIS represents children coming to care, although information on data quality was not identified.

EFFECTIVENESS / REACH

 From 2000 to 2009, ORT as a component of CB-IMCI expanded from 5 districts to all 75 districts in the country.

 In 2006, districts with community-based treatment had higher rates of diarrhea (possibly due to increased rates of diagnosis) but significantly lower episodes of diarrhea with dehydration as compared with those districts without the intervention.5 As the number of districts with the intervention increased from 2004 to 2007, rates of diarrhea with dehydration or severe dehydration among children with diarrhea decreased.5

Synthesis of research evidence

ACCEPTABILITY

 Parents who heard messages about diarrhea treatment were over 4 times more likely to treat their child’s diarrhea with oral rehydration salts (ORS) and zinc.6

 Only 39% of those parents reported treating their children with zinc, and only 15% of children overall were treated with zinc after diarrhea.6

FEASIBILITY

 The zinc program expanded to all 75 districts nationwide as the IMCI program expanded.

 10-day zinc treatment cost US$0.19-0.52 during initial rollout in private facilities and was free at public facilities.7,8

 By 2008, locally manufactured zinc tablets were available in all 30 districts where Point-of-Use Water Disinfection and Zinc Treatment Project (POUZN) was active.9

FIDELITY

  In 2016, only 30% of children receiving zinc treatment for diarrhea had a full 10-day course.10

  A mystery client study at pharmacies in Kathmandu in 2008 showed only 31% of chemists recommended zinc treatment for diarrhea, and 82% still recommended antidiarrheals.9

EFFECTIVENESS / REACH

 Reported zinc coverage remained low at 18% in the 2016 DHS and few children completed the full course. Different results from HMIS data found that more than 90% of facility-treated children with diarrhea received zinc.

Synthesis of research evidence

ACCEPTABILITY

  Children under 5 in high-risk areas sleeping under long-lasting insecticide-treated nets (ITNs) increased from 48% in 2006 to 92% in 2009.

  Changing priority to ITNs and stopping indoor residual spraying (IRS) when coverage goals were met.

FEASIBILITY

  From 2006 to 2010, 1,209,322 ITNs were distributed in Nepal.11

  ITN coverage and use increased in targeted districts.

  IRS in targeted areas and ability to expand based on data.

FIDELITY

  High-risk areas were targeted; IRS was replaced by ITNs when coverage reached threshold.

EFFECTIVENESS / REACH

  National incidence of malaria increased from 2004 to 2008, but declined in 2009 onward associated with prevention and treatment initiatives, although rates began to increase again.12,13

  2015 estimates indicate approximately 3 new cases of malaria per year per 1,000 population at risk (well below the average for South Asia), from the peak of approximately 42,000 in 1985, and no recorded deaths from malaria since 2011. Cases have been increasing recently (indigenous and imported cases).

  In high-risk districts, the percentage of children sleeping under an ITN the previous night rose from 48% in 2006 to 92% in 2009.12 Overall coverage of nets is 95% in high-risk areas.

Vaccine preventable diseases – measles, lower respiratory infections (LRIs), and meningitis

37% of the reduction in under-five mortality between 2000 and 2017

Per IHME estimates

 

Quantitative modeling results 

DECOMPOSITION METHOD

10% of the reduction in under-five mortality between 2000 and 2017 attributed to Measles, PCV, and Hib vaccination.24

3% of the reduction in under-five mortality between 2000 and 2017 attributed to vitamin A and zinc deficiency.24

LIVES SAVED TOOL

Measles, PCV, and Hib vaccination: 21,000 lives saved from 2000 to 2016.25

Vitamin A supplements: 18,000 lives saved and 12% of total lives saved from 2000 to 2016 attributed to vitamin A supplementation and vitamin A treatment for measles.25

 

Synthesis of research evidence

ACCEPTABILITY

  High levels of acceptance in the community, according to Ministry of Health (MOH) officials and implementing partners.

FEASIBILITY

  Delivery of vaccines was achieved across the country, although some disparities remain.

EFFECTIVENESS / REACH

  Increases in coverage for vaccination in all geographic districts and both urban and rural areas.

Synthesis of research evidence

FEASIBILITY

 98% of FCHVs participated in the National Vitamin A Program with 90% of both FCHV service users and non-users receiving vitamin A from FCHVs.

EFFECTIVENESS / REACH

 The average coverage has been consistently high at 85% or higher for the past 15 years.10,14,15,16

 The program scaled up to all 75 districts.

 A study conducted in 2005 showed that vitamin A supplementation reduced the odds of dying between ages 12 and 59 months by slightly more than half.17

 The Nepal Micronutrient Status Survey and DHS recorded a drop in under-5 anemia from 78% to 48% in 2006 and 46% in 2011.

