Comprehensive Field Practice

A REPORT ON

COMPREHENSIVE FIELD PRACTICE ON MANAGEMENT OF DISTRICT PUBLIC

HEALTH SERVICES Dhankuta

Submitted By Group-A

BPH Third Year (First Batch) Valley College of Technical Sciences

2011

Submitted to Department of Public Health

Valley College of Technical Sciences Mid-Baneshwor, Kathmandu

2011

A REPORT ON

COMPREHENSIVE FIELD PRACTICE ON MANAGEMENT OF DISTRICT HEALTH

SYSTEM, DHANKUTA

Submitted to Department of Public Health

Valley College of Technical Sciences Siphal, Kathmandu

2011

Submitted by Group A


2011

A REPORT ON

COMPREHENSIVE FIELD PRACTICE ON MANAGEMENT OF DISTRICT HEALTH SYSTEM,

DHANKUTA

Department of Public Health Submitted to

Valley College of Technical Sciences Mid-Baneshwor, Kathmandu

Group-A Submitted By


July 2011

GROUP MEMBERS

1. ANIL DHUNGANA 2. ANU GOMANJU

3. DINESH RUPAKHETI 4. NARESH BHATTA

5. PRABESH GHIMIRE 6. RABINA KUMARI RAJAK

7. SHREETINA K. TULADHAR 8. UTTAM GAUTAM

Group-A Comprehensive District Health Management Team


Siphal, Kathmandu

July 2011

APPROVAL SHEET

Purbanchal University

Valley College of Technical Sciences

Siphal, Kathmandu

This Field Practice Report Presented

by

Group A

Entitled

“Comprehensive Field Practice on Management of District Health System,

Dhankuta”

has been accepted as partial fulfillment of

the requirement for the degree of

Bachelor in Public Health

Approved by:

Prof. Chitra Kr. Gurung

Senior Consultant

(Field Supervisor)

Mr. Suman C. Gurung Head of Department

Department of Public Health Valley College of Technical Sciences

Kathmandu

Prof. Nabin Shrestha External Evaluator

Mr. Suman C. Gurung Head of Department

Department of Public Health Valley College of Technical Sciences

Kathmandu

iv A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta

ACKNOWLEDGEMENT

Behind the successful accomplishment of our one month Comprehensive Field Practice

on District Health System lie the candid abutments and sumptuous kindness of many

luminaries. This field practice report is therefore, not the exclusive product of our group.

We owe much of the credit to the support and assistance of many helping hands.

We express a deep gratitude to the staffs of District Health Office for their invaluable co-

operation and magnanimous hospitality. A special thank goes to Mr. Jhalak Sharma

Poudel, District Health Officer, Dhankuta, who helped us immensely by letting pilfer

times to us out of his busy schedules by providing valuable guidance and supervision

during our stay at Dhankuta. Our sincere thanks go to Mr. Ram Narayan Shrestha

(Section Officer, DHO) who helped us establish effective co-ordination with other

sections and peripheral institutions & Mr. Purna Shekhar Shrestha (Statistician) who

supported us during data review and worked as the resource person during mini-action

project. We are very much grateful to Akshay Lal Yadav (CB-IMCI Supervisor), Toya

Ghimire (Family Plannning Supervisor), Balkumari Gurung (Public Health Nurse) and

the whole DHO family for their valuable support during critical review, epidemiological

study and five year planning.

We cordially gratify all stakeholders of Dhankuta for their colossal suppo rt. FPAN,

SOLVE & NRCS also deserve special thanks for their help and support during our

institutional visits. Danda Bazaar PHC, Pakhribas HP, Parewadin SHP are also pertinent

for heartfelt acknowledgements that supported us during our observation visits to these

institutions.

Further, we would like to extend our special thanks to Dhankuta Multiple Campus for

providing us a residence in its guest house and making our stay a magnificent.

We thank the director of Valley College of Technical Sciences Dr. Yubin Pokhrel for

providing financial allowance, logistics support and transportation services Prof. Hari

Bhakta Pradhan and Mr Suman C. Gurung (HOD) for their constructive feedback and

continuous support, Mr. Bishnu Choulagai (field co-ordinator) for his valuable

v A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta

orientations, Prof. Chitra Kr. Gurung (field supervisor) and all the staffs of Valley

College of Technical Sciences.

We also would like extend our warmest appreciation to our colleagues for their cheerful

encouragement, amiable affection and ongoing support.

Last but not the least we would like to gratify all those who helped us directly or

indirectly to make our field practice a successful.

July, 2011 Group A

vi A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta

ACRONYMS

ABER Annual Blood Examination Rate

ADRA Adventist Relief Development Agency

AIDS Acquired Immune Deficiency Syndrome

ANC Antenatal Care

ANM Auxiliary Nurse Midwife

ARI Acute Respiratory Infection

ASL Authorized Stock Level

B/CEOC Basic/ Comprehensive Emergency Obstetric Care

BCG Bacillus Calmette Guerin

BNMT Britain Nepal Medical Trust

BPH Bachelor of Public Health

CAC Comprehensive Abortion Care

CB-IMCI Community Based Integrated Management of Childhood Illness

CB-NCP Community Based Neonatal Care Programme

CBOs Community Based Organizations

CBR Crude Birth Rate

CDD Control of Diarrhoeal Diseases

CDMA Code Digital Multiple Access

CDO Chief District Officer

CDR Crude Death Rate

COPD Chronic Obstructive Pulmonary Disease

CPR Contraceptive Prevalence Rate

CYP Couple Years of Protection

DACC District Aids Co-ordination Committee

DDC District Development Committee

DEO District Education Office

DHMT District Health Management Team

DHO District Health Office

DHOr District Health Officer

vii A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta

DHS District Health System

DoHS Department of Health Services

DOTS Directly Observed Treatment – Short Course

DPT Diphtheria, Pertusis & Tetanus

EHCS Essential Health Care Services

EOP Emergency Order Point

EPI Expanded Programme on Immunization

FCHV Female Community Health Volunteer

FEFO First Expiry First Out

FP Family Planning

FPAN Family Planning Association Nepal

FY Fiscal Year

GOs Governmental Organizations

HF Health Facility

HFMC Health Facility Management Committee

HI Health Institution

HIV Human Immuno- deficiency Virus

HMIS Health Management Information System

HP Health Post

HPI Health Post Incharge

HURSADEC Human Rights Social Awareness and Development Centre

HWs Health Workers

IEC Information Education and Communication

INGOs International Non Governmental Organizations

IPD Indoor Patient Department

IUD Intra Uterine Device

KAP Knowledge Attitude Practice

LA Lab Assistant

LDOr Local Development Officer

LMD Logistics Management Division

LMIS Logistics Management Information System

viii A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta

MAP Mini Action Project

MB Multi Bacillary

MCHWs Maternal and Child Health Workers

MDGs Millennium Development Goals

MO Medical Officer

MoHP Ministry Of Health and Population

MWRA Married Women with in Reproductive Age

NA Not Available

NDHS Nepal Demographic Health Survey

NESOG Nepal Society of Obstetricians and Gynecologists

NGOs Non Governmental Organizations

NTP National TB Programme

NHEICC National Health Education Information and Communication Centre

NHP National Health Policy

NHSP-IP National Health Sector Program- Implementation Plan

NHTC National Health Training Center

NIP National Immunization Programme

NPC National Planning Commission

NRCS Nepal Red Cross Society

NSMLTP National Safe Motherhood Long Term Plan

OPD Out Patient Department

OPV Oral Polio Vaccine

ORS Oral Rehydration Solution

ORT Oral Rehydration Therapy

P1 Priority- One

PAC Post Abortion Care

PB Pauci- Bacillary

PEM Protein Energy Malnutrition

PGR Population Growth Rate

PH Public Health

PHC/ORC Primary Health Care/ Out Reach Clinic

ix A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta

PHCC Primary Health Care Center

PME Planning, Monitoring and Evaluation

PNC Post Natal Care

PUO Pyrexia of Unknown Origin

RBM Roll Back Malaria

RH Reproductive Health

RHCC Reproductive Health Co-ordination Committee

RHD Regional Health Directorate

RHTC Regional Health Training Centre

RMS Regional Medical Store

RTI Respiratory Tract Infection

SHP Sub Health Post

SLTHP Second Long Term Health Plan

SM/FP Safe Motherhood/ Family Planning

SMNH Safe Motherhood and Neonatal Health

SMP Safe Motherhood Program

SOLVE Society for Local Volunteer’s Effort

SPR Slide Positivity Rate

SWOT Strength, Weakness, Opportunity and Threat

TADA Travel Allowance Daily Allowance

TB Tuberculosis

TBA Traditional Birth Attendant

TT Tetanus Toxoid

U5

URTI Upper Respiratory Tract Infection

Under Five

UTI Urinary Tract Infection

VAD Vitamin A Deficiency

VDC Village Development Committee

VHW Village Health Worker

VSC Voluntary Surgical Contraception

WHO World Health Organization

x A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta

SUMMARY

This report is the outcome of comprehensive field practice on management of district

health system conducted from 21th Baisakh to 20st

Jestha 2068 B.S. in Dhankuta district.

