Intraglandular Foreign Body - Unusual Aetiology of Submandibular Gland Sialadenitis.

Obstructive sialadenitis of submandibular gland is commonly due to sialoliths and strictures in the Wharton's duct. Other endogenous pathologies include mucous plugs and polyps. Foreign bodies of Wharton's duct and submandibular gland are rare. Retrograde migration of foreign bodies via ductal orifice, traversing the ductal system to its final intraglandular location is an even rare entity. These often present with painful swelling of the gland and at times with a purulent sialitis. Diagnostic modalities include plain radiography, ultrasonography, sialography, as well as computed tomography and magnetic resonance imaging. Treatment includes antibiotics, incision and drainage of abscess, and removal of foreign body either surgically (intra-oral approach or sialadenectomy) or more recently via sialoendoscopy. This is a case report of 30 years male with accidental cannulation of Wharton's duct with grass that eventually got lodged in the deep lobe of the gland, and was managed with sialadenectomy.

Huge Lipoma of Left Parotid Region with Intra-Parotid Extension.

Lipoma is a benign mesenchymal tumor originating from adipose tissue. The occurrence of this tumor in head and neck is less frequent and it rarely involves parotid gland. These are asymptomatic and occur both in the deep and the superficial lobe of the parotid. The most favored age group is from the fifth to sixth decade of life and is 10 times more common in the males. A 66-year-old male patient, with left parotid region lipoma is reported in this article. A fine-needle aspiration biopsy and ultrasonography were performed to establish the preoperative diagnosis and to plan the correct surgical approach. It was managed by surgical excision of lipoma with removal of cuff of superficial parotid tissue on superior aspect with preserving facial nerve. Follow-up examinations were planned to assess any facial nerve injury complications.

Comparison of Surgical Outcome of Bipolar Scissors with Conventional Cold Dissection Tonsillectomy.

Background The tonsillectomy is the most common Ear, Nose, and Throat (ENT) surgical procedure. Different methods have been used to improve the outcome of the surgery. One such method is tonsillectomy performed with bipolar scissors. In our scenario, the comparison of bipolar scissors tonsillectomy with conventional cold dissection has not been done. Objective To compare the surgical outcomes of bipolar scissors tonsillectomy and conventional cold dissection tonsillectomy. Method A prospective randomized study was conducted in 40 patients who underwent tonsillectomy on one side using bipolar scissors and on the other side using conventional cold dissection. Intraoperative blood loss, operation time, postoperative pain, and postoperative hemorrhage were all analyzed in both surgical techniques. Result The median operative time was 10 minutes for bipolar scissors compared with 12 minutes for conventional cold dissection, with a p-value of 0.390 which was not statistically significant. The median blood loss was 48 mL on the bipolar scissors side and 60 mL on the conventional cold dissection side, with a p-value of 0.232 which was also not statistically significant. The overall postoperative hemorrhage rate was 12.5%. Of these, 4 (10%) occurred on the bipolar scissors side (left side mainly) and 1 (2.5%) on the conventional cold dissection side (also left side), with a p-value of 0.002 which was statistically significant. There was no statistically significant difference in the pain scores between the two methods in both rest and swallowing (p > 0.05). Conclusion The bipolar scissors did not show any benefit over conventional cold dissection in terms of surgical time, intraoperative blood loss, or postoperative pain. However, postoperative hemorrhage was more common with bipolar scissors. Therefore, conventional cold dissection remains a safe technique for tonsillectomy in adult patients.

Dhulikhel Hospital Checklist Protocol for Temporal Bone Computed Tomography Scan Analysis: How We Do It?

The temporal bone is very complicated anatomical structure. Any disease process within this structure mandates thorough anatomical knowledge of the corresponding structure. The High resolution computed tomography (HRCT) temporal bone is the best way to look inside this complex bone. The importance of knowledge about how to read and look inside the CT scan temporal bone lead us develop the Dhulikhel Hospital Check list protocol. This protocol will help aspiring otologist and otolaryngologist to read and know details about the underlying structures.

