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National Child Health Strategy

BHUTAN

2014 – 2018

Department of Public Health

Ministry of Health

2014

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Table of ContentsAbbreviations.........................................................................................................5List of Acronyms......................................................................................................7Foreword from the Minister....................................................................................8Message from the Director General........................................................................9Acknowledgement................................................................................................10Executive summary...............................................................................................111. Situation Analysis...........................................................................................131.1. Background...........................................................................................................131.2. Socio-demographic context...................................................................................131.3. Health System in Bhutan.......................................................................................131.4. National Health Policy...........................................................................................141.5. Child Health Program in Bhutan............................................................................151.6. Program initiatives relevant to child Health...........................................................17

1.6.1. Reproductive Health....................................................................................................171.6.2. Acute Respiratory Infections and Diarrheal Diseases...................................................171.6.3. Vaccine Preventable Diseases......................................................................................171.6.4. Nutrition......................................................................................................................181.6.5. Water, Sanitation and Hygiene....................................................................................191.6.6. Community Involvement.............................................................................................191.6.7. Disability and rehabilitation.........................................................................................20

2. National Child Health Strategy.......................................................................212.1. Vision....................................................................................................................212.2. Objective..............................................................................................................212.3. Strategic Priority Areas..........................................................................................212.4. Guiding principles.................................................................................................24

2.4.1. Aligned to the 11th FYP and other relevant policies and strategies.............................242.4.2. Action-oriented and Result-based...............................................................................242.4.3. Improved coordination and linkages for implementation............................................252.4.4. Gender sensitive..........................................................................................................262.4.5. Sustainable...................................................................................................................26

3. Cross-cutting approaches...............................................................................273.1. Integration............................................................................................................273.2. Health Information and governance......................................................................273.3. Strengthening institutional arrangements.............................................................273.4. Capacity Building...................................................................................................283.5. Monitoring and Supervision..................................................................................283.6. Quality assurance..................................................................................................283.7. Equity...................................................................................................................284. Strategic priorities..........................................................................................294.1. Strategic Priority 1:To increase access to quality integrated services to improve child health, reduce neonatal and childhood morbidity and mortality..................................................31

4.1.1. Increase antenatal visits to a minimum of 8 visits.......................................................314.1.2. Number of HIV positive pregnant women eligible for ART increased and maintained at 100% 324.1.3. Institutional delivery increased from 63% to >80%......................................................324.1.4. Improve quality of neonatal services and decrease neonatal deaths from 26/1,000 live births to 13/1,000 live births.......................................................................................................334.1.5. Postnatal visits increased from 61% to 80% by 2018...................................................33

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4.2. Strategic Priority 2: To improve quality services for prevention of childhood illness and to reduce morbidity and mortality due to diarrhoea and pneumonia through IMNCI............35

4.2.1 Provide IMNCI in accordance with established guidelines and standards through all health facilities............................................................................................................................354.2.2. Community IMNCI (C-IMNCI) introduced in 205 Gewogs............................................354.2.3. Quality of IMNCI assured in all health facilities............................................................36

4.3. Strategic Priority 3: To fully immunise all children with primary series of vaccines.374.3.1. Achieve and sustain immunization coverage of more than 95%..................................374.3.2. Introduce new vaccines for prevention of common childhood illness.........................384.3.3. Specific vaccine preventable childhood diseases eliminated and eradicated..............38

4.4. Strategic priority 4: To improve nutritional status of infant, children and mother..394.4.1. Improved maternal nutrition for child health..............................................................394.4.2. Promote Infant and Young Child Feeding Practices.....................................................394.4.3. Strengthen supplementation activities and rehabilitation units for children under five.

404.4.4. Improve coordination with MOA and MoE for child nutrition.....................................404.4.5. Strengthened Growth Monitoring Program.................................................................40

4.5 Strategic Priority 5: To increase access to safe drinking water, and sanitation facilities and promote conducive environment for women and young children.....................................41

4.5.1. Water and Sanitation facilities improved for child health............................................414.5.2. Child health through improved personal hygiene........................................................414.5.3. Improved environment for child and maternal health.................................................42

4.6 Strategic Priority 6: To strengthen community and household capacity for improved child and maternal health, young child nutrition and care practices.................................................43

4.6.1. Linkage between communities and health services strengthened..............................434.6.2. Parents and caregivers adopt key family practices to improve child health, growth and development...............................................................................................................................434.6.3. Functional VHWs/UHWs in Chiwogs and urban centres increased to at least 1,600 by 2018 444.6.4. Improved early health-care seeking behaviour by mobilizing individuals, families and communities................................................................................................................................44

4.7. Strategic Priority 7: To reduce prevalence of childhood disability...............................454.7.1. Develop National Policy and strategy on disability in children.....................................454.7.2. Develop increased awareness about childhood disabilities in communities...............454.7.3. Develop high risk follow up program in referral health facility for early detection of childhood disability......................................................................................................................454.7.4. Access to counselling on children’s disability increased.............................................464.7.5. Rehabilitation services for childhood disabilities are made.........................................464.7.6. Collaboration with relevant Civil Society Organizations (CSO).....................................46

5. References.....................................................................................................476. Annexure:........................................................................................................48Annexure 1: Budget Preparation Checklist........................................................................48Annexure 2: Membership of the Child Health Advisory Group....................................50Annexure 3: Participants for NCHS Framework option: 10 June 2013...............................51Annexure 4: Participants for development of NCHS: 13-15 June, Paro...............................52Annexure 5: Participants for review and finalization of draft NCHS: 24-26 July 2013, Paro.53

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Abbreviations

AEFI : Adverse Effects Following ImmunizationAHB : Annual Health BulletinANC : Antenatal Check-upARI : Acute Respiratory InfectionARV : Antiretroviral DrugsBEmONC : Basic Emergency Obstetric & Neonatal CareBHU : Basic Health UnitBHWs : Basic Health WorkersC4CD : Care for Child DevelopmentCDD : Control of Diarrheal DiseasesCDG : Constituency Development Grant CEmONC : Comprehensive Emergency Obstetric & Neonatal CareCDH : Community Development for Health CHAG : Child Health Advisory GroupCMO : Chief Medical OfficerC-IMNCI : Community Integrated Management of Neonatal and Childhood IllnessCRRH : Central Regional Referral HospitalCRS : Congenital Rubella Syndrome CS : Caesarean Section CSO : Civil Society OrganizationCSS : Community Systems strengtheningDHO : District Health OfficerDHS : Dzongkhag Health ServicesDMO : District Medical OfficerDMS : Department of Medical ServicesDoPH : Department of Public HealthDPT : Diphtheria, Pertussis and TetanusDPT-Hep B : Diphtheria Pertussis Tetanus – Hepatitis BDT : Diphtheria TetanusDYT : Dzongkhag Yargay TshogchungECCD : Early Child Care and DevelopmentEmONC : Emergency Obstetric and Neonatal CareENBC : Early Neonatal Birth CareEPI : Expanded Program on Immunization ERRH : Eastern Regional Referral HospitalFYP : Five Year PlanGNH : Gross National HappinessGNHC : Gross National Happiness CommissionGYT : Gewog Yargay TshogchungHA : Health AssistantHAART : Highly Active Anti Retroviral therapyHBsAg : Hepatitis B Surface AntigenHP : Health PromotionHib : Hemophilus Influenza bHIV : Human Immunodeficiency VirusHRH : Human Resources for Health

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IEC : Information, Education and CommunicationIMR : Infant Mortality RateIMNCI : Integrated Management of Neonatal and Childhood IllnessesIYCF : Infant and Young Child FeedingJDWNRH : Jigme Dorji Wangchuck National Referral HospitalKMC : Kangaroo Mother CareLG : Local GovernmentMSTF : Multi Sectoral Task ForceMCH : Maternal and Child HealthMDG : Millennium Development GoalMIS : Management Information SystemMMR : Maternal Mortality RatioMoH : Ministry of HealthMNCH : Maternal and Neonatal Child Health MR : Measles RubellaNCHS : National Child Health StrategyNACP : National AIDS Control ProgramNCIP : National Committee on Immunization PracticesNFE : Non Formal EducationNICU : Neonatal Intensive Care UnitNNS : Neonatal Sepsis NRU : Nutrition Rehabilitation UnitNHS : National Health Survey OPV : Oral Polio VaccineORC : Out Reach ClinicORS : Oral Rehydration SaltPHED : Public Health Engineering DivisionPPTCT : Prevention of Parent-to-Child-TransmissionPNC : Post Natal ClinicOT : Operation TheatrePN : Post NatalRGOB : Royal Government of BhutanRHU : Reproductive Health UnitRIHS : Royal Institute of Health SciencesRH : Reproductive HealthRHU : Reproductive Health UnitRPR : Rapid Plasma RegainRWSS : Rural Water SchemeToT : Training of TrainersTT : Tetanus ToxoidUCI : Universal Childhood ImmunizationUHV : Urban Health VolunteerUNICEF : United Nations Children’s FundU5MR : Under 5 Mortality RateUMSB : University of Medical Sciences of BhutanVCT : Voluntary Counselling and TestingVHW : Village Health WorkerVPDP : Vaccine Preventable Disease ProgramVHWP : Village Health Worker ProgramWHO : World Health Organization

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List of Acronyms

Chiwog :Sub unit of Gewog (block).

Dzongkhag Tshogdu :Development committee at the district level.

Dzongda :Administrative Head of districts.

Dzongkhag :District.

Gewog Tshogde :Development committee at the block level.

Gewog (Block) :This is the smallest administrative unit of the government in Bhutan.

Gup :Elected head of local government at gewog

Mangmi :Deputy to the administrative head of a gewog.

Pawo :Male traditional Healer

Pawmo :Female traditional healer

Thromde :It is the municipal third level administrative unit. It is also known as throm.

Thromde Health Officer :Representative of Health in bigger municipalities, equivalent to District Health Officer

Tshogpa :Is an elected representative of a Chiwog.

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Foreword from the Minister

It gives me immense pleasure to write this foreword for the first National Child Health Strategy of Bhutan. The health of our children is hugely important as they are the builders of the nation tomorrow. Bhutan has prioritized child health and endeavoured to reduce infant and under five year mortality significantly though we still fall short of national targets.

Information indicates that we continue to have neonatal mortality rate of 26, Infant Mortality Rate of 47 and Under Five Mortality rate of 60.1 deaths / 1000 live births respectively. It is evident that neonatal mortality contributes both to infant mortality and U5 mortality considerably. Further, preterm birth complication, intra-partum complications like “baby unable to breathe” and infections add to neonatal mortality. Within the ages ranging from 1 month to 59 months, infections are the most common reason for sickness and death. Most of the common causes of death and illness in children are preventable. These signposts that we need put our focus and our efforts in improving facilities and skills in order to reduce fatalities in the neonatal period and further emphasizing on managing infections in neonate as well as infant and children. It is timely that a national child health strategy was drawn that brings all actors in child heath under the strategy for better coordination, integration, completeness of interventions and effective implementation of various activities that will ultimately augment health of children in Bhutan.