The objective of our study was to develop knowledge and skills regarding management

of district health system. The study design was descriptive & cross sectional and was

mainly based on secondary data analysis/review and primary information was collected

to triangulate the findings.

Dhankuta district, situated in eastern development region, constitutes of 2 electoral

constituencies, 1 municipality, 11 illakas, 35 VDCs and 333 wards covering 891 sq. km.

Dhankuta has the population density of 190.19 per sq. km and total population of

166,479. The major ethnic group is Rai.

District hospital, 2 Ayurvedic Ausadhalayas, 2 PHCCs, 11 HPs, 24 SHPs. 151 EPI

Clinics, 79 PHC/ORCs, 315 FCHVs and private hospitals and clinics are major

institutions for the delivery of health services in the district.

The leadership was of democratic type. Horizontal co-ordination was with different

government line agencies and vertical co-ordination with RHD and MD under DoHS. 16

posts under DHO were vacant.

Store was poorly maintained but logistics supply was done timely. HMIS reporting from

peripheral levels were satisfactory. However, DHO still couldn’t maintain co-ordination

with private sectors regarding reporting.

Major programs in the district were NIP, Nutrition, CB-IMCI, Family Planning and Safe

Motherhood Programme, FCHV and PHC/ORC Programme, TB and Malaria Control,

Leprosy Elimination and HIV/AIDS Prevention and Control Programme.

xi A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta

The vaccine coverage was around 72.26% (066/67). Depo was the widely accepted FP

device. The 4 ANC visits were 56.75%. The delivery conducted by HW and SBAs was

17.58%.

TB case finding rate was lower than national level. Four new cases of HIV/ AIDS were

reported in FY 067/68. The average no. of people served by FCHVs in FY 066/67 had

increased than that of FY 065/66. The reporting has also increased as compared to

previous years.

CAC service was available in district hospital and Marie Stopes Center. In the FY 066/67

878 people had received this service. District hospital and PHCCs were providing BEOC

services. Skin disease counts the top position on top ten diseases followed by ARI.

On the basis of three years record of IPD cases in district hospital, an epidemiological

study was done on Pneumonia.

Critical reviews were done on eight different topics which were Safe Motherhood

Programme, Recording and Reporting, Integrated Supervisions, Logistic Management,

CB-IMCI, NIP, PHC/ ORC Programme, NTP and Staffing situation.

Mini Action Project was done on Recording and Reporting. In the program, orientation

on revised version of HMIS tools was given and also problems and issues on

recording/reporting were identified and solutions were drawn.

A five year plan on Safe Motherhood was done with the goal to improve maternal health

and survival of women in Dhankuta district with the budget of NRs. 28,257,600 for five

years. The plan was prepared in LFA.

The findings were shared and discussion session was held in the DHO in presence of

staffs from DHO, District Hospital and DACC.

(500 words)

xii A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta

HEALTH SERVICE COVERAGE FACT SHEET, DHANKUTA

FY 2064/65 to 2066/67

Reporting Status 2064/65 2065/66 2066/67 1 Hospital 100 100 2 PHCC 100 100 3 HP 100 100 4 SHP 100 100 5 PHC/ORC 89 82 6 FCHV 94 95 7 EPI Clinics 92 93 Expanded Programme on Immunization 1 BCG Coverage 77.9% 70.27% 75.13% 2 DPT-3 Coverage 75% 70.21% 65.27% 3 Polio-3 Coverage 74.1% 70.21% 70.11% 4 Measles Coverage 70.9% 70.60% 72.26% 5 % of Pregnant women receiving TT-2 Nutrition Programme 1 % of Pregnant women receiving Iron tablets 48% 43.32% 57.44% 2 % of Postpartum Mother receiving Vitamin A 45.5% 35.55% 43.53% Acute Respiratory Infection (ARI) 1 Reported Incidence of ARI/1,000 <5 Children New

Visits (by HF) 289 412 450.55

2 Reported Incidence of ARI/1,000 <5 Children New Visits (by Community)

616 648.56 895.25

3 Percentage of new Pneumonia 55.2% 55% 52.30% Control of Diarrhoeal Diseases (CDD) 1 Incidence of Diarrhoea/1,000 <5 Children New

Cases (by HF) 129 123.70 165.13

2 % of Severe Dehydration 0.69% 0.02% 0.11% Safe Motherhood Programme 1 Antenatal First Visits as % of Expected Pregnancies 32.80% 47.10% 62.47% 2 Delivery Conducted by SBA at Home and Health

Facility as % of expected pregnancy 7.9% 7.8% 11.4%

3 Deliveries Conducted by SBA and Health Workers at Home and Health Facility as % of Expected Pregnancies

17.44% 14.8% 17.58%

4 Deliveries Conducted at Health Facilities as % of Expected Pregnancies

32.8% 42.34% 57.86%

5 PNC First Visits as % of Expected Pregnancies 34.1% 33.88% 44.89%

xiii A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta

Family Planning Programme 1 Pills 3.9% 5.4% 5.4% 2 Depo Provera 13.3% 14.7% 12% 3 IUCD 0.84% 1% 0.97% 4 Norplant 0.81% 1.32% 1.69% 5 Contraceptive Prevalence Rate 30.83% 37.52% 34% Tuberculosis Control Programme 1 Cure Rate 88% 90% 91% 2 Case Finding Rate 41.5% 27% 33% Leprosy Control Programme 1 New Case Detection Rate (NCDR) /10,000 0.16 0.21 0.05 Curative Services 1 Total OPD New Visits 20901 24889 25054 2 Total OPD New Visits as % of Total Population 11.24% 11.88% 13.25%

xiv A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta

TABLE OF CONTENTS

Contents Page No.