Comparison of Hearing Result and Graft Uptake Rate between Temporalis Fascia and Tragal Cartilage in Endoscopic Myringoplasty.

Background There are different methods to repair the perforation of the tympanic membrane. Recently cartilage has been used for the repair and results are comparable to temporalis fascia. For surgical procedure endoscope had added good assistance in middle ear surgery. Though the one hand technique the image quality and results are on par with the use of a microscope. Objective To compare the graft uptake rate and hearing results between temporalis fascia and tragal cartilage in endoscopic myringoplasty. Method This is a prospective, longitudinal study conducted among 50 patients who underwent endoscopic myringoplasty using temporalis fascia and tragal cartilage with 25 patients in each group. The hearing was assessed by comparing pre with post-operative ABG (Air bone gap) and ABG closure in speech frequencies (500Hz, 1 KHz, 2 KHz, 4 KHz). The status of graft and hearing results was evaluated on 6 months of follow up in both the groups. Result Out of total 25 patients enrolled for study in both (temporalis fascia and cartilage) groups, 23 (92%) patients in each group had graft uptaken. The audiological gain in the temporalis fascia group was 11.37±0.32 dB whereas in the tragal cartilage group it was 14.56±1.22dB. The audiological gain between the two groups did not show any statistically significant (p = 0.765). However, the pre and post-operative hearing difference was statistically significant in both temporalis fascia and tragal cartilage group. Conclusion Tragal cartilage has similar graft uptake rate and hearing gain when compared with temporalis fascia in endoscopic myringoplasty. Hence, tragal cartilage can be used for myringoplasty whenever required without any fear of deterioration in hearing.

Multiple Epidermal Inclusion Cysts of Epiglottis.

Epiglottic cysts are benign laryngeal lesions. Though congenital cysts are often life-threatening, they are usually painless and symptomless in adults, or present with slight, though perceptible, interference with either swallowing or speaking or respiration. Early recognition and diagnosis by routine mirror laryngoscopy is advocated. Prompt removal or draining is the treatment. This is a case report of 42-year-old woman with complaints of feeling of something in throat, sleep apnoea and hoarseness, who on routine mirror laryngoscopy was found to have two large cysts arising from the free border of the epiglottis. The final histopathology reported the cysts as epidermal inclusion cysts.

Does the Preoperative Neutrophil-to-lymphocyte Ratio and Platelet-to-lymphocyte Ratio Associate with Clinic-pathological Characteristics in Papillary Carcinoma of Thyroid.

Background Thyroid cancer is associated with local and systemic inflammatory activities. Many systemic inflammatory markers including the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) had shown credible and independent prognostic biomarkers in different malignant conditions. These markers are easy to reproduce, measure and inexpensive also. So, the preoperative evaluation of NLR and PLR is helpful in evaluating tumor growth and prognosis of papillary carcinoma of thyroid. Objective To evaluate the association of pre-operative NLR and PLR with clinic-pathological characteristic in papillary carcinoma of thyroid. Method This was a retrospective study performed in thirty one patients with the diagnosis of papillary carcinoma of thyroid. Preoperative NLR and PLR values were correlated with the clinical parameters like age, gender, lymph node metastasis, tumor size and pathological features (e.g., multifocality, bilaterality, extrathyroidal spread). Result There were thirty one patients, amongst which 13 were male and 18 were female. Similarly, the age distribution ranges from 27-68 years. The value of NLR was 2.37±1.09, and the value of PLR was 96.69±49.53.The increase in NLR was associated with increase in tumor size with statistically significant results. Similarly, increase in PLR was associated with increase in tumor size and multifocality with statistically significant results. Conclusion Increase NLR and PLR is associated with lymph node metastasis, extra thyroidal extension, multifocality of tumor and also bilaterality, so the risk can be stratified beforehand with measurement of NLR and PLR.

Comparative Study between Operative versus Non-operative Treatment for Base of Fifth Metatarsal Fractures in Young Adults.