I am more than happy that experts from within and outside the Ministry of Health have deliberated on several occasions to synthesize and build this strategy. The strategy follows life cycle approach of improving maternal health which in turn will improve the process of pregnancy and health of new-born and its health in adulthood. The strategy considers to improve maternal health for outcome of pregnancy; facilitating improvements in managing neonates effectively; revitalizing approach to managing Pneumonias, Diarrhoea and other infections through the IMNCI; improving nutrition; sustaining Universal Child Immunization; improving water, sanitation and hygiene facilities; community systems strengthening through supporting the village health volunteers and establishing and strengthening “chiwog tshogpa” as a platform for communication on health at the community and improving facilities for childhood disability prevention and providing appropriate services for disabled children.

I am confident having a NCHS will introduce cost effective and most appropriate interventions that will improve the health of children of our nation. I also believe that every intervention is appropriately budgeted and are implemented within the timeframe for perceived results. It is my sincere belief that the NCHS cascades down up to the facility level and beyond for better health of our children.

I appreciate the technical support of the UNICEF to developing this important document and thank each and every member involved in its development.

MinisterSowai Lhenkhang.

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Message from the Director General

Bhutan is a rural agrarian country with 69% population living in the villages. Most villages in many dzongkhags are connected by motorable road. Yet, there are distant and far flung hamlets and nomadic population who are inaccessible to modern day health facilities.

Bhutan has prioritised child health in the last few decades which has resulted in the sharp decline of IMR and under five mortality rates. However these fall short of MDG targets. To date, neonatal mortality, of 26/1000 live births, contributes to 55% of the infant mortality and 34% of under-five mortality. Preterm birth complications, intra-partum complications and infections are the major causes of mortality. Infections, particularly pneumonia contribute significantly to mortality in 1-59 months age group.

It is a matter of great importance that most causes of child mortality are preventable. To this effect, the Department of Public Health puts forward the National Child health Strategy that brings all relevant programs, ministries and development partners together for a common task of improving child health in Bhutan.

The NCHS proposes to improve child health through the following priority areas:

1) To increase access to quality, integrated services to improve new born and maternal health and reduce neonatal and maternal morbidity and mortality;

2) To improve quality of service for prevention of childhood illness to reduce morbidity and mortality due to common infectious diseases like pneumonia and diarrhoea;

3) To fully immunize all children with the primary series of vaccines; 4) Improving health, nutrition and care of Infant and young children.5) To increase access to safe drinking water, improved sanitation facilities and promote

conducive environment for women and young children;6) To strengthen community and household capacity for improved child and maternal

health, young child nutrition, caring and rearing practices;7) To reduce prevalence of childhood disability.

I am confident that the “National Child Health Strategy” will go a long way in helping planners, supervisors, implementers, donors and beneficiaries of the services in enhancing the health of the children of Bhutan.

I sincerely appreciate the UNICEF for all technical support provided in developing this important document.

Tashi Delek.

(Dr. DORJI wangchuk)Director GeneralDepartment of Public Health.

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Acknowledgement

The Department of Public Health, Ministry of Health, Royal Government of Bhutan would like to acknowledge the UNICEF for the financial and technical support in developing this document. The Department of Public Health would like to extend its thanks to all the officials and individuals who provided assistance and support in developing this document.

The Department of Public Health would like to acknowledge the valuable comments and inputs from the team of experts and District health officials and focal persons of various departments in the Public Health Department who contributed diligently towards the development of the National Child Health Strategy.

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Executive summary

The National Child Health Strategy (NCHS), 2014 – 2018, is the first comprehensive child health strategy that has been developed so far. To date, several policies, plans and strategies have existed and which have contained child health components (such as child nutrition, newborn care etc.), although there has not been one single national strategy to bring all child health priorities together. The NCHS seeks political support and commitment at the highest level for effective implementation.

The strategy provides a strategic framework for the MoH to lead other stakeholders to support through greater alignment of activities, resource allocation and programming. In all instances, the NCHS has been developed through a varied and participatory approach that builds on recent program reviews and is based on available data and information. Extensive inputs from numerous stakeholders and beneficiaries have helped to define the NCHS, including: the Ministry of Health, dzongkhag representatives, BHU staffs, mothers and children and development partners.

Bhutan’s long-term vision for child health is “zero newborn, infant or child dies from preventable causes and all children are progressing towards better health and happiness.” This vision is intended to guide all child health actions for all stakeholders during the implementation period. The primary focus of the NCHS will be on children under 5. However, given the importance of good pregnancy practices and maternal health on children, a continuum of care approach has been adopted to ensure that all children from conception to the age of 5 are supported through the NCHS.

The objective for the NCHS is “to ensure that all children have access to and use high-quality, integrated, holistic services in a sustainable manner”. It is especially important for the NCHS to ensure that use of – and not just access to – services is increased over the next five years. Aspects of increased quality and holistic and sustainable integration of health with other sectors such as education are also key components of the NCHS.

Seven strategic priorities for child health have been identified and they will be guided by the six guiding principles which encompass Bhutan’s beliefs and values regarding child health. The seven strategic priority areas as follows:

1) New born and maternal health;2) Child health through IMNCI;3) Childhood immunization;4) Nutrition for child health;5) Hygiene and sanitation;6) Community participation for child health and7) Disability and rehabilitation in children.

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The success of the NCHS will only be defined by how well it is planned, resourced and implemented. In other words, if the NCHS is to be more than “just a strategy document” and if it is to truly make a significant impact on the health and well-being of children, it will need to be planned for, financed and implemented effectively.

In order for the strategy to be implemented effectively, action plans have been developed to broadly guide the seven strategic priorities over the next five years. What is now required is to allocate adequate resources, provide regular supervision, monitoring and timely evaluation.

While much has been done in the past, the NCHS brings all stakeholders together for combined effort to improving child health in Bhutan and in realizing the MDGs and other national targets.

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1. Situation Analysis

1.1. Background

Bhutan is a landlocked country in the Himalayas that covers almost 38,394 square kilometres. The country is surrounded by Sikkim in the west, West Bengal and Assam in the south, Arunachal Pradesh in the east and by China in the north. Bhutan’s population is estimated at 7, 20,6971. The country is administratively divided into three regions (Western, Central and Eastern) and 20 Dzongkhags (districts) that are further divided into 205 Gewogs which are the administrative blocks.

1.2. Socio-demographic context

About 69 %2 of the population live in rural areas. Large part of the country is well connected by a good road network but some population still need to walk several hours to reach the nearest health facility. Dispersed population and mountainous terrain are major challenges for access to health facilities as well as service delivery. Population and Housing Census of Bhutan 2005 revealed that the overall male to female ratio was 111 males to 100 females. Approximately one third of the Bhutanese population (30.1%) is below 15 years of age; 0-4 years constituting 11.5%; 5 to 9 years 9.4% and 10 to 14 years 9.3% while a little less than 5 % is older than 64 years. About 60 % belong to the economically active age group of 15-64 years.

Bhutan's development has been guided by the concept of Gross National Happiness (GNH). The concept aims to balance spiritual and material advancement through sustainable and equitable economic growth and development, preservation and sustainable use of the environment, preservation and promotion of cultural heritage, and good governance. Development improvements – including in child health – have also been spurred on by the leadership of Bhutan’s monarchy who have prioritized socio-economic growth; increased literacy rates; support to public health and improving education.

1.3. Health System in Bhutan

The health care delivery system is three-tiered and staffed by trained health care providers at all levels. At the highest level is the National Referral Hospital (JDWNRH) in Thimphu, along with Regional Referral Hospitals at Gelephu in the South central and Mongar in the Eastern region. The hospitals located in the district headquarters represent the middle level and the BHUs linked to these hospitals represent the lowest level health units. Each hospital and BHU has a certain number of ORC that provide mobile health services. In addition to curative services, all these levels provide preventive, promotive and emergency services. There is a network of 31 district hospitals, 192 basic health units and over 550 outreach clinics3 which are manned by 194 doctors, 736 nurses, 578 BHWs and HAs and an array of paramedical workers, indigenous physicians and smenpsas. In addition, there are 1,190 VHWs based in chiwogs, who are volunteers from the community with basic training in

1 Statistical year book of Bhutan, 20122 Statistical year book of Bhutan, 20133Annual Health Bulletin, 2013

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health, who serve as an important link between the communities and the health services. They participate actively in outreach activities.

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Figure 1: Health care delivery in Bhutan.

Referral

Bhutan continues to pursue primary health care (PHC) approach to cover the nation’s scattered population with basic health care which includes integrated preventive, promotive and curative care services that have reached to more than 90% of the population. In the absence of private medical practice, the government is the sole provider of health care. Each year, the government spends around 7.4 to 11.4% of total government expenditure on health4.

While Bhutan has a wide selection of sound, evidence-based and rational health strategies, such as the EPI Strategy, VHW strategy, NCD strategic plan, Adolescent health strategy etc., investigation indicates that these strategic plans and priorities very rarely are translated into district plans which mainly consist of infrastructure projects such as the number of new ORCs that will be constructed, and other tangibles such as the number of trainings to be conducted. In other words, the priorities of most strategic plans are not captured in the annual district health plans.

1.4. National Health Policy

The National Health Policy is a comprehensive health document that accords high priority to maternal and child health and demands provision of comprehensive quality maternal and child health care. The policy calls for provision of free and equitable access to safe, quality and cost effective vaccines for all children and pregnant women to protect against vaccines-preventable diseases , promotion of breast feeding, appropriate nutrition and prevention of malnutrition and Integrated Management of Neonatal and Childhood Illness. Health is the responsibility of state and is provided free of cost to the people. This includes comprehensive health care at all stages of life.

4Policy and Planning Division, 2009

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Outside Country Referral

Regional Referral Hospital (2)

District Hospitals (31)

Basic Health Units Gr. I & II (192+)

Village Health Workers (1190)

National Ref. Hospital

1.5. Child Health Program in Bhutan

Child health does not claim a specific “child health program” in the MoH that is responsible for overseeing and coordinating all child health activities. Instead, several child health components are subsumed under other health programs. Newborn care, for instance, sits within the RH program. Immunizations for newborn and infants remain under the jurisdiction of the VPDP program. Breast feeding, child care and nutrition with Nutrition Program, respiratory and diarrheal diseases with ARI and Diarrheal program etc. and these programs are overlooked and co-ordinated through two main divisions (Communicable and Non Communicable) under the Director General, DoPH. Bhutan has clearly made impressive gains with regards to child health over recent years particularly in the area of immunization, hygiene, water and sanitation, MMR, IMR etc.