GROUP MEMBERS ii

APPROVAL SHEET iii

ACKNOWLEDGEMENT iv

ABBREVIATIONS vi

SUMMARY x

HEALTH SERVICE COVERAGE FACT SHEET xii

TABLE OF CONTENTS xiv

LIST OF TABLES xviii

LIST OF FIGURES xxi

CHAPTER I: INTRODUCTION 1-10

1.1 Background 1

1.2 Objectives 3

1.3 Methodology 4

1.4 Validity and Reliability 7

1.5 Logistics 9

1.6 Plan of Action 10

CHAPTER II: DISTRICT PROFILE 11-20

2.1 Introduction 11

2.2 Political and Administrative Division 11

2.3 Geographical Features 12

2.4 Socio-economic Status 12

2.5 Climate 14

2.6 Major Rivers 15

2.7 Tourist Places 15

2.8 Cultural and Religious Heritages 15

xv A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta

2.9 I/NGOs 16

2.10 Government Organizations 16

2.11 Development Resources 16

2.12 Transportation 17

2.13 Communication 17

2.14 Water Supply and Sanitation 18

2.15 Crime Incidents 18

2.16 Demographic Characteristics 19

2.17 Map of Dhankuta 20

CHAPTER III: DISTRICT HEALTH SYSTEM 21-61

3.1 Introduction 21

3.2 District Health Management in System Model 24

3.2.1 Service Inputs 25

3.2.2 Process 29

3.2.3 Output 40

3.2.3.1 Child Health Programme 40

3.2.3.2 Reproductive Health Programme 47

3.2.3.3 Disease Control Programme 52

3.2.3.4 FCHV Programme 54

3.2.3.5 PHC-ORC Programme 55

3.2.3.6 Curative Services 56

3.3 Top Ten Diseases in Dhankuta 59

3.4 SWOT Analysis of District Health System 59

3.5 Recommendations 61

CHAPTER IV: VISITED ORGANIZATIONS 62-81

4.1 Peripheral Health Institutions 62

4.2 Supporting Organizations 74

xvi A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta

CHAPTER V: EPIDEMIOLOGICAL STUDY 82-86

5.1 Introduction 82

5.2 Objectives 82

5.3 Rationale 82

5.4 Methodology 83

5.5 Study Variables 83

5.6 Epidemiological Characteristics 83

5.7 Findings and Discussions 84

5.8 Conclusions 86


CHAPTER VI: CRITICAL REVIEW 87-121

6.1 Logistics Management 87

6.2 Integrated Management of Childhood Illness 93

6.3 National Immunization Programme (NIP) 97

6.4 Recording and Reporting 101

6.5 Staffing Situation 106

6.6 Case finding in National TB Programme 109

6.7 Primary Health Care outreach Clinics Programme 114

6.8 Integrated Supervision 117

CHAPTER VII: MINI-ACTION PROJECT 122-126

7.1 Introduction 122

7.2 Rationale 122

7.3 Objectives 122

7.4 Date, Venue and Time 123

7.5 Methodology 123

7.6 Plan of Action 124

7.7 Activities 125

7.8 Results 125

xvii A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta

7.9 Evaluation of MAP 125

7.10 Sustainability of MAP 126

CHAPTER VIII: FIVE YEAR PLAN 127-146

8.1 Introduction 127

8.2 Rationale 127

8.3 Process of Developing the Plan 128

8.4 Plan Format 129

8.5 Goal and Objectives 129

8.6 Targets 130

8.7 Safe Motherhood Plan in LFA 131

8.7 Major Activities 137

8.8 Targets for Safe Motherhood Programme 142

8.9 Budget Plan 144

CHAPTER IX: OTHER ACTIVITIES 147-151

9.1 District Presentation 147

9.2 Participated Programmes 150

CHAPTER X: CONCLUSIONS AND RECOMMENDATIONS 152-154

10.1 Conclusions 152


BIBLIOGRAPHY 155-156

ANNEX 157

xviii A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta

LIST OF TABLES

Table no. Table Title Page No.

1 Work Plan of Comprehensive Field Practice 10

2 Level & Sex-wise Distribution of Students 12

3 Institution-wise Distribution of Education 13

4 Distribution of Ethnicity in Dhankuta 13

5 Language Distribution in Dhankuta 14

6 Distribution of Land in Dhankuta 16

7 Transportation Facility in Dhankuta 17

8 Crime Incidents in Dhankuta 18

9 Demographic Characteristics of Dhankuta 19

10 Staffing Pattern of DHO 25

11 Distribution of Health Institutions in Dhankuta 26

12 Health Logistics in DHO 27

13 LMIS Reporting Schedule in Dhankuta 39

14 Immunization Coverage 40

15 Vaccine Wastage 41

16 Immunization Drop-out Rate 41

17 Problems and Constraints in Immunization Programme 42

18 Growth Monitoring Status of Under-5 Children 43

19 Achievements of Child Nutrition Programme 44

20 Achievements of Nutrition Programme for Mothers 44

21 Problems and Constraints in Nutrition Programme 45

22 Service Statistics of ARI Control 46

23 Problems and Constraints in ARI Control Programme 46

24 Service Statistics of CDD 47

xix A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta

25 Service Statistics of Family Planning 48

26 Acceptors of Family Planning Devices 48

27 Problems and Constraints in FP Programme 49

28 Trends of ANC Visits 49

29 Delivery Services Statistics in Dhankuta 50

30 Trends of PNC Visits 50

31 Problems and Constraints of SM Programme 51

32 Service Statistics of Malaria Control Programme 52

33 Achievements of Malaria Control Programme 53

34 Service Statistics of Leprosy Control Program 53

35 Service Statistics of FCHV Programme 54

36 Problems and Constraints of FCHV Programme 55

37 Service Statistics of PHC-ORC Programme 55

38 Problems and Constraints of PHC-ORC Programme 56

39 Service Statistics of District Hospital 57

40 Other Service Statistics in District Hospital 57

41 Top-Ten Disease in Dhankuta 59

42 SWOT Analysis of District Health System 60

43 Staffing Pattern of Dandabazar PHCC 63

44 Service Indicators of Dandabazar PHCC 65

45 Staffing Pattern of Pakhribas Health Post 68

46 Service Indicators of Pakhribas Health Post 69

47 Data trends on ARI Incidence 94

48 Four Years Trend Analysis on Immunization 98

49 Immunization Drop-out Rate 99

50 HMIS Reporting from Different Institutions 102

51 HMIS Reporting Status of Different Organizations 103

52 Post wise Staffing Situation 107

53 DOTS Treatment Centre wise case Detection Ratio 112

xx A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta

54 Trends in PHC/ ORC Conducted in Dhankuta District 115

55 Routine Supervision Strategy in District Level 118

56 Supervision Status of the District 119

57 Plan of Action of MAP 124

58 Safe Motherhood Plan in Log-Frame Approach 131

59 Major Activities in Safe Motherhood Plan 137

60 Targets for Safe Motherhood Programme 142

61 Budget Plan for Safe Motherhood Programme 144

xxi A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta

LIST OF FIGURES

Table no. Figure Title Page No.

1 Map of Dhankuta District 20

2 District Health System in Dhankuta 22

3 Central Role of DHO Within the DHS 23

4 System Model of District Health System 24

5 PME Cycle of DHO 29

6 Planning Cycle of District Health Services 30

7 Micro-planning in Dhankuta 31

8 Organizational Structure of HIs in Dhankuta 33

9 Organogram of DHO 34

10 HMIS Process in DHO, Dhankuta 37

11 LMIS Process in DHO, Dhankuta 38

12 Health Budgeting Process in Dhankuta 39

13 Time Distribution of Pneumonia 85

14 Sex Distribution of Pneumonia 85

15 Age Distribution of Pneumonia 86

16 Logistics Flow System 89

17 Logistics Management Information System 90

18 Trends of Diarrhoeal Incidence 95

19 New Growth Monitoring Coverage in Dhankuta 95

20 Year wise TB Case Detection Ratio 111

21 Phases of MAP 124

CHAPTER I

INTRODUCTION

1 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta, 2011

CHAPTER I

INTRODUCTION

1.1 Background

The district is the most peripheral unit of local government and administration that has

comprehensive powers and responsibilities. It differs greatly from country to country in

size and degree of autonomy, and population may vary from less than 50,000 to over

300,000. It comprises first and foremost “a well-defined population living within a

clearly delineated administrative and geographical area”. The district is the level where

health policies and health sector reforms are interpreted and implemented.

The district headquarter is usually in the main town where there are the offices of all the

principal ministries that are concerned with district and local affairs, such as health,

agriculture, education, social welfare and community development. The district is the

natural meeting point for “bottom-up” community planning and organization, and for

“top-down” central government planning and development. It is, therefore, a natural

place for the local community needs to be reconciled with national priorities.

(Manual of Epidemiology for District Health Management: WHO; 1989)

The term district is widely accepted as a generic term for the level of health systems

management where plans and budgets are prepared and implementation is co-ordinated

with local government and with other sectors.

(Strengthening Health Management in Districts and Provinces, WHO; 1995)

A district health system includes the interrelated elements in the district that contribute to

health in homes, educational institutions, workplaces, public places and communities, as

well as in the physical and psychosocial environment. It includes self-care and all health

care personnel and facilities, whether governmental or non-governmental, up to and

including the hospital at the first referral level and the appropriate support services

(laboratory, diagnostic and logistic support).

(Health Sector Reform and District Health Systems: WHO; 2004)


The following are some of the components of a district health system:

• district health office;

• district hospital or hospitals;

• health centers;

• community, neighborhoods and households;

• Private health sector, NGOs and mission health services.

The sound health of the district inevitably requires the effective and efficient

management of district health system.

Management of district health services is a process whereby action is taken related to

resources, such as people, finances, equipment and facilities, to achieve identified goals.

The District Health Office is responsible to ensure the equitable delivery of high quality,

cost-effective district health services. DHO is also concerned with the day-to-day

management of the district health system. Common DHO functions include planning,

supervision, budgeting and finance control as well as problem-solving and crisis

management.

Bachelor of Public Health is an undergraduate degree which aims to prepare professional

public health specialist who are technically and managerially competent and significantly

responsible in the planning, implementation, monitoring and evaluation of overall district

level public health services as well as in the administration and management of district

public health system.

The comprehensive field practice on management of district health system is one

of the important practice oriented field based program, designed by Purbanchal

University for the students of BPH 3rd year to provide an opportunity to learn the needed

managerial skills and other technical skills in terms of district health management. This

field practice aims to develop the basic skills in the students to assess resources

potentiality and constraints, prioritize the health problems and set strategies for solving

them, assist in developing suitable options and action plan for addressing the priority

health problems in the districts. So, the BPH product should be able to carry out the


responsibilities designed for the district (public) health officer, which is not only possible

through theoretical classes in the campus but it also requires practical exposures in the

real field. Holistic practical learning is not justifiable without such type of field program.