Background The treatment of displaced base of fifth metatarsal fracture remains controversial regarding the conservative and operative treatment. Objective To investigate the therapeutic effect of operative and non-operative treatment for base of fifth metatarsal fractures. Method This was retrospective comparative study performed in Civil Service Hospital, Kathmandu, Nepal from December 2014 to November 2019. Patients were randomly divided into two groups by computer generated technique. Group1 included 17 patients who underwent open reduction and internal fixation using tension band wiring, whereas group 2 included 17 patients who underwent non-operative treatment with boot cast. Result The AOFAS and VAS-FA scores at 3 months in operative and non-operative groups were 89.34±2.14 versus 86.94±2.22 (p < 0.05) and 5.58±0.87 versus 3.58±0.93 (p < 0.05). Similarly, AOFAS and VAS-FA at 12 months after treatment were 90.94±2.43 versus 90.17±1.55 (p > 0.05) and 0.64±0.280.94±0.39 (p > 0.05) in operative and non-operative groups respectively. The average time to bear full weight and return to work were 6.82±1.13 versus 7.08±1.24 weeks (p > 0.05) and 8.76±1.20 versus 10.35±1.41 weeks ( p < 0.05) respectively. The mean of VAS score at 3months of treatment is 5.58±0.87 for non-operative group and 3.58±0.93 for operative group (p <0.05). Conclusion Operative intervention has been preferred over the non-operative treatment in young adults or athletes with more than 3 mm displaced fifth metatarsal base fracture to achieve anatomical reduction of fracture, hasten the recovery and rehabilitation and to decrease the complications associated with non-operative treatment.

Clinical Profile and Diagnosis of Obstructive Sleep Apnea Syndrome using Overnight Polysomnography in a Tertiary Care Hospital.

Background Obstructive sleep apnea is a highly prevalent yet largely under-diagnosed disease that poses a significant burden on the healthcare system. Objective To determine the role of predictors for Obstructive sleep apnea syndrome and its severity in Nepalese population. Method Prospective and analytical study conducted in the Department of Otorhinolaryngology and Head and Neck surgery at Kathmandu University Hospital between March 2018 and June 2020. A total of 85 adult patients with Obstructive sleep apnea with an Epworth sleepiness score greater than 10 were included. Overnight polysomnography was done and scoring of sleep associated events were done according to the American Academy of Sleep Medicine criteria. Participants were classified as simple snoring and mild, moderate or severe Obstructive sleep apnea syndrome groups depending on the Apnea Hypopnea Index values. Relationship of Apnea hypopnea index was analyzed with age, neck circumference, body mass index and Epworth Sleepiness score. Result Simple snoring was seen in 18(21.17%) patients, 14(16.47%) had mild Obstructive sleep apnea, 13(15.29%) had moderate Obstructive sleep apnea, whereas the severe group consisted of 40(47.05%) patients. The minimum Epworth Sleepiness Score was 10 and the maximum was 25. The Apnea hypopnea index correlated positively with Body mass index (p=.010) and Epworth sleepiness score (p <.001). However, Apnea hypopnea index had no association with age (p=.437) and neck circumference (p=.118). Conclusion Health professionals need to be extremely vigilant while examining patients presenting with Obstructive Sleep Apnea. Polysomnography is the investigation of choice in the early identification of this treatable disease.

Fungicide Application Timing Essential for the Management of Leaf Spot and Fruit Rot on Pomegranate (Punica granatum L.) in Florida.