Table 1:Selected child health indicators

Sl.# Indicators Year 20121 Infant Mortality rate per 1000 live birth 472 Under five mortality per 1000 live birth 693 Infants exclusively breastfed for the first 6 months of life (%) 144 Children aged <5 years stunted (%) 33.55 Children aged <5 years underweight (%) 12.76 Children aged <5 years washing (%) 5.97 Low-birth weight newborns (%) 9.98 Population using improved drinking-water sources (%) 96.19 Population using improved sanitation (%) 58.410 Population using solid fuels (%) 39.5

NB: Source: BMICS 2010

Approximately 11.5% of people are in the age range 0 to 59 months and every year around 14000 children are born. Bhutan has made tremendous progress in child health and attained UCI in 1991 and has sustained it. IMR is reduced to 47 and U5MR rate to 69% 1000 live birth for 2010(AHB 2013) and it is a considerable drop from the 1990 baseline of 96 IMR and 138 U5MR.Existing statistics show that the neonatal mortality rate has decreased from 38 per 1000 live births in 2000 to 30 in 2004. Commonest reasons for under 5 morbidity are ARI 41.5%, diarrhoea 13.6% and pneumonia 5.4% of all childhood morbidity5.

In the absence of a Child health program, Child Health is currently guided by the Child Health Advisory Group (CHAG) which is composed of heads of programs that deal with aspects of child health, specialist and child health experts, district representatives and members from the WHO, UNICEF and the Save the Children Fund.

5Annual Health Bulletin, 2013

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Figure 2:Trend in incidence of diarrhoea and Pneumonia in children under five years of age6

2008 2009 2010 2011 20120

500

1000

1500

2000

2500

3000

3500

Diarrhoea Incidence (Per 10,000 under 5 Children)

Pneumonia Incidence (Per 10,000 under 5 Children)

CHERG estimated neonatal mortality in Bhutan of preterm complications at 42%, intra-partum complications as 37% and infections at 19%. Mortality in children 1 to 59 months are due to pneumonia 27.8%, diarrhoea 13.2% and a total of 87% are due to infections.

Given the high morbidity and mortality rate and yet to achieve MDG targets, comprehensive child health strategy is expected to achieve the national health targets. At this point, having a specific child health program in the MoH requires policy change and major reorientation of existing programs under the Department of Public Health.


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1.6. Program initiatives relevant to child Health.

1.6.1. Reproductive Health

As child health is intimately related to maternal health, the MoH is committed to safeguarding the health of children and women. Towards this, the RH Program implements policies, programs and services is focusing on new born, under five, pregnant and postpartum women.

Newborn mortality is high which is contributing to a high infant mortality rate of 47/1000 live birth7. Evidence globally indicates that good health in pregnancy and safe deliveries with skilled providers dramatically increase the chances of good newborn health and future health for infants.

Under the 11th FYP, the RH program will scale up ANC to 8 visits, institutional delivery, intensify newborn, intra partum and postnatal care and intensify advocacy and awareness. Evidence already shows of increasing trend of institutional delivery with 63% pregnant women delivering in health facilities8. However, since home delivery is discouraged that those who deliver at home are devoid of skilled care during birth and any other support. Postnatal care in Bhutan is still inadequate and can be partly attributed to high new born and maternal death rates. While Bhutan is on track to achieving MDG 4, it is widely felt that efforts need to be reinforced.

1.6.2. Acute Respiratory Infections and Diarrheal Diseases

Acute Respiratory Infection (41.5%), diarrheal diseases (13.6%) and skin infections (15.4%) are the commonest cause of morbidity in U5 age group. The CHERG estimate of pneumonia mortality in Bhutan for neonatal and 1 to 59 months is 11% and 28% respectively.ARI is aggravated by indoor air pollution caused by high use of solid fuels for heating and cooking in Bhutanese homes. This predominantly affects children from rural areas, the poorest households, and those whose parents or caretakers are not literate. This can only be addressed by improving the quality of rural households’ energy sources or introducing improved systems for smoke free combustion. Reducing prevalence of ARI and diarrhoea is essential if Bhutan is to achieve Millennium Development Goal (MDG 4), which calls for a reduction by two thirds of the under-five mortality rate by 2015, as compared with the 1990 baseline.

The MoH has commenced the initiative of IMNCI that promotes childcare practices for children under-five in preventing and reducing morbidity and mortality from acute respiratory infections (ARIs), diarrhoea, communicable diseases such as measles and rubella and other infections contributing to malnutrition.

1.6.3. Vaccine Preventable Diseases

Expanded program on immunization was introduced in Bhutan in 1979. The country achieved UCI in 1991 which was marked by national immunization levels focusing on wide vaccination coverage for major diseases like BCG, diphtheria, tetanus, pertussis, poliomyelitis, measles and hepatitis B. In June 2011, pentavalent vaccine was successfully

7Bhutan multi indicator survey, 20108Annual Health Bulletin, 2013

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reintroduced into the routine schedule of immunization. To reach and sustain the target of more than 95 percent coverage by 2015, the program continues its advocacy, social mobilization, and behavior change communication towards timely completion of immunization schedule for each child.

The immunization coverage for BCG is 95%, DPT3 is 95%, OPV3 is 95%, Hep3 is 95% and Measles coverage of 95%, newborns protected against tetanus of 89%. Rubella vaccine was successfully introduced in the year 2006.

Morbidity due to vaccine preventable diseases have decreased significantly to tuberculosis prevalence rate at 16/10000 population; OPV, whooping cough, pertussis, tetanus were not reported and a case of measles and 2 cases of rubella for 2012.Looking at the overall coverage trend, immunization coverage increased from 85 % in 2000 to 94.5 % in 20109. Sustaining UCI gains and expanding immunization coverage, introducing new vaccines, and strengthening monitoring and surveillance and eliminating polio by 2014 are some of the future plans chalked out by the government under Immunization Plus program.

1.6.4. Nutrition

Appropriate nutrition in pregnancy and for children is a critical intervention for good health and development as part of a continuum of care approach for mothers and their young. Evidence globally strongly indicates that poor nutrition of pregnant mother leads to worse outcome for her and her baby, and this undermines the health, physical and mental growth and development of infants and children later in life. Under nutrition during pregnancy and first few years of life predispose one to NCDs in adulthood. Evidence also indicates that poor nutrition in pregnancy and in childhood is directly correlated with poorer and less educated families and communities.

Nutrition remains a problem in Bhutan. Regarding children under the age of five, 11% are underweight, 37% are stunted and 4.6% are wasted10. Alarmingly, children’s nutritional status typically declines from six months after birth and persists until the age of two to three years. Poor breast-feeding and complementary feeding practices leads to increased rates of malnutrition and poor development during the most critical period of growth. Exclusive breast feeding rates are sub-optimal with only 10% of mothers exclusively breastfeeding for the first 6 months11, which leads to poor health outcomes. Food insecurity affects one in ten households in Bhutan for almost a quarter of the year.

Prevalence of stunting increases from the time of birth to two years of age, when it reaches 36%. Stunting is almost double between the least and most educated and those in the lowest and highest wealth quintiles. Anemia has been a major public health problem with 55% of women, and 81% of children (6-60 months of age) being anemic in the study of 2003 12. Anemia during pregnancy leads to increased risks and complication of pregnancy and delivery. Anemia during pregnancy leads to increased prevalence of anemia in children, and result in lower long-term productivity.

9Annual Health Bulletin, 201310National Nutrition Survey 200811National Nutrition Survey, 200812National anemia study 2003.

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The 11th FYP targets to reduce severe and moderate stunting in children to less than 20% from a base line of 37%; moderate to severe wasting from a 5.9% baseline to less than 3 % and underweight of 11% baseline to less than 5% by 201813.

1.6.5. Water, Sanitation and Hygiene.

Diarrhoea is one of the leading causes of under-five morbidity in Bhutan although it is on a decline. Diarrheal incidence among U5s per 10,000 is in an increasing trend from 2,257 cases in 2011 to 2,368 in 201214. Diarrheal incidence among children whose faeces are unsafely disposed of is higher than among children whose faeces are safely disposed15.

Water, sanitation and hygiene is stewarded by the Public Health Engineering Division (PHED) and improving WASH across Bhutan is a priority in the 11FYP, especially improving the health of the rural population by reducing the incidence of water borne and related diseases through provision of safe drinking water and improved sanitation.

By 2010, 96% of the population had access to improved drinking water sources, which resulted in the early achievement of MDG 7 target to reduce by half those without access to safe drinking water by 2015. The 11th 5YP targets 100% access to safe drinking water. Access of Bhutanese population to improved sanitation is 58.4%. There is a considerable disparity by area of location with 78% of the urban population having access to improved sanitation compared with only 51% of the rural population. Bhutan aspires to achieve more than 80% access to improved sanitation by 201816.

1.6.6. Community Involvement

At the community the VHWs, MSTF, Chiwog Tshogpa and the religious groups are the key stake holders.

VHWs work in tandem with and under close supervision of the health staff in the Basic Health Units. There are a total of 1190 VHWs and the VHWP is in the process of identifying further gaps and training an adequate number so as to provide these basic services to every Bhutanese home. The VHWs are a link between the community and the health services. The VHWs identify pregnancy in their jurisdiction early, line list and ensure adequate number of ANC visits. They support pregnant for institutional delivery, ensure post natal visits, support breast and complementary feeding, immunization and in minor illnesses. There are impediments to this unique model of volunteer services which are high attrition rate, low level of functionality and inconsistent educational background.

Some chiwogs have community level MSTF and Community Action Group. These are community groups that work to support the community in all aspects of health with special focus on children and women. Proposals have been made to expand this service to every chiwog as Chiwog Tshogpa whereby identified, influential members of community, men and women and religious leaders work in unison with the health systems through the process of communication for Development.

1311th FYP Document14Annual Health Bulletin, 2013. 15 Bhutan multi indicator survey, 20101611th 5YP document

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1.6.7. Disability and rehabilitation

Disability of any form prevents child from optimal growth and development. Prevalence of any disability among Bhutanese children in the age range 2-9 years old in at least one functional domain is 21%. Around 19% children have mild, 2% moderate and 0.7% have severe disability. Disability in cognition is by far the most prevalent at 15%, followed by behavioural domain of 5.6% and fine motor domain at 5.5%. Younger children aged 2 -5 years have more disability (27 %) compared to 16% for children aged 5-9 years. It is higher among poor children with 26% for the lowest wealth quintile compared to 14% for the highest quintile. Younger and poorer children are twice as likely to have a disability compared with rich children17.