1.2 Objectives

1.2.1 General Objective

• To develop knowledge and skills regarding management of district public

health services by exploring the health system of Dhankuta district.

1.2.2 Specific Objectives

• To analyze the demographic and health profile of Dhankuta District.

• To explore the epidemiological factors regarding specific diseases

phenomenon.

• To critically appraise the different health and/or management aspects of

District Health System.

• To develop a Comprehensive Five Year Plan on a prioritized health or

management issue.

• To plan, implement and evaluate a Mini Action Project (MAP).


1.3 Methodology

1.3.1 Study type

The study design was cross sectional descriptive type as the data were

collected and reviewed at a particular point of time and findings were

presented in descriptive forms through texts, tables and figures.

1.3.2 Study area

Dhankuta district was conveniently selected as the area of study for our

comprehensive field practice. It was finalized as the study area after

communication with the DHOr.

1.3.3 Study duration

The time duration for our study was of 30 days beginning from 21st Baisakh to

20th

Jestha.

1.3.4 Techniques and tools of data/information collection

• Secondary data review

Data review was done from monthly monitoring and annual performance

review worksheets of four fiscal years from FY 2064/65 to FY 2067/68,

that were available at the statistical section of DHO. Service statistics of

district hospital were also reviewed from hospital records. Discharge

registers were used to review the cases of pneumonia among IPD cases.

Various secondary data review formats were prepared and used for data

review.

• Interview (Key informant, In-depth)

Interview was done with DHOr to understand the overall management

issues of DHO and to identify the health status of Dhankuta. The interview

was done using interview guidelines. Section officer and various

programme officers (FP supervisor, Public Health Nurse, IMCI


supervisor) were also interviewed for critical review on various health

programmes and management issues. Statistician was interviewed to

analyze the recording and reporting status of the district and store keeper

was also interviewed to critically analyze the logistics management system

operating within the district

The in-charges of Dandabazar PHCC, Pakhribas HP and Parewadin SHP

were interviewed using interview guidelines to identify the management

issues within their institutions.

Further, interview was done with the head of various supporting

organizations viz. FPAN, NRCS, BNMT and SOLVE.

• Meeting (formal and informal)

At the very beginning, formal meeting was conducted with the whole

DHO family for sharing our objectives of field visit and appeal for co-

ordination. Numerous informal meetings were conducted to facilitate our

study process. Meeting was done with public health nurse for preparing

five- year plan, with statistician to discuss on issues regarding MAP, and

with DHOr during supervisory visits from the college.

• Observation

District medical store and cold chain centre in the district health office

were observed to explore the logistics management system of the district.

The observation was done using observation checklist.

The peripheral institutions (Dandabazar PHCC, Pakhribas HP and

Parewadin SHP) were also observed to analyze the managerial system of

these institutions regarding waste management, store management,

infrastructures and logistics.


1.3.5 Data Sources

In order to prepare the socio-demographic and health profile of the district, the

information was collected from various agencies and institutions. Health

System being the concern of our study, District Health Office was the chief

source for information collection. Necessary information regarding district

profile was available from District Development Committee. Other related

data were collected from several other line agencies such as District Education

Office (Education related data), District Police Office (data on crime

incidents), District Agriculture Development Office, District Traffic Police

Office (data on RTAs), and District Livestock Development Office.

Information were also collected from FPAN, NRCS, SOLVE and BNMT

regarding supportive health programmes conducted in the district.

1.3.6 Analysis

Data analysis involved series of processes. The collected data from the manual

monthly monitoring sheets were first verified from the electronic version of

monitoring sheets. The data were then classified according the objectives and

three years data trend were analyzed by preparing tables and charts.

1.3.7 Data/ Information Presentation

All the collected information was presented through various graphs, tables and

necessary figures. Figures included organograms, flow charts of various

management systems (Logistics management and information systems),

managerial processes (planning cycle, co-ordination, budgeting) and other

necessary frameworks to generate the clear concepts on various processes

within district health system. Three years data trend were presented through

tabular forms. Texts were used to describe the findings more clearly and

precisely.


1.3.8 Dissemination

The dissemination of findings regarding the collected information was done

through two different approaches. Two presentation sessions were organized

at the seminar hall of DHO to present the major findings of our study. After

the completion of our field practice, the presentation was also organized at the

college.

Finally, the overall information was disseminated through the comprehensive

report.

1.3.9 Ethical consideration

The official letter was submitted from campus to the DHO.

Objectives of the study were clarified to the stakeholders of the

district.

Verbal consent was taken prior to interview.

Assurance of the confidentiality on sensitive issues was done.

1.4 Validity and Reliability

1.4.1 Validity

• External Validity

The information that was collected from DHO included comprehensive data

from each and every VDCs of the district. Hence, findings can be generalized

to the entire population within the district.

• Construct Validity

Pre-testing of interview guidelines for health post incharge was done by

interviewing HP in-charge of Dharmasthali VDC and necessary

modifications were made in the tool. However due to constraint of time we

were unable to test all the tools that were prepared for the study in Dhankuta.


• Content Validity

Before going to assigned district, we were given four days’ orientation

classes on various subjects to be considered during the course of our study.

Numbers of reports from senior batches of different colleges were reviewed

to design the various tools (interview guidelines and secondary data review

formats) as well as to identify core aspects to be studied during the field stay.

The tools were later revised during the orientation classes in presence of field

co-ordinator.

• Face Validity

Findings and conclusions were accepted and valued by DHOr as well as

other staffs of DHO during the presentation session.

1.4.2 Reliability

• Information Collection

All the records were maintained in the form of detailed notes. Information

that was collected during the interview was presented exactly as what had

been told by the interviewee (DHOr, programme officers, section officer,

statistician and store keeper).

• Data Verification

Each data collected from monthly monitoring sheets were cross-checked so

that any mis/under responding could be corrected.

• Tabulation of data

Cross checking of tables was done among the subgroups to maintain

consistency as far as possible.


• Comparisons

Our findings showed similar results when compared against the report of the

previous comprehensive field study done at Dhankuta by senior batch from

Tribhuwan University.

• Supervision

Intermittent supervision was done by field coordinators Prof. Chitra Kr.

Gurung and Bishnu Choulagai and DHOr Jhalak Sharma Poudel was

assigned as the local supervisor.

1.5 Logistics

• Lodging and Fooding:

We stayed at the guest house of Dhankuta Multiple Campus for which we had to

pay Rs 12000. We had arranged our fooding at the canteen of the same campus at

Rs 60 per meal.

• Stationeries:

The necessary stationeries were provided by the college.

• Financial support:

A daily allowance of Rs. 300 was provided by the college.

• Camera and films:

We had three digital cameras to take the photos of important events during our

study period.

• Computing materials:

We had 1 lap-top & 3 calculator for data entry and computation.

• Transportation:

The two way transportation facility was provided by the college.

10 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta

1.6 Plan of Action

Table 1: Work plan of comprehensive field practice

Activities 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Departure to Dhankuta

Arrangements

Rapport Building

NGOs/ INGOs Visit

Data Collection

Data Analysis

Critical Review

PHCC/HP/SHP Visits

Epidemiological Study

Mini-Action Project

First Presentation

Five Year Planning

Final Presentation

Departure to Campus

CHAPTER II

DISTRICT PROFILE


CHAPTER II

DISTRICT PROFILE

2.1 Introduction

Dhankuta District, a part of Koshi Zone, is one of the seventy-five districts of Nepal. The

district covers an area of 891 km² and has a population (2001) of 166,479. Dhankuta is

the district headquarter and a major administrative region in the Eastern region. Dhankuta

Bazaar, on the North-South Koshi Highway, is the administrative headquarters for the

Eastern Development Region, and is home to a number of NGOs/ INGOs and various

other aid agencies. The large bazaar of Hile further up the road is an important trading

centre and major road head, serving the remote hinterlands of the Arun valley and

Bhojpur.

2.2 Political/Administrative Division

• Development Region: Eastern

• Zone: Koshi

• District headquarter: Dhankuta municipality

• Electoral constituency: 2

• Municipality 1

• Illaka: 11

• VDCs: 35

• Ward: 333

The districts are uniquely placed at a level where they are in a position to maintain a vertical relationship with higher management levels, horizontal relationship with other local departments and an external relationship with the communities and organizations they serve.