Pomegranate (Punica granatum L.) has emerged as an alternative fruit crop for growers dealing with devastating threats to citrus and avocado in the southeastern United States. However, foliar and fruit diseases are major constraints to commercial pomegranate production. Replicated field trials were performed in 2015 at three separate sites in Florida (Dover, Plant City, and Parrish) to evaluate Merivon (pyraclostrobin and fluxapyroxad), Luna Experience (fluopyram + tebuconazole), and a rotational program consisting of these two fungicides as well as Penncozeb 75DF (mancozeb) for the management of leaf spot and fruit rot of pomegranate. The fungicide programs were evaluated on the varieties Vietnam in Dover, FL; Angel Red in Plant City, FL; as well as Christina, Azadi, Vikusnyi, Alsirinnar, Sakerdze, and Wonderful in Parrish, FL. Mean leaf spot severity varied across sites at the end of each trial in August, with values ranging from 4.5 to 62.5% in Plant City, 7.5 to 45.8% in Dover, and 4.5 to 54.2% in Parrish. Based on area under the disease progress curve, all treatments that included at least one at bloom application significantly reduced disease levels compared with postbloom treatments and the nontreated control across all trial sites. Based on fruit rot incidence, Luna Experience and Merivon, when applied twice at bloom in the beginning of the season, reduced disease by 66.6 and 88.4%, respectively, in comparison with the nontreated control in Plant City. A rotational program further reduced disease by at least 97% at the end of the season in Parrish. The proper timing of fungicide application and rotation with different modes of action provided a feasible disease management option for pomegranate growers in the Southeast United States.

Universal Neonatal Hearing Screening: An Experience at Tertiary Care Hospital.

Background Hearing loss among neonates is one of the important health issue in pediatric population which may remain unnoticed until the child reaches a certain age. The importance of universal early screening, diagnosis and intervention in reducing the negative impact of congenital hearing loss has been described all over the world. Objective To observe the outcome of hearing screening by Automated Auditory Brainstem Response (AABR) in newborns delivered in Dhulikhel Hospital and neonates admitted in an intensive care unit (NICU) of Dhulikhel Hospital. Method A prospective study was done in neonates who were born at Dhulikhel Hospital, Kathmandu University Hospital from February 15th, 2017 to October 30th, 2019. AABR was used for their hearing assessment within 24 hours of birth and again at about 6 weeks of age in those neonates who failed the initial test. All the neonates admitted in NICU were studied regarding the risk factors based on Joint committee on Infant Hearing. Those who failed the test for the second time were referred for detailed audiological diagnostic work up. Result The screening rate was 92.6% of the total deliveries. A total of 5517 neonates comprising of 2800 males and 2717 females were screened from total deliveries of 5956 neonates in the study period. Among them, NICU (sick) babies were 422 (7.7%) and well babies were 5095 (92.3%). Out of them, 1675 failed the test in the first screening and 374 failed in the second screening. So, the total number of referred babies in second screening was 6.7% (374) out of 5517 screened. Amongst them, well babies were 6.59% (336), out of 5095 screened and sick babies were 9% (38) out of 422 screened. Low birth weight and prematurity were found to be the commonest risk factor present among them, followed by the use of ototoxic medications, hyperbilirubinemia and prolonged use of mechanical ventilation. Conclusion Automated Auditory Brainstem Response (AABR) is a very useful tool for hearing screening which should preferably be done in all the neonates where possible. It should be done within one month of life and those with confirmed hearing loss should receive early appropriate intervention for better hearing in future.

Diagnostic and Treatment Delays among the Tuberculosis Patients in the Urban Area of Western Nepal.