No concrete program exist for disability prevention in children and initiatives to support such children are at its infancy. There is a further need to study the determinants of childhood disability. Enhancing antenatal care, improving intra partum and post natal care are some measures that curtail neonatal disability. Promoting early detection so that appropriate and timely interventions take place, and developing programs for parental education are important steps towards improving quality of lives of disabled children. Inclusive health and education services for children with disabilities are other important measures that the Royal Government must undertake to fulfil some important basic needs of disabled children for productive lives.

17Two stage child disability study; Bhutan 2010-2011.

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2. National Child Health Strategy

Bhutan has prioritized investments in child and maternal health in the preceding decades, which is indicated by a sharp decline in IMR and U5 MR. Though the decline has been significant, these still fall short of the MDG targets. Program initiatives for child health have been in place under the umbrella of the DoPH for last several decades. Under each program several schemes are established that has a bearing on the health of children. Each of these schemes is put in place through the District health services.

A strategy document on child health brings together all the elements of issues related to child health and means of mitigating them in one document which makes it easy to implement all such activities either individually or through partnership with other national ministries and development partners involved in child health.

Vision for child health have been set and objectives of the NCHS laid down which will be realised through seven priority areas. These are implemented through a combination of guiding principles which are as follows: alignment with existing policies and strategies; action oriented; improved coordination & linkages; child and community centered; gender sensitive and sustainable.

2.1. Vision

The vision of NCHS is “Zero newborn, infant or child dies from preventable causes and all children are progressing towards better health and happiness.”

2.2. Objective

The objective for the NCHS is “To ensure that all children have access to and use high-quality, integrated, holistic equitable services in a sustainable manner”.

2.3. Strategic Priority Areas

Seven strategic priorities have been identified for the NCHS. These will serve as the primary child health priorities for Bhutan over the next five years, and which all partners and service providers will be expected to align with and support. The seven, comprehensive priorities of the NCHS are:

1) New born and maternal health2) Child health through IMNCI3) Childhood immunization 4) Nutrition for child health5) Hygiene and sanitation6) Community participation for child health 7) Disability and rehabilitation in children

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Figure 3: Schematic diagram of the NCHS, Bhutan

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Vision “Zero newborn,

infant or child dies from preventable causes and all children are progressing towards better health and happiness.”

Objective “To ensure that all children have access to and use high-quality, integrated, holistic equitable services in a sustainable manner”.

Strategic Priorities1. New born and maternal health 2. Child health through IMNCI3. Childhood immunization 4. Nutrition for child health 5. Hygiene and sanitation6. Community participation for child health7. Disability and rehabilitation in children

2.4. Guiding principles

Six comprehensive guiding principles have been identified for the NCHS, and which will underpin and direct the NCHS over its duration. The guiding principles should remain unchanged even if the objective, priorities and approaches for the NCHS change or are modified in time to reflect the changing realities for child health in Bhutan. Guiding Principles describe the values, beliefs, standard and philosophy pertaining to quality assurance and performance improvement that stakeholders comply with in supporting the NCHS. The six guiding principles of the NCHS are:

1) Aligned to the 11th FYP and other relevant policies and strategies;2) Action-oriented and result based;3) Improved coordination and linkages with other health initiatives and sectors;4) Child and community based especially targeting the vulnerable groups;5) Gender sensitive;6) Sustainable.

2.4.1. Aligned to the 11th FYP and other relevant policies and strategies

Currently there are a number of strategies, guidelines and policies already exiting and functioning towards improvement of child health, namely:

1) RH strategy; 2) National Strategic Plan for HIV/AIDS (PPTCT and paediatric care);3) EPI Multi Year Strategic Plan ;4) National Health Promotion strategy; 5) IMNCI Module adapted from UNICEF and WHO;6) IYCF strategy;7) VHW Policy and strategy;8) WASH strategy;9) C4CD parenting module adopted from UNICEF and WHO;

The National Child Health Strategy, which is in line with the national health policy and the 11 FYP goals and objectives, draws relevant pursuit of all the health strategies to the advantage of child health.

2.4.2. Action-oriented and Result-based

NCHS is a practical strategic document that delivers results for children and their mothers throughout Bhutan. By being “action-oriented” the NCHS takes a practical approach to improving child health. “Results-based” means that the NCHS prioritises measurable and meaningful results throughout its duration.

The NCHS will be “implementable” especially at the national, regional and district hospitals; in all health facilities and in every community. Only by being implementable, remaining simple, focussed and user friendly for execution at the dzongkhag level, will the NCHS achieve the expected results and generate desired change to the health of children of Bhutan.

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2.4.3. Improved coordination and linkages for implementation

In order for the NCHS to be able to achieve its expected objectives and results, effective coordination and implementation among numerous stakeholders at various levels of Bhutan’s health system will be required, as well as with other sectors such as education, GNHC and others. Clear roles and responsibilities need to exist in order to support effective coordination and implementation. The main roles and responsibilities of the NCHS stakeholders can be summarised as follows.

2.4.3.1. Central level coordination

Central level stakeholders are many and include the MoH, development partners especially UNICEF and WHO, other government sectors such as Education, and GNHC, all of whom play critical roles in supporting the NCHS and MoH will be responsible for overall coordination and implementation.

Within MoH, the child health components are planned for and implemented under various programs such as the RH, Nutrition, VHWP, VPDP etc., but there is no specific child health program that brings all these together. To improve on this, the MoH will improve coordination internally by exploring ways in which to best implement the strategy.

While the central level will not be responsible for direct service provision, they will take the overall leadership on policy, planning, resource mobilization, capacity building, technical backstopping, supervision, monitoring and evaluation.

2.4.3.2. District level coordination

District level stakeholders are primarily the DHOs, as well as the district hospital in-charges. The roles and responsibilities of the DHOs in particular are similar to those for the central MoH, except that they are entirely focussed on one district. DHOs will be the primary coordinator of child health activities in their districts and they will be responsible for ensuring effective coordination and integration of child health services throughout the districts.

2.4.3.3. Community level coordination

At the community level the stake holders are health workers, VHWs, agriculture extension workers, teachers, NFE teachers, community leaders, religious groups, traditional healers and formal and informal community groups like chiwog tshogpa, MSTF and women’s group.

Improved coordination is required among those groups to enable effective implementation of the child heath strategy. However, given the importance of community participation, it is strongly recommended that additional support is provided for community system strengthening. The selected member would be the main steward of the initiative strongly supported by the local health worker.

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2.4.4. Gender sensitive

As the primary care giver and guardian of children, women are fundamental to improving and sustaining better child health in Bhutan. However, women can face various socio-economic and cultural barriers that can prevent them (and subsequently their children) from accessing and using health services.

Modern day fathers have an increasing role in growth and development of children. Psychological research across families from all ethnic backgrounds suggests that fathers' affection and increased family involvement help promote children's social and emotional development. This is even enhanced by changing economic role of women that father’s traditional task as breadwinner and conveyor of moral value is diluted requiring them to diversify inclusive of taking care of children.

As such, the NCHS will prioritise support for women and that they are mainstreamed into all interventions. Simultaneously, the supplementary role of fathers will also be stressed and institutionalized. All child health activities will be designed, planned and implemented through a gender-lens and priorities will be provided to interventions that encourage women to use available health services.

2.4.5. Sustainable

Efforts will be made by the MoH to ensure sustainability of child health strategy by aligning the NCHS strategy with national priorities and goals. In accordance with national policy, health services will continue to be provided free. Activities of the child health strategy will be streamlined in the five year plans and subsequent annual work plans.

Some effective innovative measures could be (a) health insurance that complement state health support (b) effective prevention and case management to limit expenditure fluctuations; (c) continuing non-formal education for non-literate women and girls and delaying marriage beyond 18 years for all girls. (d) Alternate service availability for those who can afford out of pocket expenditure for their own health.

Further, as an immediate measure to ensure program financial sustainability, Dzongkhag Health Sector will:Advocate and convince gewog leaders that a portion of CDG is allocated every year at the gewog level for health promotion as health is a continuum as continuum of life is.Guarantee that gewogs and Dzongkhags allocate adequate fund every year in the annual budget plan for community systems strengthening and for health.

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3. Cross-cutting approaches

Cross cutting approach is necessary to serve as the overarching technical and programming framework that holds the NCHS together. These approaches will be mainstreamed and integrated into all activities and interventions under the NCHS and should be considered by all stakeholders during planning and implementation phase at central, district and community levels.

3.1. Integration

Child health services will be integrated into one stop holistic child health service provision. This will ensure all U5 children seeking health care get integrated child health and nutrition interventions in a holistic manner, contributing to their survival and optimal growth and development. IMNCI screening process will be reinforced for every child that visits the health facility.

3.2. Health Information and governance

Information utilization for monitoring, policy decisions, planning and programming is critical. BHUs should be able to compile, analyse and use data to help them better understand their communities, track and support mothers and children and to improve their own programming approach. Similarly district should use BHU information to better plan and execute health initiatives and understand key trends in child health. Data from the BHU and districts must find its central programs and planners via the HMIS and feedback is guaranteed to the primary source. Improved capacity in collecting, managing and using information is vital to understanding and assessing the progress of implementation of the NCHS. The overall leadership and governance for health care system in Bhutan is sound and this must be sustained.

3.3. Strengthening institutional arrangements

The MoH will seek ways to ensure that child health in Bhutan is led and coordinated by a specific child health program within the Ministry. To strengthen institutional arrangements and improve coordination, a proposal is being made for restructuring of the Department of Public Health to allow establishment of a specific program for child health. The child health program aims to increase coordination of activities, resources and planning with external stakeholders. Appointment of child health focal person at the district level may be considered to lead child health activities in a similar manner. This cross-cutting approach will support implementation of the NCHS specifically the third guiding principle which is “improved coordination including multi-sectoral stakeholders”.

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3.4. Capacity Building

The Human Resource Development Unit in the Ministry of Health will coordinate the in- country and ex-country trainings to save cost, time and duplications of activities. The implementation of the NCHS encompasses training of health workers and community participants to a large extent and this requires a centrally coordinated approach. The priority lists of activities are detailed in the annexure with indicative cost.

3.5. Monitoring and Supervision

Monitoring and supervision is an integral component of the National Child Health Strategy. All activities are monitored and supervised at different levels of interventions. The monitoring reports are evaluated and the feedback provided to different stake holders or implementing partners.

3.6. Quality assurance

A mechanism will be mainstreamed into all activities at all levels to ensure that the quality child health services are provided and sustained. Commitment to quality will be reflected also in other components such as planning and budgeting for child health. Strengthening supportive supervision and monitoring of service delivery will further enhance quality assurance.