(District Health Planning Manual)


2.3 Geographical features

2.3.1 Topography

• Area: 891 sq Km

• Latitude: 26º35’ to 27º11’ North

• Longitude: 87º19’ to 87o

• Altitude: 120 meter(Ahale VDC) to 2702 meter (Murtidhunga VDC)

33’ East

2.3.2 Boundaries

• East: Teharathum and Panchthar

• West: Bhojpur and Udayapur

• North: Sankhuasabha

• South: Morang and Sunsari

2.4 Socio- economic status

2.4.1 Education

2.4.1.1 Level and sex wise distribution of students

Table 2: Level and sex wise distribution of students

Level Females Males Total

Primary schools 16775 17131 33906

Lower secondary 7218 6984 14202

Secondary schools 3520 3218 6738

Source: District Education Office, Dhankuta


2.4.1.2 Distribution of Educational (institutions level wise)

Table 3: Institution wise distribution of education

Level Government Private Total

Primary 215 23 238

Lower Secondary 36 1 37

Secondary 45 7 52

Higher Secondary 16 2 18

Higher Level 3 - 3

Total 315 33 348

Source: District Education Office, Dhankuta

2.4.2 Ethnicity

Table 4: Distribution of Ethnicity in Dhankuta

Ethnic Grouops Percentage

Rai 24.51%

Magar 10.34%

Limbu 14.20%

Chhetri 19.85%

Brahmin 5.49%

Tamang 6.28%

Others 19.33%

Source: ‘Jilla Parswochitra’; DDC (065/66)


2.4.3 Languages

Table 5: Language distribution in Dhankuta

Language Percentage

Nepali 44.87%

Bantawa 19.72%

Magar 8.87%

Limbu 13.75%

Tamang 5.21%

Yakhha 2.94%

Others 4.83%

Source: Annual Report; DHO (066/67)

2.4.4 Religions

• Buddhist

• Hindu

• Kirat

• Islam

• Christian

2.5 Climate

• Sub tropical: <1200 Meter

• Temperate: 1200-2100 meter (mid hilly region)

• Cold temperate: 2100-3300 meter (high hills)

• Average rainfall: 14.95*

• Minimum rainfall yearly: 7.1

mm *

• Maximum temperature: 28.6º c

mm

• Minimum temperature: 7.1º c

*

Source: Annual Report; DHO (066/67)

*


2.6 Major Rivers

• Tamor khola

• Muga khola

• Patale khola

• Arun khola

2.7 Touristic places

• Bhedetar

• Dhawanje Danda

• Thulo Rukh

• Hile

• Pahkribas

• Panchakanya shahid smirti

• Raja-rani

2.8 Cultural/religious heritages

• Jalapadevi/Chintanj Devi Temple

• Nishan Bhagwati

• Siva Panchanya/Bishranti Temple

• Pathibhara Devi Temple

• Madhu Ganga mahadevsthan

• Nageshor Mahadev Temple

• Margasthan Temple

• Chaturbahu Temple

• Bisranti Temple


2.9 I/NGOs

• HUSADEC

• PARDEP

• SOLVE

• BNMT

• Marie Stopes

• FPAN

2.10 Governmental Organizations

• District Administration Office

• District Development Committee

• District Forest Office

• District Police Office

• Drinking Water Development Office

• District Veterinary Office

• District Livestock Service Office

2.11 Development Resources

• Land

Table 6: Distribution of land in Dhankuta

Features Area (hectares) Percent occupied

Cultivable Land 40723 49.55

Forests 36383 44.11

Pasture Land 220 0.04

Others 5203 6.40


• Irrigation

Evergreen Irrigation: 1255 hectare (6.44%) of total cultivated land

Seasonal irrigation: 2640 hectare (13.66%) of total cultivated land

No irrigation facility: 15603 hectare (80%) of total cultivated land

2.12 Transportation

Koshi Rajmarga (Madan Bhandari Marga) is 64 Km black topped south to north

road that divides whole district into two halves.

3.12.1 Transportation facility in the district

Table 7: Transportation facility in Dhankuta

Description Value

VDC/Municipality with transportation facility 13+1

Length of road( in kilometer) Black topped 50.58

Gravel 48.68

Kacchi bato 113.8

Total 213.6

2.13 Communication

Postal Services: 38

Telephone:

• MARTS: 23

• PSTN : 1806

• PSTN (Hile): 1806

• CDMA

pre-paid: 1677

post-paid: 421


• GSM

pre-paid: 18135

post-paid: 248

• Sky Phone

pre-paid: 6548

post-paid: 35

Source: Nepal Telecom; Dhankuta

2.14 Water Supply and Sanitation

• Drinking Water Coverage: 82%

• Toilet Coverage: 21%

• Total completed Water Projects from DDC: 44

• Benefitted Population: 71599

2.15 Crime Incidents

Table 8: Crime incidents in Dhankuta

Fiscal year Homicide Organized/

economic

crime

Social

Offence

Crime related

to women &

child

Suicide RTAs

064/65 10 5 5 5 8 7

065/66 15 1 8 3 17 8

066/67 31 1 22 1 13 12

067/68

(till chaitra)

14 3 14 2 10 11

Source: District Police Office, Dhankuta


2.16 Demographic Characteristics

Table 9: Demographic characteristics of Dhankuta

Indicators District Figure

Population

• Male

• Female

• Total

87972

80860

168832

Sex Ratio (M:F) 108.8:100

Dependency Ratio

• Child Dependency

• Old Dependency

• Total

50.56

13.01

63.57

Total Households 29222

Average family size 5.78

Population Density 190.19 per sq. km

Fertility Status

• Crude Birth Rate ( CBR)

20.86 per 1000

Mortality

• Crude Death Rate (CDR)

5.30 per 1000

Literacy Rate

• Male literacy

• Female literacy

• Total Literacy Rate

74.75%%

66%

70.59%


2.17 Map of Dhankuta

Figure 1: Map of Dhankuta District

Note: The shaded areas represent the places of visits during our study period.

CHAPTER III

DISTRICT HEALTH SYSTEM


CHAPTER III

District Health System in Dhankuta

3.1 Introduction

As defined by the World Health Organization, the District Health System (DHS) is a

more or less self-contained segment of a national health system, which includes all the

institutions and individuals concerned with the improvement of health.

(District Health Planning Manual, 2002)

The district is the key level for the management of primary health care (PHC). Ideally, all

health-related activities taking place in the district should be coordinated into a District

Health System. The mix of manpower and facilities providing health care in districts

varies greatly from country to country. In the main communities, rural and urban, there

may be community health workers, clinics and health centers, together with traditional

and private medical practitioners. A government district hospital and the headquarters

staff for all the district health programmes are often located in the main town.

(Manual of Epidemiology for District Health Management, 1989)

The health care system of Dhankuta is the sum total of three main systems; Traditional

Health Care System, Modern Health Care System and Supportive System. Akin to other

Districts, Dhankuta also has a long history of traditional medical practices with faith

healers and ayurvedic practitioners playing a compassionate role in the provision of

health care. Nevertheless, Modern Health Care system is the major system of health care

delivery in government and private run health institutions within the district.

The comprehensive field practice was based on the study of district health system.

However we principally focused on the public health section of DHO under modern

health care system. Hence, not much emphasis was given on the traditional health care

system and only limited study was done on other supportive health care system.


The District Health Office is the centre of a network of activities concerned with health

that extend from the main district (headquarter) to the village level. It has the

responsibility to implement monitor and supervise preventive, promotive, rehabilitative

and curative health programmes within the district.

DISTRICT HEALTH CARE SYSTEM

Traditional Health Care System

Modern Health Care System

SupportiveSystem

AyurvedicHealth System

Homeopathic clinic

TraditionalHealingSystem

Koshi Zonal Ayurvedic

Ausadhalaya -1

AyurvedicDispensary -2

Private Ayurvedic

Clinics

Traditional Healers

District Public Health Office

District Hospital

Private Clinics

PHCC -2 HP -11 SHP -24

FCHVs -315 EPI Clinic -151

PHC- ORC -79

Government Organizations I/NGOs

DDC

DAO

DEO

DVO

DFO

DWDO

NRCS

BNMT

SOLVE

FPAN

Marie Stopes

Figure 1: District Health System of Dhankuta

The District Health Office manages, administers and coordinates district health matters

and serves as a link between the districts and higher levels; regional and central. It is

managed by a multidisciplinary team referred to as the District Health Management Team

(DHMT). The District Health Office in Dhankuta is headed by the Senior Public Health

Administrator.