HIV

<1% of the reduction in under-five mortality between 2000 and 2017

Per IHME estimates

 

Quantitative modeling results 

DECOMPOSITION METHOD

<1% of the reduction in under-five mortality between 2000 and 2017 attributed to PMTCT/ART.24

LIVES SAVED TOOL

350 lives saved and <1% of total lives saved from 2000 to 2016 attributed to PMTCT/ART.25

 

Synthesis of Research Evidence

FEASIBILITY

 This service reached 70% of the districts and close to 50% of the health facilities by the end of 2016.18 (See also Reach).

FIDELITY

 While HIV counseling and testing for pregnant women has remained low, representing poor fidelity, the provision of prophylaxis to mothers increased to 35% in 2015 and jumped to 67%, with a lag in prophylaxis of exposed infants from 8% in 2010 to 26% in 2015.

EFFECTIVENESS/REACH

 Geographic reach expanded but actual coverage remained low, although it is increasing. Antiretroviral (ARV) therapy for HIV-positive women increased from 21% in 2013 to 33% in 2014, infant prophylaxis from 14% in 2012 to 26% in 2014, and early infant diagnosis from 3% in 2012 to 6% in 2014.19

 Increased decentralized coverage and access to PMTCT at district level in collaboration with private sectors, communities, and NGOs.19

 HIV screening and counseling and ARV medicines available in all districts of Nepal

 Maternal-to-child transmission rate declined slightly from 40% in 2012 to 36% in 2014.19

Nutritional deficiencies

4% of the reduction in under-five mortality between 2000 and 2017

Per IHME estimates

 

Quantitative modeling results 

DECOMPOSITION METHOD

15% of the reduction in under-five mortality between 2000 and 2017 attributed to changes in child growth failure and suboptimal breastfeeding.24

LIVES SAVED TOOL

13,000 lives saved and 8% of total lives saved from 2000 to 2016 attributed to nutrition interventions.25

 

Synthesis of Research Evidence

FEASIBILITY

 Community outreach is widespread and integrated management of acute malnutrition (IMAM) services are delivered through 165 outpatient therapeutic sites to SAM patients without medical complications and 13 stabilization centers (for SAM children with medical complications)

EFFECTIVENESS/REACH

 In 2014–2015, 11 IMAM districts admitted 4,680 SAM children to outpatient therapeutic programs and discharged 5,483 children.11

 In 2016–2017 15,633 SAM children were admitted to outpatient therapeutic program in 21 districts.

 National scale-up was still underway in 2016.

 15,633 SAM children in 2016–2017 were admitted in outpatient therapeutic program in 21 districts. Of these, 13,378 were discharged, and 10,651 (80%) had a complete recovery. Among all discharged SAM cases, less than 1% died and 10% were defaulters, which are within the Sphere (organization working on nutrition during disaster situations) standards of effectiveness of IMAM Program.11 Reduction in wasting (and stunting) was also seen.

Neonatal disorders

29% of the reduction in under-five mortality between 2000 and 2017

Per IHME estimates

 

Quantitative modeling results 

DECOMPOSITION METHOD

4% of the reduction in under-five mortality between 2000 and 2017 attributed to reductions in low birth weight.24

3% of the reduction in under-five mortality between 2000 and 2017 attributed to skilled birth attendance.24

LIVES SAVED TOOL

56,000 lives saved and 35% of total lives saved from 2000 to 2016 attributed to neonatal and antenatal interventions.25

 

Synthesis of Research Evidence

FEASIBILITY

 In 2006, only 29% of eligible women delivering in facilities received cash transfers.20

 In 2013, 90% of eligible women received transportation cash transfers, but only 43% received free delivery services.21

 Challenges with fund transfers and accountability.

 EmONC was available in all 75 districts nationwide and increased accessibility to cesarean sections.

 Concerns about quality overall and CEmONC signal functions.

EFFECTIVENESS/REACH

 Expanded to all 75 districts nationwide by 2009.