3.7. Equity

Equitable access of child health services to all and utilization of services for all will be emphasized. Special focus will be on vulnerable population through targeted interventions. Women and girls will be supported to use the available services. Involvement of men will be promoted to support women and girls to access the health services.

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4. Strategic priorities

The Royal Government of Bhutan is a signatory to the United Nations Millennium Declaration and the United Nation’s Secretary General’s Global Strategy for Women’s and Children’s Health, “Every Woman, Every Child”. The Government’s commitments to international development goals have translated into national policies and strategies supportive of maternal and child health. Continued commitment will be necessary to sustain the achievements made thus far and to incorporate emerging and newer issues that have received lesser attention.

Table 2: Child Health Indicators

Indicator Current status(BMIS, 2010)

Target for 2018

IMR (deaths/1000 live birth) 47 <20/1000 live birthU5MR(deaths/1000 live birth) 69 <30/1000 live birthNeonatal Mortality Rate 26 <13/1000 live birth

The NCHS has identified the following seven priority areas for addressing the child health issues for the period between 2014 and 2018, they are:

1) To increase access to quality, integrated services to improve new born and maternal health and reduce neonatal and maternal morbidity and mortality;

2) To improve quality of services for prevention of childhood illness and to reduce morbidity and mortality due to common infectious diseases like pneumonia and diarrhoea;

3) To fully immunize all children with the primary series of vaccines; 4) Improving health, nutrition and care of Infant and young children.5) To increase access to safe drinking water, improved sanitation facilities and promote

conducive environment for women and young children;6) To strengthen community and household capacity for improved child and maternal

health, young child nutrition, caring and rearing practices;7) To reduce prevalence of childhood disability.

The national child health strategy creates opportunities for a comprehensive and robust maternal and child health service. The strategy adopts life cycle approach to address child health issues by integrating maternal and child health interventions. It also calls for improving child health through implementing and expanding IMNCI services to all health facilities and beyond. Further it garners support for child health through sustaining high immunization coverage, improving nutrition, increased access to safe drinking water and sanitation and providing prevention and rehabilitative services for children with disability.The strategy stresses on integration of activities, involvement of stakeholders, community level participation, supervision and monitoring.

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The strategy outlines, that routine child health services will be delivered through the MCH Clinics with one stop integrated trajectory approach (Figure 3) particularly at the Hospitals and BHU I.

All children under five years of age will first report to the MCH clinic with the MCH Handbook who will be screened for Nutrition (Height/Weight) and developmental milestones and provide supplements (vitamin A and de-worming) and counseling on C4CD and IYCF. Next, the child will be referred to either immunization services or IMNCI from where they will be directed to focused counseling, admission or home care depending on the requirement.

Figure 4: Integrated Routine Child Health Service: A holistic one stop trajectory

As the child goes back to the community, the care giver is equipped for managing the child at home.

The home health centre which is the initial health centre where the mother registered for her pregnancy will track and follow up the child till five years of age to complete the MCH hand book which is required to be presented to the school authority during school admission. The child health profile will be transferred to the school health card.

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Play corner for child

Emergency

Specialist Services

Step 3

Step 2

Step 1

Home Care

Home Health Centre tracks, follows up, monitor each child up to 5 yrs. of age using MCH handbook.

Specific/focused Counselling:Maternal nutrition, C4CD, IYCF, “1000 golden days”,

EPI, FP, HIV/AIDS, Primary Prevention, Adv. on treatment & follow up, home care.

EPIIMNCI (Triage) (Inpatient/Outpatient)

Screening & triage: Ht/Wt, Counselling on C4CD & IYCF

& Vitamin A, De-worming,

RegistrationMother & Child

Play corner for children

4.1. Strategic Priority 1:To increase access to quality integrated services to improve child health, reduce neonatal and childhood morbidity and mortality.

Indicator Current status (11fyp) Target for 2018Neonatal death per 1000 live birth 26/1000 live birth 13/1000 live birth8 ANC attendance 12% >60%ANC HIV counselling 44% 100%Any PNC visit 61% >80%Institutional delivery 63% >80%

Source: 11thFYP Document

New born and maternal health interventions will be revitalized and taken to scale throughout Bhutan. All hospitals, BHUs, ORCs and communities will be reached with more extensive and better quality newborn and maternal care services, advice, information and counselling. Maternal health has its impact on the outcome of pregnancy and health of the child in its adulthood. Given that maternal health especially is under the remit of the RH program in the MoH, and is covered well under the RH Strategy, the integration of maternal health with newborn health is the primary priority for the NCHS. With this in mind, newborn care is the main focus of this strategic priority, but the NCHS recognises that it is impossible to separate newborn care from maternal health.

4.1.1. Increase antenatal visits to a minimum of 8 visits

Recent guidelines for antenatal care emphasize an eight visit schedule with targeted activities to be conducted, targeting to increase to at least 4 ANC visits from 77% to over 90%. Effort will be made to create awareness among pregnant women about the necessity of 8ANC visits.

To increase ANC visits to 8, the NCHS will prioritise line listing and early booking of pregnant women in communities. To do this, and especially to target the unreached and at-risk groups, a more robust community-based identification and referral network will be established and maintained. An improved VHW program will play a critical role in enabling this to happen. The UHWs will also be fundamental to enabling urban pregnant women to attend 8 ANC visits at their nearest health facility, through extensive community education and awareness. All dzongkhags are encouraged to identify the most vulnerable groups viz. nomadic populations; urban poor; single mothers and pregnant teenagers who are most likely not to attend at least 4 ANC visits, to target them for enhanced ANC visits during their annual planning sessions.

Community health workers in rural and urban areas require a functional referral and communication network with their attached BHU in order to encourage more women to attend 8 ANC visits. Better community-based information gathering and analysis will be needed to enable VHWs and UHWs to track pregnant women and encourage them to attend ANC sessions, and for post-ANC visit to be effectively made. Community networks will be established among women, men, VHWs, tshogpas and other community workers to encourage and support women for completing the ANC visit.

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4.1.2. Number of HIV positive pregnant women eligible for ART increased and maintained at 100%

The NACP in collaboration with the RH program will strengthen integration of PPTCT in Maternal care to achieve the goal of ‘zero transmission in new born’. A critical approach to PPTCT of HIV in Bhutan will be through preventing new infections. Intensive campaigns and promotions will be rolled out by NACP in urban areas and border towns where HIV prevalence is high. Pregnant women will continue to be counselled during ANC visits on preventing HIV.

Infected reproductive age women will be encouraged to avoid unwanted pregnancy by providing appropriate family planning methods.

VCT is integrated into ANC and is offered to all pregnant women on an opt-out basis after counselling. Currently up to 44% ANC attendees receive HIV counselling and testing. Most of the pregnant women accept testing on being offered which is done in the first trimester. VCT is provided by all Grade 1 BHUs and counselling by all BHUs. Testing facilities will be extended across the country, especially in HIV “hotspots”.

All eligible pregnant women will receive HAART which is initiated by District Medical Officer and followed up by the District Counsellor. Short-term ARV prophylaxis, to prevent parent to child transmission during pregnancy, delivery and breastfeeding for HIV-infected women will be followed according to the national guidelines for PPTCT. Pregnant HIV positive women will be encouraged to opt for delivery by caesarean section. Thus the NCHS also advocates and facilitates implementation of the NACP.

4.1.3. Institutional delivery increased from 63% to >80%

While progress is made in increasing number of institutional deliveries, acceleration of efforts is needed in many districts. This requires concomitant enhancement in institutional facilities for safe delivery. The Health Promotion Division will work closely with the RH and VHW program to identify barriers to develop interventions for increased demand for institutional deliveries.

VHWs and BHU staff will be important conduits of information, as will various media vehicles such as radio that have extensive penetration into rural areas. Community groups and traditional healers will also be engaged in supporting institutional delivery. Chiwog Tshogpa and other women network will support pregnant women for ANC, plan for safe delivery, support referral, PNC and neonatal care.

Special initiatives will be explored in communities that are aware of the benefits, but face barriers to actually using services such as opportunity costs of travelling to a health facility to give birth, the perceived lack of client-friendly services available in facilities and/or traditional beliefs regarding delivering a baby in a clinical facility. Therefore, creating community support to help pregnant women and their families for institutional delivery is crucial.

The VHWs and chiwog tshogpas will also have a key role of educating women, tracking and supporting them throughout their pregnancy and accompanying them to facilities in good time for delivery. In order for this to be realised, efforts across various programs will be required to support the VHW program.

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Additional EmONC facilities will be added in the 11th 5YP to the existing network to increase to 10 facilities. Erstwhile centres will be strengthened and newer ones are well equipped and manned.

4.1.4. Improve quality of neonatal services and decrease neonatal deaths from 26/1,000 live births to 13/1,000 live births

The NCHS encourages a comprehensive and multi-pronged approach to tackling neonatal death across Bhutan.

Preterm birth complications contribute significantly to neonatal deaths. The NCHS recommends that mothers are educated on understanding and recognizing preterm labour and the need of reporting, for perceived preterm birth, to the health centre at the earliest.

The NCHS recommends that antenatal steroids be made available for all mothers that are at risk for preterm deliveries.

Given the extent of newborn deaths, the current “National Newborn Care Standard Guideline” will be revised and a “National Neonatal Resuscitation Program” established.

NCHS supports for establishment of well-equipped and functioning EmONC in populous districts like Thimphu, Phuntsholing, Punakha, Gelephu, Samtse, Trashigang, Mongar, Pemagatshel and Trongsa. Minimum of one neonatal nurse practitioner must be made available in every EmONC Centre.

NICU facilities with trained manpower namely neonatal nurses and neonatologist will be established at the JDWNR Hospital, Eastern regional referral hospital Monggar, Central Regional referral hospital Gelephu, Phuentsholing General Hospital and in any other populous district.

Ambulances with neonatal transfer facilities and manpower will be supported by the NCHS for safe transfer of preterm babies to higher centres requiring advance neonatal care.

It is expected that health workers, especially those who are BHU based need to be reoriented and trained on follow up of normal pregnancy, ANC, recognising danger signs in pregnancy and in neonates; conduct safe delivery, neonatal resuscitation (helping babies breath) and sepsis, etc., periodically on rotation basis in EmONC and neonatal setup. A syllabus will be drawn for health workers to undergo such training.

Appropriate number of neonatal nurses and paediatrician will be trained in neonatal intensive care and neonatologist will be trained in the five year plan period.

In line with the priority of the NCHS to better collect and use health data and information, every maternal and newborn death is audited and recorded. The auditing is done both at the dzongkhag level as well as at the program level with feedback provided to concerned health centre.