The district health services extend from the community level health workers to the

hospitals. The district hospital is the main centre for curative health care and is the first

referral level. In organizing the district health services, the DHO also collaborates with

local government and non- government organizations, liase with community

representatives and organizations and practice intersectoral co-ordination.

Figure 2: The central role of the district health office within the district health system


3.2 District Health Management in System Model

District Health Management System in Dhankuta is dynamically proceeding through

various efforts and activities. The functioning of the management aspect of different

programmes in the district health office can be described by the Input, process and output

model below in the figure:

Figure 3: System Model of District Health System, Dhankuta

The health system model based on a System Approach illustrates the three important elements of a district health system - the community, the health care delivery system, and the environment in which the other two are located.

(Planning for Health Services at the District, 1997)


3.2.1 Service Inputs

i. Human Resources

Staffing Pattern of DHO

Table 10: Staffing pattern of DHO

Posts Sanctioned Fulfilled Vacant

Public Health Administrator 1 1 0

Medical Superintendent 1 0 1

Medical Officer 4 3 1

District Supervisors 8 7 1

Staff Nurse 6 0 1

Lab Technician/ Assistant 1 1 0

Radiographer 1 0 1

HA/ Sr. AHW 16 16 0

AHW 41 41 0

ANM 21 20 1

MCHW 24 23 1

VHW 37 28 9

ii. Budget

The overall budgeting & finance was under the control of finance section under

DHO. The total amount of released budget for DHO, Dhankuta (in the fiscal year

067/68) was Rs. 7,40,91,500. (Source: Account Section, DHO)


iii. Infrastructures

• Institutions

Table 11: Distribution of health institution in Dhankuta

Health Institutions Number

District Public Health Office (DPHO) 1

District Hospital 1

Koshi Zonal Ayurvedic Ausadhalaya 1

Marie Stopes Centre 1

District Public Health Clinic 1

Primary Health Care Centre (PHCC) 2

Health Posts (HP) 11

Sub- Health Posts (SHP) 24

Primary Health Care- Outreach Clinic (PHC-ORC) 79

EPI Clinic 151

DOTS Centre 14

DOTS Sub-centre 24

Private Hospitals 2

• Buildings

The DHO office was situated in two buildings. The account section was operating

in its own building while other sections were operating at the building of District

Hospital. The new DHO building was under construction. The District Hospital’s

building was sponsored by ADRA. Most of the PHCCs and HPs had their own

buildings but some SHPs were serving through the VDC buildings.

Dhankuta Model Hospital situated at the district headquarter was one of the two

private sector hospitals in Dhankuta district. It had been operating its activities

from its own building.


iv. Logistics

The available no. of logistics in District Health Office (including District

Hospital) can be described under following headings.

Table 12: Health Logistics in District Health Office

Logistics Number Remarks

District Store 1

Cold Chain Centers 1

Cold Chain Sub-centers 3

Deep Fridge 4

Refrigerators 4 Only 2 in operation

X-ray machines 1

Microscope 2

Vehicles 1 3 motorbikes

Ambulance 1

Seminar Hall 1

v. Drugs & Equipments

61 different types of drugs (excluding cold chain items) and surgical items were

available at the store room of DHO.

vi. Health Service Programs

Programs under DHO Dhading were reviewed by using information’s obtained by

Monthly Monitoring Profile of District Health Office Dhankuta. Major programs

running are as follows.

1. Child Health

• National Immunization Programme

• Nutrition

• Community Based Integrated Management of Childhood Illness (CB-IMCI)

• Community Based Neonatal Care Program ( CB- NCP)


2. Family Health and reproductive health

• Family planning

• Safe motherhood

• FCHV program

• Primary Health Care /Outreach Clinic

• Comprehensive Abortion Care Services

3.Disease control

• Tuberculosis Control

• AIDS & STD Control

• Malaria Control

4. Curative Services

• Out-patient Department Services

• Inpatient Department Services

• Emergency Services

• CAC/ PAC

• Emergency Obstetric Services

5. Supporting Programs

• Training

• Health Education, Information & Communication

• Logistics

• Laboratory Services

• Administrative Management

• Financial Management


3.2.2 Process

The DHO, Dhankuta performs a series of managerial and technical functions on a regular

basis to translate its inputs into valuable outcomes. The processes performed by DHO can

be summarized under the following headings:

i. Planning Monitoring and Evaluation

Planning, monitoring and Evaluation are the core functions of district health

management.

Figure 4: PME cycle of District Health Office, Dhankuta

Both top-down and bottom-up planning approaches can easily be coordinated because of direct contact at all levels. Communication with the target population and its participation in planning and organization are fairly easy to handle. Management (e.g. supervision) is more transparent and reliable. Coordination is easy to achieve between the various programmes and services at different levels. Intersectoral cooperation can take place (e.g. with agriculture, education, water, sanitation and housing sectors).

(Health Sector Reform & District Health System, WHO, 2004)


• Planning

Health Planning is the identification and elaboration (within existing resources) of means

and methods for providing in the future, effective health care relevant to identified health

needs for a defined population.

Planning of district health services in Dhankuta involves series of activities. The planning

in Dhankuta was done by taking into consideration, the government plans and policies,

regulations, short & long-term national plans, organizational structure, budget ceiling &

administrative capacity.

Figure 5: Planning cycle in district health services

District Health Planning contains characteristics of micro- as well as macro-planning; however, it is more akin to the former. Micro-planning, as its name implies, comprises of planning services and interventions at the micro level, that is regional or district levels in detail



The planning process was participatory and decentralized type where the various

stakeholders involved in situation analysis, prioritization & target setting. The baseline

information was first obtained from the community levels (VDCs). The prioritization and

target setting was done in consideration to following elements:

• Target population

• National Priority

• Skills

• Major public health issues

• Unmet need

• Effect impact

These priorities were passed to the illaka level, where similar activities were performed

and subsequently passed to the district level similarly and to the central level (as shown

in figure 7). Finally, the NPC endorsed the plan with necessary modifications.

NPC/ MOF

MOHP

RHD/ DOHS

District (DHO)

Illaka

VDC

Flow of Baseline information

Flow of budget ceiling

Figure 6: Micro planning in Dhankuta


After receiving the final set plans, the District Health Office set strategies and activities

to achieve the pre-determined objectives. Finally, the plan was brought into

implementation through DHO via all the health system operating in Dhankuta.

• Monitoring

Large numbers of approaches were employed by the DHO, Dhankuta in order to monitor

all the district health services and programs. Monitoring indicators were widely used to

measure the achievements of programme target. Monitoring had been performed by the

DHO on a regular as well as monthly basis. Participatory monitoring were done to

observe the performance and progress, verify the courses of action and to identify

deviations so as to provide necessary feedback.

Supervision

Supervision of district public health services had been performed using integrated

supervision checklist. Supervision of peripheral health institutions was done by DHO on

a periodic basis. Moreover, centre (MOHP/ DOHS) also supervised DHO at least once a

year, and by region (RHD, Dhankuta), at least three times a year.

• Evaluation

The district health office was concerned with the evaluation of two main aspects

• Programme Evaluation

• Performance Evaluation

Program evaluation was done by internal as well as external evaluators assigned by DHO.

The variety of methods like interview, observations, report review was done to evaluate

the public health programme and activities.

Performance evaluation was by self as well as participatory appraisal.


ii. Organizing

The government health system of the entire district in Nepal follows the similar

organization flow chart. The organization of health institutions in Dhankuta as no

exception to other District health systems, are shown below in the form of flow chart.

District Health Office District Health Office

Primary Health Care Centers- 2

FCHVs

Health Posts- 11

Sub- Health Posts-24

PHC/0RC- 79 EPI Clinics-151

Figure 7: Organization of health institutions in Dhankuta


The District Health Office is the central body within the district health system for a

network of health related activities. Public Health Section forms a portion of district

health office. District Hospital is another important component within the DHO. The

organogram of DHO, Dhankuta can be shown as follows:


Store Section

Statistical Section

Indoor

Laboratory

District Hospital

Administrative Section

Finance Section

Emergency

OPD

Primary Health Care Centre (PHCC)

Health Posts/ Sub Health Posts

Immunization Programme

Maternal & Child Health

CDD/ARI/Nutrition/ IMCI

Health Education/

Training

Family Planning

Disease Control Section

•TB/ Leprosy•HIV/AIDS & STIs•Malaria Control

PHC-ORC EPI Clinics FCHVs

Figure 8: Organogram of District Health Office, Dhankuta


iii. Staffing

The various level and mix of human resources were working in the DHO & within its

system. These staffs could be broadly categorized into two levels; Technical &

Administrative staffs.