 Facility-based delivery increased to 57% by 2016 and (+) maternal postnatal care increased, but (-) postnatal care for infants remained at less than 5% even among the wealthiest quintile.22 Neonatal mortality decreased by 3%, after introduction of the free delivery services, and reduced further to 7% among lower-caste and indigenous ethnic groups.23

Other factors

 

Quantitative modeling results 

DECOMPOSITION METHOD

6% of overall reduction in under-five mortality between 2000 and 2017 is attributed to improvements in water, sanitation, hygiene, and air quality. Beyond the reductions attributed to interventions and aforementioned risk factors, an additional 27% of the reduction in under-5 mortality is attributed to risk factors from other communicable diseases, other non-communicable diseases, and other injuries.24

LIVES SAVED TOOL

14,000 lives saved and 9% of total lives saved from 2000 to 2016 attributed to water, sanitation, and hygiene interventions.25

The Lives Saved Model estimates a total of 160,000 lives saved and a reduction in under-5 mortality rate of 33%. The modeled results capture 58% of the observed decline in mortality as estimated by IGME. The additional estimated decline (per IGME estimates) could be attributed to other factors that are not measurable or that fall outside of direct health system interventions (e.g., women’s empowerment and economic development).25

 

Contextual factors including conomic growth, improvements in gender equality and women's empowerment, education, and improvements in sanitation

The primary research findings suggest additional contextual factors and preconditions for success that contributed to under-5 mortality reductions in Nepal, which were outside of the health system interventions. These include economic growth, improvements in gender equality and women’s empowerment, education, and improvements in sanitation and infrastructure.