4.1.5. Postnatal visits increased from 61% to 80% by 2018

Giving birth in a health institution, receiving skilled birth assistance and postnatal care are considered critical for reducing both maternal and newborn mortality. The first 24-hour

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period after birth is especially critical to prevent neonatal and maternal death and hence first PNC is recommended within this period.

The MoH through the institution of RHUs, BHUs and VHWs will create awareness among pregnant mothers for the need of three postnatal visits, the first being within 24 hours of birth, second visit in 3 to7 days and third visit in 4 to 6 weeks. The chiwog tshogpa and other women network at the chiwog and villages will be utilised for motivating women for PNC. Post-natal home visits by trained BHU staff should become a part of the routine care for new born and women.

In the event that the health worker is unable to make the second and third visit, it will be done by the VHW who will report the condition of the mother as well as the child over mobile phone to the health worker at the time of visit. Post natal follow-up and referral by VHWs in their communities will be reinforced in their tasks, training and supervision and monitoring.

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4.2. Strategic Priority 2: To improve quality services for prevention of childhood illness and to reduce morbidity and mortality due to diarrhoea and pneumonia through IMNCI

Indicator Current status Target for 2018Diarrhoea incidence 24% 11%Pneumonia incidence 15% 7%Institute community IMNCI -- To all 205 Gewogs

Diarrhoea and ARI continue to remain the two most common causes of childhood morbidity18. These illnesses attribute greatly to mortality especially in the 1 to 59 month age group. Much effort has been invested to put in place specific measures that reduce burden due to these illnesses. Improved quality of primary prevention of childhood illness and case management and reduced incidences of these illnesses has been targeted for 2018.

4.2.1 Provide IMNCI in accordance with established guidelines and standards through all health facilities

Bhutan has started to make significant progress in building capacity of health workers and rolling out IMNCI in all health facilities. These initiatives will be further supported and strengthened to improve the child health. An integrated approach will be followed to improve parenting practices for holistic development of children. The Care for Child Development (C4CD) approach, to support families to care for their children, will be an integral component of the IMNCI care package. This will focus on increasing parents’ understanding and skills for good child care practices. Health workers will be trained to support parents and care givers in improving parenting skills. Linkages will be strengthened with the Ministry of Education’s ECCD Program for delivery of health care services in the school going children.

To standardize and improve quality IMNCI services, capacity building, supervision and monitoring etc. will continue for health workers in hospitals, BHUs and at program level. Upgrading of skills and knowledge of health workers in IMNCI will be prioritized.

4.2.2. Community IMNCI (C-IMNCI) introduced in 205 Gewogs

Families have major responsibility of caring for their children with support from their communities. Success depends on good partnership between the communities and health providers.

In order to complement facility-based management of childhood illnesses and increase participation of communities and households in improving child care, Community IMNCI with C4CD will be introduced in 205 Gewogs. Capacity of VHWs/UHWs will be strengthened to inform, educate and support parents and caregivers in adopting the sixteen key family practices towards reducing illness and death in under-five.

Since delayed initiation of antibiotics in pneumonia is one important cause of infant mortality, VHWs will initiate antibiotics for pneumonia on receiving confirmation from concerned health worker with further concurrence from the health helpline.


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4.2.3. Quality of IMNCI assured in all health facilities

Quality of services provided is indispensable to their effectiveness. To ensure quality of IMNCI, supportive supervision, monitoring and information flow will be strengthened at all levels. This is to ensure correct practices and availability of drugs and equipment and to enhance technical capacity.

The MoH has adopted already set standards in IMNCI which are followed by every health worker. The national supervisors will conduct follow up supervision to each district to ensure standardization of services as well as to assess provision of C-IMNCI services.

During the five year period a study will be conducted to determine the quality and effectiveness of facility-based IMNCI and such information will be tapped to improve services.

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4.3. Strategic Priority 3: To fully immunise all children with primary series of vaccines.

Indicator Current status Target for 2018Sustain immunization coverage 95% 98%Eradicate Polio - 2014Eliminate measles - 2016

Source: 11thFYP Document

Bhutan achieved Universal Child Immunization (UCI) in 1991 and has sustained it since then. The immunization coverage for BCG is 95%, DPT3 is 98%, OPV3 is 95%, HepB 95% and Measles coverage of 95% and newborns protected against tetanus of 89%. Morbidity due to vaccine preventable diseases has decreased significantly. Sustaining UCI gains and ensuring full coverage of all children with primary series of vaccines are some priorities in ensuring improved child health in Bhutan.

4.3.1. Achieve and sustain immunization coverage of more than 95%

The NCHS aims to build on and extend the extensive immunisation coverage that already exists. Small pockets of populations in some dzongkhag do not receive immunization services. Therefore, greater focus will be provided to reaching this unreached and remote population. The program will conduct mapping of unreached population residing in remote and difficult area; urban unreached and mobile population. Priority areas include Trongsa, Gasa, Trashi Yangtse, Paro and Urban Cities having DPT-HepB-Hib coverage below 90%19. The MoH will plan and conduct catch up campaign where ever necessary and especially in these areas.

Effort will be made for an uninterrupted supply of vaccines, consumables and equipment to sustain the high EPI coverage. Having uninterrupted chain of supplies and logistics will be imperative to ensuring that essential vaccines are procured, stored and distributed effectively to sustain UCI.

19JRF, 2013

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4.3.2. Introduce new vaccines for prevention of common childhood illness.

New vaccines which are essentials will be introduced as and when a benefit of introducing such vaccines outweighs the cost. Possible newer vaccines for introduction are particularly rotavirus (RV) and pneumococcal conjugate vaccines (PCVs) as diarrhoea and pneumonia still remain important causes of childhood illness.

New technologies for cold chain will be introduced and capacity of the health workers will be built on use and maintenance.

OPV is being considered to be shifted to IPV which will begin by 2015. This will be in line with the Regional global end game strategy.

4.3.3. Specific vaccine preventable childhood diseases eliminated and eradicated

The last polio case was reported in 1986 and neonatal tetanus in 2006. In line with Global and Regional plans and targets to eradicate and eliminate vaccine preventable disease, Bhutan will accelerate activities according to the multiyear plan.

Surveillance for poliomyelitis, neonatal tetanus and measles are in place. Poliomyelitis is targeted to be eradicated in 2014 followed by elimination of measles and neonatal tetanus and control of rubella and congenital rubella syndrome (CRS).

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4.4. Strategic priority 4: To improve nutritional status of infant, children and mother

Indicator Current status(National Nutrition &

IYCF Survey 2008)

Target for 2018

Stunting prevalence 37% <20%Underweight prevalence 11% <5%Exclusive breasting feeding 10% >50%Anaemia in children 81% <60%Vitamin A supplementation coverage children 6 to 59 months.

50% >80%

Source: National Nutrition &IYCF Survey 2008

National Anthropometric Survey of 2009 has shown that 37% of the children under five are stunted and 11% underweight20. Acute malnutrition is more prevalent during the first three years of life while more children are stunted in the older age groups (30-35 months) than in the lower age group and similar pattern is observed in the underweight prevalence. Taking cue from above pattern, life cycle approach of targeting pregnant mother, infants and children is the best strategy to affect the overall child health program.

Interventions requires integrated approach with key programs namely Reproductive Health (MCH/ANC/PNC), Vaccines Preventable Diseases Program, IMCI and with Ministry of Agriculture (Food security and products) and Ministry of Education (Care for Child Development and Comprehensive School Health Program).

A major focus need to be on information dissemination, behaviour change, capacity building of health workers and child care givers in the areas of maternal nutrition, infant and young child feeding practices, supplementations and continued basic health services.

4.4.1. Improved maternal nutrition for child health

Improving women's nutrition is critical for the health of child. The strategic priority is to ensure that all pregnant women in Bhutan are equipped and able to have appropriate nutritional status throughout their pregnancy. Promoting early booking for pregnant mothers for ANC, identifying high risk pregnant mothers and ensuring minimum eight ANC visits before delivery are important measures that help improve maternal nutrition. Adequate supply of iron, folic acid tablets and encouraging compliance to iron, folate and calcium supplementation is necessary. Mandatory counselling for primigravida mothers during ANC and PNC with standardised messages is crucial for both mother and child nutrition and care. Developing comprehensive maternal nutrition guidelines encompassing nutrition during pregnancy, after delivery, Infant and Young Child Feeding Practices, immunization, health care services (ANC/PNC and growth monitoring) is vital and the NCHS will prioritise these as major interventions.

4.4.2. Promote Infant and Young Child Feeding Practices

Healthy Infant and Young Child Feeding practices must be revitalized to promote, protect and support appropriate infant and young child feeding. The strategy aims to implement 20National Nutrition Survey, 2008

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Chandralal Mongar, 07/23/14,

This is from National Anaemia Study 2003

Chandralal Mongar, 07/23/14,

The figure for Vit A coverage is 87.9%. Confirmation needed

infant and young child feeding policy and strategy. The NCHS support to initiate and sustain exclusive breastfeeding for 6 months and for timely introduction of complementary foods. In accordance with the ratification of the SAARC Code for Protection of Breastfeeding and Young Child Nutrition in 2003, NCHS will adopt policies to protect breastfeeding rights of working women and establishing means for its enforcement as proposed in the draft IYCF policy.

Nutritional status of nomadic communities will be assessed and focused interventions will be initiated.

4.4.3. Strengthen supplementation activities and rehabilitation units for children under five.

Sustain and monitor the on-going supplementation program namely, universal iron supplementation for pregnant and lactating mothers; Vitamin A supplementation and de-worming for children 6 to 59 months and all school going children. Children in these age range 6-59 months should receive vitamin A supplements every six months.

The weekly iron supplementation program in schools, which was initiated in 2004 needs to be reviewed.

Identification and timely referral of moderate and severely undernourished children to nutrition rehabilitation units will be strengthened. Capacity of NRU staffs on nutritional rehabilitation will be strengthened by way of training of such workers outside the country in established nutrition rehabilitation centres.

4.4.4. Improve coordination with MOA and MoE for child nutrition

One of the continued challenge and drawback has been lack of integrated approach between Ministry of Health and Ministry of Agriculture. While Health dwells on improving the nutrition, Agriculture Ministry is responsible for the production and food security. Kitchen Garden for Better Nutrition, back yard farming, off season production, food storage, household level fishery, poultry and piggery comes as immediate priority in NCHS. The role of agriculture extension workers in improving the protein energy malnutrition must be exercised. Coordination at Ministry and extension level must be strengthened. Joint Food and Nutrition Action Plan is proposed to bring coordinated approach between the key Ministries to address food and nutrition issues.

Given the far reaching impact of iron folic supplementation program, MoE takes charge of the on-going iron supplementation program in schools with technical backstopping from MoH.