The Administrative staffs involved the following:

Section officer

Accountant

Statistician

Store Keeper, etc.

There were different levels of technical staffs working in the DHO, some of which are as

follows:

Public Health Administrator

Health Assistants

ANM

AHW, etc.

• Career Opportunities

Training was the most effective motivating factors for the staffs in DHO, Dhankuta. The

numerous training activities had been organized for the staffs. Opportunities for inter-

districts were also provided to the staffs.

iv. Directing

• Decision making

The decisions on various public health issues & programmes were made on the basis of

consensus obtained by the discussions between DHOr and respective program

supervisors, and sometimes via meetings and discussions with various other line

agencies, NGOs and INGOs.


• Delegation

The supreme authority for the management of overall district health system lay on

District Public Health Officer. However, in the absence of DHOr, the authority was

delegated to the medical superintendent.

• Leadership

DHOr in Dhankuta was highly enthusiastic and committed to his roles and

responsibilities. He believed and followed the democratic approach for all forms of

managerial and technical activities to bring into operation. All the staffs were highly

influenced by his activities. His inspiration shaped the source of motivation for many

staffs.

• Communication

Communication system of DHO, Dhankuta was highly effective. The office was well

equipped with various means of communication. The DHO used letters for official and

formal communication. However, other sorts of informal communication were made via

telephone & internet.

The DHO office had good communication with all the peripheral institutions as well as

higher authorities (regional and central). The DHO also maintained inter-sectoral

communication with its supporting I/NGOs and line agencies.

v. Co-ordination

The DHO maintained an effective co-ordination both horizontally as well as vertically.

Horizontal co-ordination was with different government line agencies. The DHO had its

vertical co-ordination with RHD and MD under DOHS. Co-ordination with peripheral

staffs was good. However, co-ordination seemed weaker with one of the supporting NGO

i.e. FPAN because of which there were problems like inappropriate reporting, program

duplication, etc. The co-ordination with other I/NGOs were very good. The community

usually acted as dormant towards the public health programs conducted by DHO. Hence,

the co-ordination with the community was lacking.


vi. Recording and Reporting

• Health Management Information System

There were 38 different types of HMIS tools in operation for recording and reporting of

services. All the personnel responsible for recording and reporting were well trained on

HMIS. The reports were regularly received from peripheral institutions and then

forwarded to the RHD and HMIS section under DOHS.

The HMIS process in DHO, Dhankuta can be explained by the figure as follows:

Department of Health Services

Regional Health Directorate


District Hospital

PHCCs/ HPs

SHPs

EPI clinics/ PHC-ORC/ FCHVs

District

Illaka

VDC

Community

Regional

Central

Feedback

Reporting

12th of the succeeding month

7th of the succeeding month

3rd of the succeeding month

Last day of the same month

Figure 9: HMIS process in DHO, Dhankuta


• Logistic Management Information System

The recording and reporting of logistics in DHO, Dhankuta were done using various

LMIS forms like entry form, dispatch form and order form. Reports of every received

commodities and supplied logistics were sent by peripheral institutions to the district

store trimesterly using various LMIS and audit forms. The district sent a report to RMS

as well as LMD every three months and the feedback was sent by LMD to the district.

Store keeper was responsible for the LMIS in DHO, Dhankuta. Data-base and inventory

system were managed by a computer operator.

Regional Medical Store( Biratnagar)

District Medical Store(DHO, Dhankuta)

Sub-Health PostsHealth Posts PHCCs

Logistics Management Division(Teku)

Feedback

Reporting

Regional Health Directorate( Dhankuta)

Figure 10: LMIS process in DHO, Dhankuta


The reporting schedule of LMIS for DHO can be shown in the table as follows:

Table 13: LMIS reporting schedule in Dhankuta

LMIS flow Time of reporting

SHP to HP/PHC 3rd of Shrawan/ Kartik/ Falgun/ Baisakh

HP/PHC to DHO 7th

DHO to RMS & LMD

of Shrawan/ Kartik/ Falgun/ Baisakh

15th of Shrawan/ Kartik/ Falgun/ Baisakh

v. Budgeting

The budgeting of health sector within the district involves series of processes. The

budgetary ceiling will be provided by MOF which flows downwardly and subsequently

to the DHO. The budget release is done quarterly by the District Treasury and Account

Control Office.

Figure 11: Health budgeting process in Dhankuta


3.2.3Service Outputs

3.2.3.1 Child Health Programme

3.2.3.1.1 National Immunization Programme

The National Immunization Programme (NIP) is a high priority programme (P1) of

Government of Nepal, hence, a major programme under DHO. It has significantly

contributed to reduce the burden of vaccine preventable diseases and child mortality.

Nepal is one of the countries on track to achieve the Millennium Development Goal on

Child Mortality Reduction. The DHO has been taking the responsibility to ensure that a

successful immunization programme is implemented at the district and grass-root level.

Primary Health Care Centres (PHCs), Health Posts (HPs), and Sub-Health Posts (SHPs)

has been implementing National immunization programmes in their respective

municipalities and Village Development Committees (VDCs) by extending the EPI

clinics as per their micro plan.

The immunization coverage in the Dhankuta district can be summed up in the table

below:

Table 14: Immunization Coverage

Immunization 064/65 065/66 066/67 06768

(till chaitra)

Regional National

BCG 77.9% 70.27% 75.13% 61.33% 87.4% 84.9%

DPT-3/ Hep-B 3 75% 70.21% 65.27% 62.31% 83.3% 81.2%

Polio-3 74.1% 70.21% 70.11% 62.08% 82.9% 80.9%

Measles 70.9% 70.60% 72.26% 52.65% 78% 75.4%

The data on immunization coverage in Dhankuta since last four years shows a decreasing

trend. The coverage is lower as compared to national average.


Table 15: Vaccine Wastage

Vaccine 064/65 065/66 066/67 067/68

(till chaitra)

National

(065/66))

BCG 83.95% 85.85% 86.21% 84.18% 79.8%

DPT/Hep B 36.06% 44.02% 27.47% 9.53% 21.9%

Polio 39.30% 45.48% 37.55% 27.47% 25%

Measles 72.78% 73.47% 75.20% 75.37% 61.1%

The vaccine wastage rate as shown in the above table depicts that there has been a high

wastage of vaccine in the past three years from fiscal year 064/65 to 066/67. However the

data of 067/68 (available till chaitra) shows that the wastage rate has decreased to some

extent. The wastage of vaccine is higher than that of national average except for DPT/

Hep -B

Table 16: Immunization Drop-out Rate

Immunization 064/65 065/66 066/67 067/68

(till chaitra)

National

(065/66)

BCG vs Measles 8.9% -0.47% 3.82% 14.16% 11.3%

DPT 1 vs DPT 3 1.6% 0.06% 7.89% -4.91% 2%

The above table depicts that the BCG vs Measles drop-out rate is highly increased from

066/67 to 067/68. However DPT I vs DPT 3 drop-out is decreasing in 067/68.


• Problems and Constraints

Table 17: Problems and constraints in immunization programme

Problems Actions to be taken Responsibilities

Over estimation of target

population

-Periodic census should be taken by

local HFs and target should be set

by DHO.

-DHO and

Local HFs.

Insufficient fuel for cold

chain sub-center.

-Sufficient budget should be

allocated and released in time. Other

sources (eg. VDC budget) should be

explored.

-DHO

-VDC

-Local HFs

Vacant post of EPI Officer in

district

-DHOr should take steps to fulfill

the vacant post

-DHO

-DOHS/CHD


3.2.3.1.2 Nutrition

Malnutrition remains a serious obstacle to child survival, growth and development in

Nepal. The most common forms of malnutrition is protein-energy malnutrition (PEM)

The other form of malnutrition are iodine, iron and vitamin A deficiency. Each type of

malnutrition wrecks its own particular havoc on the human body, and to make matters

worse, they often appear in combination. Malnourished children are more likely to die

from common childhood illness than those adequately nourished. In addition,

malnutrition constitutes a serious threat especially to young child survival and is

associated with one third of child mortality.

Nutrition programme is one of the major child health programme run by DHO in

Dhankuta. The achievements of nutrition programme can be discussed in the table as

follows:

Table 18: Growth Monitoring Status of U5 children

Indicators 064/65 065/66 066/67 067/68

(till

chaitra)

Regional National

(065/66)

New Growth Monitoring

(coverage)

32.9% 30.18% 24.92% 17.15% 44.04% 44.81%

Proportion of

malnourished children

(among new cases);

Wt/Age

2.6% 3.74% 2.48% 0.55% 3.2% 4.7%

The new growth monitoring coverage shows a sequential reduction in the last four years.