Background Diagnosis and treatment of tuberculosis is vital for health system to identify, treat patients as early as possible and to reduce frequency of new cases of a disease among the contacts of known cases. Objective To determine the diagnostic and treatment delay in the urban population of the western, Nepal and factors associated to it. Method An institutional based cross-sectional study was conducted in urban area of Western Nepal. Category I 142 TB patients aged over 15 years visiting DOTs centre during period of three months were included in study. Interview schedule was designed to elicit information on socio- demographic characteristics and history of symptoms. Diagnostic and treatment delay was calculated, chi square test was applied to find associations and non - parametric tests (Mann Whitney U test and Kruskal Wallis H test) for evaluating group differences. Result Out of 142 TB clients, mean age was 38.12 years. Majority (58%) were males. Around 44% belong to upper, 30% middle and 26% lower economic class. Study showed median diagnostic delay 34 days (Q3 =68 Days, Q1 =19 Days), treatment delay less than a day (Q3 =1 Day, Q1 =0 Day) and total delay 33.50 days (Q3 =71 Days, Q1 =19 Days). Smear positive patients had significantly higher risk of diagnostic delay compared to negative (OR=2.18. P=0.035). However, no significant associations found between socio-economic/demographic classes with delay. Median delays was more amongst married (Q3 =86 Days, Median =72 days, Q1=24 Days compared to single/separated (Q3 =74 Days, Median =57 days, Q1 =15 Days) and other socio-demographic variables had no significant differences. Conclusion Delay in diagnosis and treatment in Urban region of Western, Nepal was shorter compared to other places in Nepal and neighboring countries. Shorter delay for smear negative pulmonary tuberculosis raises doubt that cases are not examined according to the national TB control programs manual.

Improved postnatal care is needed to maintain gains in neonatal survival after the implementation of the Helping Babies Breathe initiative.

AIM: Helping Babies Breathe (HBB) is a neonatal resuscitation protocol proven to reduce intrapartum-related mortality in low-income settings. The aim of this study was to describe the timing and causes of neonatal in-hospital deaths before and after HBB training at a maternity health facility in Nepal. METHODS: A prospective cohort study was conducted at the facility between July 2012 and September 2013. All 137 staffs, including medical doctors and midwives, were trained in January 2013. The causes of 299 neonatal deaths and the day of death, up to 27 days, were collected before and after the training course. RESULTS: Deaths caused by intrapartum-related complications were reduced from 51% to 33%. Preterm infants survived for more days (p < 0.01) during the neonatal period, but overall in-hospital neonatal mortality was unchanged (p = 0.46) after training. The survival rates linked to complications of infection, congenital anomalies and other causes were unaffected by the intervention. CONCLUSION: The continuum of postnatal care for newborn infants needs to be strengthened after Helping Babies Breathe training, to maintain the gains in neonatal survival on the day of delivery. Additional interventions in the postnatal period are therefore required to increase neonatal survival at facilities in low-income settings.

Dwiroopa punicae sp. nov. (Dwiroopaceae fam. nov., Diaporthales), associated with leaf spot and fruit rot of pomegranate (Punica granatum).

During a survey of diseases affecting pomegranate in the southeastern USA we identified a unique species of Diaporthales causing leaf spotting and fruit rot. Objectives of this study were to provide a morphological description of the putative new species, use DNA sequence data of three gene loci (LSU, ITS and rpb2) to accurately place the fungus within the Diaporthales, and to prove Koch's postulates. Morphological and phylogenetic comparisons confirmed the fungus to represent a new species and family, for which the names Dwiroopa punicae sp. nov. and Dwiroopaceae fam. nov. are proposed. This is the first report of a species of Dwiroopa being pathogenic to Punica granatum.

Effect of the COVID-19 pandemic response on intrapartum care, stillbirth, and neonatal mortality outcomes in Nepal: a prospective observational study