Schools must insist on producing Mother and Child Health Card during admission and transfer vital information to school health monitoring card. Six monthly de-worming and vitamin A supplementation coupled with IEC will be continued.

4.4.5. Strengthened Growth Monitoring Program.

Monitoring child health through the MCH clinic using the MCH handbook is an important feature in the implementation of the National Child Health Strategy. Growth Monitoring Program enables regular contact between health workers, mothers and children under five.

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This also provides an opportunity for monitoring and strengthening cognitive development in a child through C4CD approach. The current strategy of alternating vitamin A and de-worming will be strengthened. Further, all children visiting health centre will be channelled through the MCH unit for nutrition screening and counselling on IYCF and Care for Childhood Development. The child also receives vitamin supplements and de-worming tablets. The child will be followed up with MCH handbook by the home health centre till five years of age, ensuring appropriate immunization and regular growth monitoring.

4.5 Strategic Priority 5: To increase access to safe drinking water, and sanitation facilities and promote conducive environment for women and young children.

Indicator Current status Target for 2018Population using improved drinking water sources 96.1% 100Population using improved sanitation facilities 58.4% >80%

Source: AHB 2013

Bhutan achieved the MDG target for water and sanitation in 2003-2004; it is still short of meeting its own goals of 100% access to safe drinking water and sanitation. According to the Annual Health Bulletin 2013, 96.1% of households have access to safe drinking water and 58.4% have improved sanitation facilities. However, when issues of reliability, quantity and quality are taken into consideration, these coverage figures fall substantially. Functionality of rural piped-water schemes (MoH in 2008) show at least one-thirds of schemes was performing sub-optimally. Also high incidence of water and sanitation related diseases remains stubbornly high. Hence, NCHC emphasizes that water and sanitation interventions are scaled up in all districts with focus on those districts that are most at risk and in need of support.

4.5.1. Water and Sanitation facilities improved for child health

The NCHS will promote usage of safe drinking water at household level. Further, access to improved toilets and hand washing facilities will be supported.

To standardise and improve quality of water and sanitation services, capacity building of concerned field workers and community groups will be highlighted.

NCHS will support Public Health Engineering Division to review access of communities to safe drinking water and identify measures for its improvement.

4.5.2. Child health through improved personal hygiene

Maintaining personal hygiene contributes to healthy life. Promotional activities through IEC and field activities will disseminate important messages crucial to child health. In close coordination with Health Promotion Division, various children targeted advocacy, behavioural change communications and community mobilisation advocacy material will be developed. Key messages to be delivered through promotional activities are drawn up through formative research.

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Key priority result are: reinforcing practice of hand washing with soap; promoting oral health (tooth brushing), bathing and washing; educating on safe disposal of child faeces; drinking clean water and promoting hygienic child feeding practices.

4.5.3. Improved environment for child and maternal health

Living environment can affect health of child and mother making them vulnerable to diseases and risks to accidents. Provision of local, easy to construct facilities will ensure proper disposal of wastes. For dzongkhags endemic to malaria and dengue, targeted interventions for environmental sanitation will reduce the chances of disease outbreak. PHED will pilot test appropriate technologies for improving environmental health and sanitation which the NCHS will promote. Key sub priority result areas under this include the followings.

Educating on safe disposal of household waste;Design and promote clean household environments (proper animal shed, footpath, household waste disposal, drainage, grey water management and household safety)Indoor air population contributes to childhood ARI and conjunctivitis. The NCHS support the NCD to minimise indoor pollution for child health.Introduction and promotion of conducive housing designs (safe electrical points, ventilation, recreational room and safe storage of other hazardous materials); Up gradation of standard sanitation facilities including child, women and disabled friendly sanitation facilities; safe wastewater treatment for clustered community;Rural sanitation and hygiene promotion;Community approaches to total sanitation.

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4.6 Strategic Priority 6: To strengthen community and household capacity for improved child and maternal health, young child nutrition and care practices.

Indicator Current status

Target for 2018

Minimum one functioning Village Health Worker(VHW) per chiwog.

- All chiwogs

Establishment and strengthening of chiwog tshogpas for health.

- 70% of the chiwogs

Source: 11 FYP

Communities and households form a key resource to reduce illness and death in children and women, therefore investing in building capacity of communities for ownership and active involvement in decisions and interventions to improve health and nutrition will accelerate reduction in disease burden and death. A key strategy in improving child health and nutrition is through integrated community-based interventions. VHWs/UHWs are frontline health workers, who play critical role in complementing health services. Every chiwog will have a minimum of one VHW and a Chiwog Tshogpa which will support the community and family in strengthening their capacity for improved maternal and young child nutrition. This will be a platform at the village level for people to discuss their health needs.

4.6.1. Linkage between communities and health services strengthened

Village Health Workers are a linkage between the communities and the health services. The health workers will work closely with VHWs to develop their capacity, provide supportive supervision and monitoring and guidance. The VHWs will encourage pregnant mothers to attend ORCs and BHUs for early booking to prevent any serious medical conditions. Enhanced participation of VHWs in their community work under close supervision of the health workers will guarantee strengthened linkage between health services and the community.

4.6.2. Parents and caregivers adopt key family practices to improve child health, growth and development

Key family health practices especially among children, women and girls are improved. These include immunizations, family planning, nutrition, and age-appropriate child health and life skills programs. Attention will be paid to increasing women’s access to child health services. Strategies include formative research to improve quality of targeted communications, scaling up of culturally appropriate community and facility based health communication programs, increased male involvement and access for male partners to sexual and reproductive health services, and scaling up evidence-driven interventions to address harmful gender norms.

Rural household avail the services of traditional healers before they seek help from BHUs. Traditional healers have an important position in the society. They influence care giving and family health practices of households at times of illness. Traditional healers will be educated about child health, IYCF and key family practice for their important role in educating families and for early referral.

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4.6.3. Functional VHWs/UHWs in Chiwogs and urban centres increased to at least 1,600 by 2018

Village Health Workers are considered instrumental in translating the child health strategy at the community (Chiwog) level. The NCHS will work in tandem with VHW program to strengthen it weakness and challenges. VHW gap for rural and urban areas will be ascertained and dzongkhags will identify difficult to reach communities. As a policy, each chiwog will have a VHW. However, the health worker along with the gup can decide to have more than one in larger and scattered chiwog. Required numbers of VHWs are selected appropriately and trained, who will conduct behaviour change communication and social mobilisation around the key family practices and support households in adopting such practices, through regular house-to-house visit and providing information and education on specific issues of concern to households.

Each dzongkhag and BHU will plan how to support VHWs for behaviour change communication and demand promotion at the community level to improve child health and nutrition.

4.6.4. Improved early health-care seeking behaviour by mobilizing individuals, families and communities

Early health care seeking behaviours including early identification of signs and symptoms of childhood illnesses will be promoted. Attention will be focussed on early detection of signs and symptoms; basic awareness on home care; women’s empowerment and ability to seek services with support from their spouses and communities; and increased access to facilities like support systems for transportation for patients and pregnant women from the community to health facilities.

Wide scale and individual communication to educate communities and families about danger signs and symptoms, with focus on safe motherhood, newborn and child survival, HIV/AIDS, etc. will be done.

Partnerships with Chiwog tshogpa, including community leaders, traditional healers, pawo/pawmo will be strengthened to improve and facilitate early, appropriate and effective referral. As an important process towards community strengthening, NCHS will promote establishment and reinforcement of chiwog tshogpa in every chiwog.

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4.7. Strategic Priority 7: To reduce prevalence of childhood disability

Indicator Current status Target for 2018Childhood disability prevalence 21% 14%

Source: Double stage disability study, NSB &UNICEF

The two stage disability report among children 2 to 9 years in 2010-2011 revealed that 21% of children in Bhutan are living with any disability, 19% with mild disability, and about 3% with moderate or severe disability. Overall, cognitive disability is by far the most prevalent and it is particularly common among children with mild disabilities. Difficulties in speech however are relatively more common among children with moderate or severe disabilities. Apart from the above study, there is no further information available, nor is there concrete attempt made to address the problem. The child health strategy attempts to address the issue by:

4.7.1. Develop National Policy and strategy on disability in children

A rapid assessment for understanding deferential disability problems in the communities will be done. This will provide in-depth information about burden due to disability to families and to society as well as perceptions individuals and families have about disabilities. This will be one of the early means to increase evidence base concerning children living with disability. A national policy and strategy on disability will be developed in 2014-15, and which will provide a five year action plan for the MoH and all stakeholders to align with and support.

4.7.2. Develop increased awareness about childhood disabilities in communities

People living with disabilities often face stigma and discrimination. Public awareness will be organized to identify disability early, understand the need to support such children, to reduce stigma and to change attitude among disabled and non-disabled people. The special initiative of the MoH to vitalize integrated holistic one stop child care through MCH services, with C4CD as an important component in counselling package, will enable mothers to understand and identify neurodevelopmental delays in early childhood.

4.7.3. Develop high risk follow up program in referral health facility for early detection of childhood disability

Capacity within the MoH and with other key stakeholders is currently limited to detect and deal with early disability. To this end, the NCHS proposes that health workers and school teachers are trained and supported in early detection of disability. Improvements in prenatal medicine and strengthening of laboratory services will help detect disabilities early. Additional support will be provided to health workers in providing early interventions like home based stimulation, positive parenting exercises and simple advice.Capacity of health workers in concerned areas of disability prevention and rehabilitation will be developed and prenatal TORCH screening should be strengthened.

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4.7.4. Access to counselling on children’s disability increased

Given the high prevalence of childhood disability, the NCHS emphasises the need for increased counselling services to be made available to children themselves, as well as their families and communities that support them. Counsellors will be provided with specialized training and made available in the hospitals and in schools. Counselling services will be made available especially in the case of genetic disorders that necessitate marital counselling.

4.7.5. Rehabilitation services for childhood disabilities are made available

The NCHS advocates rehabilitation for children with moderate to severe disabilities in therapeutic and non-therapeutic forms. Therapeutic intervention will include treatment of disabilities; physiotherapy and use of assistive devices. Non therapeutic rehabilitation will take the form of support from families and communities; parent education and disabled friendly recreational centres.

Community based rehabilitation allows disabled to be rehabilitated in his/her own living conditions. Necessary support will be provided to communities for community based rehabilitation for those needing such services.

Specialized orthotic, prosthetic, speech and audiology services will be established and necessary assistive devices made available at the referral hospitals in a phased manner and paediatric physiotherapy services strengthened.

4.7.6. Collaboration with relevant Civil Society Organizations (CSO)

The NCHS recommends that Ministry of Health collaborates with existing relevant CSO to lobby, advocate, network, create public awareness, conduct research and provide rehabilitative services.