  1. 1
    Nepal Development Research Institute. Assessment of Community Based Integrated Management of Neonatal and Childhood Illness Program. Kathmandu: Nepal Development Research Institute; 2017. https://www.researchgate.net/profile/Pranil_Pradhan/publication/322063886_Assessment_of_Community_Based_Integrated_Management_of_Neonatal_and_Childhood_Illness_Program/links/5a41ddbc0f7e9ba868a19f97/Assessment-of-Community-Based-Integrated-Management-of-Neonatal-and-Childhood-Illness-Program.pdf. Accessed April 24, 2019.
  2. 2
    Ministry of Health and Population (MOHP), Government of Nepal. Annual Report: Department of Health Services 2071/72 (2014/2015). Kathmandu, Nepal: MOHP; 2016. http://dohs.gov.np/wp-content/uploads/2016/06/Annual_Report_FY_2071_72.pdf. Accessed September 6, 2018.
  3. 3
    Houston R, Acharya B, Poudel D, et al. Early initiation of communitybased programmes in Nepal: A historic reflection. J Nepal Health Res Counc. 2012;10(2):82-87. https://pdfs.semanticscholar.org/e8d0/d3bb8f71e7a8716ecd094f78ac45dddee40c.pdf. Accessed July 9, 2018.
  4. 4
    Ministry of Health and Population (MOHP), Government of Nepal. Annual Report: Department of Health Services 2073/74 (2016/17). Kathmandu, Nepal: MOHP; 2018. https://dohs.gov.np/wp-content/uploads/2018/04/Annual_Report_2073-74.pdf. Accessed April 22, 2019.
  5. 5
    Ghimire M, Pradhan YV, Maskey MK. Community-based interventions for diarrhoeal diseases and acute respiratory infections in Nepal. Bull World Health Organ. 2010;88(3):216-221. https://doi.org/10.2471/BLT.09.065649. Accessed April 24, 2019.
  6. 6
    Wang W, MacDonald VM, Paudel M, Banke KK. National scale-up of zinc promotion in Nepal: results from a post-project populationbased survey. J Health Popul Nutr. 2011;29(3):207-217. https://doi.org/10.3329/jhpn.v29i3.7868.
  7. 7
    Mosites E, Hackleman R, Weum KLM, et al. Nepal Zinc Case Study. Seattle, WA: Global Health Start Program, University of Washington; 2012. https://pdfs.semanticscholar.org/76ab/355a718a054e0c845fbef42d0f43954a347e.pdf. Accessed June 29, 2018.
  8. 8
    Mitchell S. Getting to know you: building a coordinated publicprivate sector strategy for increasing use of zinc in Nepal. [PowerPoint]. Point-of-Use Water Disinfection and Zinc Treatment (POUZN) Project, Abt Associates; 2009. https://www.shopsplusproject.org/sites/default/files/resources/5329_file_Mitchell_Partnerships_FINAL_2.pdf. Accessed June 29, 2018.
  9. 9
    MacDonald V, Mitchell S. Introducing Zinc Through the Private Sector in Nepal for the Treatment of Childhood Diarrhea: Results and Lessons Learned. Bethesda, MD: Point-of-Use Water Disinfection and Zinc Treatment (POUZN) Project, Abt Associates; 2009. https://www.shopsplusproject.org/sites/default/files/resources/5280_file_Nepal_Brief_FINAL.pdf. Accessed June 28, 2018.
  10. 10
    Ministry of Health, Nepal (MOH); New ERA; ICF. Nepal Demographic and Health Survey 2016. Kathmandu, Nepal: MOH; 2017. https://www.dhsprogram.com/pubs/pdf/fr336/fr336.pdf. Accessed April 25, 2019.
  11. 11
    Ministry of Health and Population (MOHP), Government of Nepal. Nepal Malaria Strategic Plan 2011-2016. Kathmandu, Nepal: MOHP; 2011.
  12. 12
    Dhimal M, Ahrens B, Kuch U. Malaria control in Nepal 1963–2012: challenges on the path towards elimination. Malaria Journal. 2014;13:241. https://doi.org/10.1186/1475-2875-13-241. Accessed April 24, 2019.
  13. 13
    Kakchapati S, Ardkaew J. Modeling of malaria incidence in Nepal. J Res Health Sci. 2011;1(1):7-13. https://www.ncbi.nlm.nih.gov/pubmed/22911941. Accessed April 24, 2019.
  14. 14
    Ministry of Health (MOH) Nepal; New ERA; ORC Macro. Nepal Demographic and Health Survey 2001. Calverton, MD: MOH; 2002. https://dhsprogram.com/pubs/pdf/fr132/fr132.pdf. Accessed April 25, 2019.
  15. 15
    Ministry of Health (MOH) Nepal; New ERA; and Macro International. Nepal Demographic and Health Survey 2006. Kathmandu, Nepal: MOH; 2007. https://dhsprogram.com/publications/publication-fr191-dhs-final-reports.cfm. Accessed April 24, 2019.
  16. 16
    Ministry of Health (MOH) Nepal; New ERA; and ICF International. Nepal Demographic and Health Survey 2011. Kathmandu, Nepal: MOH, New ERA, and ICF International; 2012. https://dhsprogram.com/pubs/pdf/FR257/FR257%5B13April2012%5D.pdf. Accessed April 24, 2019.
  17. 17
    Thapa S, Choe MK, Retherford RD. Effects of vitamin A supplementation on child mortality: evidence from Nepal’s 2001 Demographic and Health Survey. Trop Med Int Heal. 2005;10(8):782789. https://doi.org/10.1111/j.1365-3156.2005.01448.x. Accessed April 24, 2019.
  18. 18
    National Centre for AIDS and STD Control (NCASC), Ministry of Health and Population, Government of Nepal. Factsheet 5: Prevention of Mother to Child Transmission (PMTCT) in Nepal, as of Asar 2074 (July 2017). Kathmandu, Nepal: NCASC; 2017. http://www.aidsdatahub.org/sites/default/files/publication/NCASC_Factsheet_5_PMTCT_2017.pdf. Accessed April 24, 2019.
  19. 19
    National Centre for AIDS and STD Control (NCASC), Ministry of Health and Population, Government of Nepal. Country Progress Report - Nepal. Kathmandu, Nepal: NCASC; 2015. http://www.unaids.org/sites/default/files/country/documents/NPL_narrative_report_2015.pdf. Accessed April 24, 2019.
  20. 20
    Powell-Jackson T, Morrison J, Tiwari S, Neupane BD, Costello AM. The experiences of districts in implementing a national incentive programme to promote safe delivery in Nepal. BMC Heal Serv Res. 2009;9(9):97. https://doi.org/10.1186/1472-6963-9-97. Accessed April 24, 2019.
  21. 21
    Upreti A, Baral S, Lamichhane P, et al. Rapid Assessment of the Demand Side Financing Schemes: Aama and 4ANC Programmes (The Seventh Rapid Assessment). Kathmandu, Nepal: Nepal Health Sector Support Programme, Health Research and Social Development Forum, Ministry of Health and Population; 2013. http://eskay.org/wp-content/uploads/2016/08/DSF-Rapid-Assessment-7-Final.pdf. Accessed July 29, 2018.
  22. 22
    Central Bureau of Statistics Nepal, United Nations Children’s Fund (UNICEF). Nepal - Multiple Indicator Cluster Survey 2014. Kathmandu, Nepal: Central Bureau of Statistics, UNICEF; 2015. https://mics-surveys-prod.s3.amazonaws.com/MICS5/South%20Asia/Nepal/2014/Final/Nepal%202014%20MICS_English.pdf. Accessed April 27, 2019.
  23. 23
    Lamichhane P, Sharma A, Mahal A. Impact evaluation of free delivery care on maternal health service utilisation and neonatal health in Nepal. Health Policy Plan. 2017;32(10):1427-1436. https://doi.org/10.1093/heapol/czx124. Accessed April 27, 2019.
  24. 24
    Gakidou, Emmanuela, et al. "Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016." The Lancet 390.10100 (2017): 1345-1422. Institute for Health Metrics and Evaluation (IHME). Seattle, WA: IHME; 2018.
  25. 25
    Johns Hopkins Bloomberg School of Public Health. Lives Saved Tool. Baltimore, MD; 2018.
Next

Methodology

Sections

Appendix