Background: The COVID-19 pandemic response is affecting maternal and neonatal health services all over the world. We aimed to assess the number of institutional births, their outcomes (institutional stillbirth and neonatal mortality rate), and quality of intrapartum care before and during the national COVID-19 lockdown in Nepal. Methods: In this prospective observational study, we collected participant-level data for pregnant women enrolled in the SUSTAIN and REFINE studies between Jan 1 and May 30, 2020, from nine hospitals in Nepal. This period included 12·5 weeks before the national lockdown and 9·5 weeks during the lockdown. Women were eligible for inclusion if they had a gestational age of 22 weeks or more, a fetal heart sound at time of admission, and consented to inclusion. Women who had multiple births and their babies were excluded. We collected information on demographic and obstetric characteristics via extraction from case notes and health worker performance via direct observation by independent clinical researchers. We used regression analyses to assess changes in the number of institutional births, quality of care, and mortality before lockdown versus during lockdown. Findings: Of 22 907 eligible women, 21 763 women were enrolled and 20 354 gave birth, and health worker performance was recorded for 10 543 births. From the beginning to the end of the study period, the mean weekly number of births decreased from 1261·1 births (SE 66·1) before lockdown to 651·4 births (49·9) during lockdown-a reduction of 52·4%. The institutional stillbirth rate increased from 14 per 1000 total births before lockdown to 21 per 1000 total births during lockdown (p=0·0002), and institutional neonatal mortality increased from 13 per 1000 livebirths to 40 per 1000 livebirths (p=0·0022). In terms of quality of care, intrapartum fetal heart rate monitoring decreased by 13·4% (-15·4 to -11·3; p<0·0001), and breastfeeding within 1 h of birth decreased by 3·5% (-4·6 to -2·6; p=0·0032). The immediate newborn care practice of placing the baby skin-to-skin with their mother increased by 13·2% (12·1 to 14·5; p<0·0001), and health workers' hand hygiene practices during childbirth increased by 12·9% (11·8 to 13·9) during lockdown (p<0·0001). Interpretation: Institutional childbirth reduced by more than half during lockdown, with increases in institutional stillbirth rate and neonatal mortality, and decreases in quality of care. Some behaviours improved, notably hand hygiene and keeping the baby skin-to-skin with their mother. An urgent need exists to protect access to high quality intrapartum care and prevent excess deaths for the most vulnerable health system users during this pandemic period. Funding: Grand Challenges Canada. (AU)

State of midwives in Nepal: HRH to improve maternal and neonatal health and survival.

Improving health and survival of mothers and newborns depends on the delivery of evidence-based cost effective interventions through a skilled care provider. Evidence suggests that midwives are compassionate skilled care providers to mothers, and ensuring these skilled human resources is a key to progress towards Millennium Development Goals 4 and 5. With this in mind, this article analyses the state of midwifery in Nepal and what strategies are needed to ensuretheir accessibility and availability. In Nepal, as a result of community mobilization through Female Community Health Volunteers for birth preparedness and complication readiness, there has been a demand for skilled care at birth. However the supply of skilled birth attendants has been inadequate both in terms of number as well as quality of care.

Community participation and mobilization in community-based maternal, newborn and child health programmes in Nepal.

A number of studies on community mobilization for maternal and newborn health have demonstrated that community participation is of profound importance in the delivery of community based survival interventions for mother, newborn and children and a cost effective way to reduce mortality. However, the lessons learnt from the efficacy trials have not been tested within the health systems. Nepal is well known for its public health programmes and wide successes in campaign based interventions as a result of active involvement of volunteers and organizations based in the community. This paper analyzes the degree of community participation and mobilization in community-based maternal, newborn and child health programmes and its potential implication in acceleration towards achieving Millennium Development Goals 4 and 5. The study is based on analysis of the existing national community based maternal, neonatal and child health programmes in terms of degree of community mobilization and participation for ownership and sustainability of programmes. Furthermore, a qualitative assessment was carried out to assess the level of engagement of community structures in community based maternal, newborn and child health programme. None of the national community based maternal, newborn and child health programmes used the community action cycle approach and there was minimal level of involvement of community networks. The mother's groups had been least engaged in identifying and solving the maternal, newborn and child health problems and Female community health volunteer were engaged in delivering messages at household level and not through the mother's groups. Though the Community Action Cycle was studied in Nepal and it was found effective to achieve the objectives, getting its lessons into practice to design community health programs were lacking. The mother's groups need to be revitalized to ensure their active participation in identifying, analyzing and agreeing on steps to solve the problems related to maternal, neonatal and child health so that care seeking and utilization of health services will be further enhanced. The national strategies need to explore the possibilities of incorporating the community action cycle frame into its programmes, test the frame and ensure its implementation in the National community based programs in order to improve health outcomes of mother, newborn and children.

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

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

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

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

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

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