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5. References

1. Annual Health Bulletin, Ministry of Health 2013,2. Tenth Five Year Plan, Ministry of Health 20133. National Health Policy- Bhutan, 2012,4. Village Health Workers Program- DOPH, MOH Bhutan, 5. Comprehensive review of the village Health workers Program Primary Health Care,

Initiative in Bhutan June 2012 6. National Policy and Strategic Frame-Work on Prevention and Control

of Non Communicable Diseases, Royal Government of Bhutan 20097. VHW TOT guide, DOPH, MOH Bhutan, 4th edition 2009. 8. National Nutrition, Infant & Young Child Feeding Survey 2008. 9. The National EPI Coverage Survey 200910. Short Program Review of Child Health Program 20-23 Sept.2010. 11. Bhutan Multiple Indicator Survey, 2010 National Statistics Bureau, RGoB. 12. Water and Sanitation Assessment report by Sonam Chophel DoPH, Modified on

21/5/12. 13. Identification of causes of under-five deaths in health facilities in Bhutan; Department

of Public Health. Ministry of Health, 201214. National Immunization Policy and Strategy, Department of Public Health. Ministry of

Health, 201115. National Adolescent Health Strategic Plan, 2013-2015, Adolescent Health Program

Department of Public Health. Ministry of Health, 201316. Midway Rapid Assessment of Programme, Integrated Management of Neonatal and

Childhood Illness (IMNCI), Department of Public Health. Ministry of Health, 201117. Achieving Millennium Development Goal No 5 & 4 by 2015 and going beyond

through provision of value added incentives to Village & Urban Health Workers. Department of Public Health. Ministry of Health, 2012

18. National Child Health Policy 2013; Islamic Republic of Afghanistan Ministry of Public Health

19. Child Health Strategy National Government of New Zealand, http://www.moh.govt.nz

20. Two stage child disability study among children 2 to 9 years in Bhutan, National Statistical Bureau, Ministry of Education, Royal Government of Bhutan 2010 to 2011

21. Tanzania Global Health Initiative Strategy 2010 -2018.

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6. Annexure:

Annexure 1: Budget Preparation Checklist

The following indicative guide has been tabulated to help those involved in program budgeting. There may be other items to factor into a particular budget. ___________________________________________________________________________Program Costing:Salary [ ]Stationary [ ]Photocopying [ ] Printing [ ]Telephone [ ]Administration [ ]Accounting [ ]Site visits [ ]Travel, Mileage [ ]___________________________________________________________________________Printing cost associated with publications: Posters [ ] Booklets [ ] Guidelines [ ] Standards [ ] Protocols and distribution cost [ ]___________________________________________________________________________Drugs: All drug components related to be included in the costing, including supplements for all programs under child health.___________________________________________________________________________Non Drugs supplies:Weighing scales [ ]Testing kits [ ]Rapid kits [ ]Laboratory supplies [ ] ___________________________________________________________________________Material and Labour costs:Particularly for construction component, have all materials, including disposable items has been charged? Transportation cost for the materials. Are there any requirements to use existing or recycled materials? Is there any in-kind support for materials or services? Labourer cost___________________________________________________________________________Technical Assistants:Both Local and international consultants travel and Per Diems. Permissible honorarium for in house specialist or experts.___________________________________________________________________________

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___________________________________________________________________________In country Training/workshops:Participants and facilitators transportation cost [ ]Per Diem [ ]Light refreshments [ ]Working lunches [ ]Stationary [ ]Photocopies [ ]Hand-out sets [ ]Printing of training materials [ ]Audio visual equipments hire/purchase [ ]Hall hires charges [ ]Banner development [ ]Design and printing [ ]Local non civil servants TA/DA or incentives [ ]___________________________________________________________________________Out-country Trainings/workshops studies:Travel cost [ ]Stipend for long term studies [ ]Per Diem for short duration settlement allowance [ ]Tuition fees [ ]___________________________________________________________________________Studies and surveys:Cost of external and internal experts and consultants [ ]Ta/DA for enumerators [ ]Surveyors trainings [ ]Pretesting, printing of questionnaires [ ]Stationary for training and enumerators [ ]Sample testing cost [ ]Transportation for survey enumerators [ ]Data analysis [ ]Report writing [ ]Refreshments [ ]___________________________________________________________________________Contingencies: Keep 10-15% contingencies depending on Donor specific.___________________________________________________________________________

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Annexure 2: Membership of the Child Health Advisory Group.

The CHAG membership will comprise of 10 members plus co-opt members from UNICEF, WHO and Save the Children. The Chair and the member sectary will be elected by the Group for tenure of two years.

1. IMNCI-ARI/CDD Nutrition2. VPDP3. Reproductive Health 4. Head of the Department, Paediatrics5. Paediatrician6. Gynaecologist7. Chief Program Officer of Communicable and Non Communicable Diseases Division8. Chief Medical Officer (Representative)9. District Health Officer (Representative)

Co-opt members1. UNICEF, Thimphu2. WHO, Thimphu3. Save the Children, Thimphu

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Annexure 3: Participants for NCHS Framework option: 10 June 2013

1. Dr. Dorji Wangchuk, Director General, DoPH/MoH2. Mr. Jayendra Sharma, Planning Officer, PPD/MoH3. Dr. Tashi Tobgay, Director, UMSB4. Dr. Drupthob Sonam, Medical Superintendent, JDWNRH (CHAG chairman)5. Dr. Phillip Erbele, Paediatrician, JDWNRH6. Dr. Chandralal Mongar, Health and Nutrition Officer, UNICEF7. Dr. Isabel Simbeye, Health and Nutrition Specialist, UNICEF8. Dr. Karma Lhazeen, CPO, CDD/DoPH9. Mr. Ugyen Dendup, Program Officer, Nutrition Program, NCD/DoPH10. Mr. Laiden Dzed, Dietician, JDWNRH11. Mrs. Karma Doma, Sr. Program Officer, DoPH12. Mr. Karma Wangdi, Sr. Program Officer, VHW, DoPH13. Mr. Sangay Phuntsho, Program Officer, VPDP, DoPH14. Mr. Rinchen Namgyal, Dy. CPO, HCDD / DMS15. Mr. Tshering Gyeltshen, Communication Officer, HPD/DoPH16. Mr. Sonam Zangpo, Sr. Program Officer, DoPH17. Mr. Rob Wood, International Consultant C/O:UNICEF, Bhutan

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Annexure 4: Participants for development of NCHS: 13-15 June, Paro

1) Dr. Dorji Wangchuk, Director, General, DoPH / MoH2) Mr. Sonam Wangchuk, ADHO, Thimphu Dzongkhag3) Mrs. Sangay Zam, ADHO, Zhemgang Dzongkhag4) Dr. Drupthob Sonam, Medical Supdt, JDWNRH (Chairman CHAG)5) Mr. Namgay, Clinical Officer, Trashiyangtsi Hospital6) Mr. Tshewang Dorji, Sr. DHO, Trashigang Dzongkhag7) Mr. Rinchen Namgyal, Dy. CPO, HCDD / DMS8) Dr. Phillip Erbele, Paediatrician, MoH9) Mrs. Tshering Choden, Health Assistant, Wangdue Hospital10) Dr. Mimi Lhamu, Paediatrician, HoD, JDWNRH11) Mr. Sanjeev Subba, Health assistant, Sinchula BHU, Chukha Dzongkhag12) Mr. Passang Dorji, BHW, Hungtsho BHU, Thimphu Dzongkhag13) Mr. Dorji Gyeltshen, Staff Nurse, CRRH, Gelephu14) Dr H.P. Chhetri, Paediatrician, Lungtenphu RBA Hospital15) Mr. Sangay Phuntsho, Program Officer, DoPH / MoH16) Mr. Laiden Dzed, Dietician, JDWNRH17) Mr. Tshewang Rinzin, Sr. DHO, Chukha Dzongkhag18) Mr. Ugyen Dendup, Program Officer, DoPH/MoH19) Mr. Pema Wangchuk, CN, ERRH Mongar20) Mrs. Deki Pem, Lecture, RIHS21) Mrs. Karma Doma, Sr. Program Officer, DoPH22) Dr. Ugyen Tshomo, Gynaecologist, JDWNRH23) Mr. Tandin Dorji, CPO, NCD / DoPH24) Mr. Kado Zanagpo, CPO, PPD/ MoH25) Mr. Ugyen Rinzin, Executive Engineer, PHED / DoPH26) Mr. Kinley Gyeltshen, CPO, MoE27) Mr. Tashi Tshering, AIMO, HPD/DoPH28) Mr. Sangay Thinley, APO, HPD/DoPH29) Mrs. Karma Choden, CN, JDWNRH30) Mr. Ugyen Dorji, ADHO, Lhuntse Dzongkhag31) Dr. Chandralal Mongar, Health & Nutrition Officer, UNICEF32) Mr. Karma Wangdi, Sr. Program Officer, DoPH33) Mrs. Kezang Deki, Education Officer, UNICEF34) Dr. Isabel Simbeye, Health & Nutrition Specialist, UNICEF35) Mr. Sonam Zangpo, Sr. Program Officer, DoPH36) Mr. Rob Wood, International Consultant C/o: UNICEF

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Annexure 5: Participants for review and finalization of draft NCHS: 24-26

July 2013, Paro.

1) Dr. Dorji Wangchuk, Director, General, DoPH / MoH2) Mrs. Ugyen Zangmo, Sr. Program Officer, DoPH3) Mr. Yeshi Choden, Program Assistant, UNICEF4) Dr. Isabel Vashti Simbeye, Health & Nutrition Specialist, UNICEF5) Dr. Tashi Tobgay, Director, UMSB6) Mr. Rinchen Wangdi, Chief Engineer, PHED / DoPH7) Mr. Tshering Tashi, Dy. Executive Engineer, PHED / DoPH8) Mr. Karma Wangdi, Sr. Program Officer, DoPH9) Mr. Tashi Tshering, AIMO, HPD/ DoPH10) Mrs. Karma Doma, Sr. Program Officer, DoPH11) Dr. Drupthob Sonam, Medical Supdt. JDWNRH (Chairman CHAG)12) Mr. Tshewang Tamang, Sr. Program Officer, DoPH13) Mr. Leigden Dzed, Dietician, JDWNRH14) Mr. Kado Zangpo, CPO, PPD/MoH15) Mr. Kinley Dorji, National Program Officer, WHO16) Mr. Rinchen Namgyal, Dy. CPO, HCDD / DMS17) Mr. Sonam Zangpo, Sr. Program Officer, DoPH

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abbreviations - moh.gov.bt do… · web viewto date, neonatal mortality, of 26/1000 live births,...

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