The coverage seems poor as compared to national average.

The proportion of malnourished U5 children has decreased from 3.74% in 065/66 to

2.48% in 066/67 and still shows a decreasing trend in 067/68 which is lower than that of

national level.


Table 19: Achievements of child nutrition programme

Indicators 064/65 065/66 066/67 Regional National

(065/66)

Vitamin A distribution as

percent of children 6-59

months

94.84% 98.56% 97.03% 97% 92.11%

% of 6-59 months children

provided with Albendazole

92.59% 99.11% 99.57% - 95.47%

As shown in the table above, vitamin A distribution to children between 6-59 months had

decreased in FY 066/67 than that of FY 065/66 level. However, the coverage still seems

higher than that of the national level. But, the children of same age group provided with

deworming tablets seemed to have increased, which is contradictory in itself. The

coverage is however greater than the national average.

• Nutrition to pregnant mothers

Table 20: Achievements of nutrition programme for mothers

Indicators 064/65 065/66 066/67 067/68 (till

chaitra)

% of pregnant mothers receiving

iron tablets

48% 43.32% 57.44% 39.26%

% of pregnant women receiving

225 iron tablets ( Iron compliance)

13.4% 12.09% 22.01%

% of post-partum mother receiving

vit-A

45.5% 35.55% 43.53% 37.36%

% of post partum mother receiving

iron tablets

42.85% 42.39% 49.04% NA


The percentage of pregnant women receiving iron tablets has increased by 14% from FY

065/66 to FY 66/67 but shows a decreasing trend in the FY 067/68. The coverage of iron

supplementation seems unsatisfactory as it is lower to that of national and regional levels,

as shown in the table above. The iron compliance had increased nearly two times from

12.09% in FY 065/66 to 22.01% in FY 066/67. The iron supplementation during post-

partum period also showed an increasing trend.


Table 21: Problems and constraints in nutrition programme


Insufficient no. of Salter

scales/available Salter

scales are not functioning

properly

-Older Salter scales should be repaired

and adequate no. of Salter scales should

be supplied.

-Local HIs

-DHO/PHO

Over estimation of target

population

-Periodic census should be taken by

local HFs and target should be set by

DHO.

-DHO and

Local HFs.

3.2.3.1.3 Community Based Integrated Management of Childhood Illness (CB-

IMCI)

Community Based Integrated Management of Childhood Illness (CB-IMCI) is an

integrated package of child-survival programmes and addresses major killer diseases like

pneumonia, diarrhoea, malaria, measles, malnutrition in under 5 year children.

• ARI Control

Acute Respiratory Infection (ARI) as one of the major killer of children under 5 years, in

Nepal. CB-IMCI programme in Dhankuta was first implemented in fiscal year 2059/60


Table 22: Service statistics of ARI control programme

Indicators 064/65 065/66 066/67 National

ARI Incidence by HF (per 1000) 289 412 450.55 340

ARI Incidence by Community

(VHW/MCHW/FCHV) per 1000

616 648.56 895.25 660

% of new Pneumonia 55.2% 55% 52.30% NA

The table 22 shows that reported cases of ARI by both health facility and community had

increased in 066/67 than that of past two years. The reported incidence seemed higher

than that of the national figure. This increase could either be due to improvement in the

recording and reporting system or actual increase in the cases of ARI.

Despite the increase in ARI incidence, the percentage of new pneumonia cases has

decreased from 55.2% in FY 064/65 to 52.30% in FY 066/67.


Table 23: Problems and constraints on ARI control programme


HWs did not follow the

WHO classification for

ARI categories.

-Written information/order to follow

WHO classification to all health

facilities from DHO.

-DHO

-ARI supervisor


• Control of Diarrhoeal Diseases (CDD)

Diarrhoea is one of the leading killer diseases under five children in Nepal. CB-IMCI

programme intensely focuses on management of Diarrhoeal diseases among the under

five year’s children. Standard case management of diarrhoea with Oral Rehydration

therapy and Zinc tablet along with counselling for continued feeding has been provided

by DHO in all the health institutions and community level of Dhankuta district.

Table 24: Service statistics of CDD

Indicators 064-65 065-66 066-67

CDD Incidence by HF (per 1000) 129 123.70 165.13

CDD Incidence by Community (per 1000) 343 382.99 459.63

Severe Dehydration 0.69% 0.02% 0.11%

% of diarrhoeal cases treated with

ORS/Zinc

99.40% 98.27% 91.01%

The reported incidence of diarrhea by both health facility and community shows an

increasing trend. The proportion of severe dehydration although minimal (as compared to

national level i.e. 0.6%), had also increased from 0.02% in FY 065/66 to 0.11% in

066/67. The cases of diarrhoea treated by ORS & zinc had decreased in FY 066/67 as

compared to previous two years.

3.2.3.2 Family Health & Reproductive Health Programme

3.2.3.2.1 Family Planning

Family Planning Programme in Dhankuta has been operating to expand and sustain

adequate quality family planning services to communities through the district health

service network such as hospital, primary health care (PHC) centers, health posts (HP),

sub health posts (SHP), primary health care outreach clinics (PHC/ORC) and mobile

voluntary surgical contraception (VSC) camps. Female community health volunteers

(FCHVs) are mobilized to promote condom distribution and re-supply of oral pills.


Table 25: Service statistics of family planning programme

Indicators 064-65 065-66 066-67

Contraceptive Prevalence Rate (CPR) 30.83% 37.52% 34%

New acceptors (as % of MWRA) 8.71% 11.71% 11.1%

Couple Years of Protection (CYP) as % of MWRA 25.75 25.19 21.85

The trend of past three years from FY 064/65 to 065/66 shows that there was an increase

in CPR from 30.83% in 064/65 to 37.52% which had later decreased to 34% in FY

066/67. The CPR is still below to that of regional as well as national level.

The percentage of new acceptors among MWRA had however remained similar in both

the FY 065/66 & 066/67.

Table 26: Acceptors of family planning devices

Indicators

064-65 065-66 066-67 067-68

(till chaitra)

New

acceptors

Current

users

New

acceptors

Current

users

New

acceptors

Current

users

New

acceptors

Current

users

Pills 2.2% 3.9% 4.03% 5.4% 3.72% 5.4% 2.70% NA

Depo 5.82% 13.3% 6.85% 14.7% 6.60% 12% 4.66% NA

IUD 0.39% 0.84% 0.38% 1% 0.10% 0.97% 0.22% NA

Norplant 0.12% 0.81% 0.45% 1.32% 0.66% 1.69% 0.28% NA

As shown in the above table the new acceptors of pills & depo which had increased

during FY 065/66 than that of 064/65 has again shown a decreasing trend. Conversely,

there is increasing new acceptors for IUD as shown by the data from FY 066/67 to

067/68. The new acceptors for Norplant have been decreasing in 067/68.



Table 27: Problems and constraints in family planning programme

3.2.3.2.2 Safe Motherhood

The goal of the National Safe Motherhood Programme is to reduce maternal and neonatal

mortalities by addressing factors related to various morbidities, death and disability

caused by complications of pregnancy and childbirth. Hence, DHO, Dhankuta has been

determined to reduce maternal morbidity and mortality through safe motherhood

programme.

• Antenatal Care

Table 28: Trends of ANC visits

Indicators 064-65 065-66 066-67 067-68

% of first ANC visit 32.80 47.10 62.47 42.56

% of four ANC visit (among 1st 48.10 visit) 54.68 56.78 58.33

The above bar diagram depicts that the percentage of first ANC visit has decreased by

10% from the FY 066/67 to FY 067/68. However, the percentage of all four ANC visits

among the first visits shows an increasing trend.

Problems Action to be taken Responsibilities

Poor recording and reporting by

FPAN

Appeal for co-ordination should

be done

DHO


• Delivery Care

Table 29: Delivery service statistics in Dhankuta

Indicators 064-65 065-66 066-67 067-68

(till chaitra)

% of delivery conducted by SBA 7.9% 7.8% 11.4% 8.7%

% of delivery conducted by HW

(including SBA)

17.4% 14.8% 17.58% 13.57%

Proportion of mothers having

obstetric complications from

B/C EOC centers

0.34% 0.89% 3.58% 2.38%

The delivery conducted by health workers (including SBAs) had increased from 14.8% in

FY 065/66 to 17.58% in FY 066/67 but the available data till the chaitra of FY 067/68

shows that the delivery by HW has been decreasing. The reported cases from BEOC/

CEOC centers show that the proportion of women having obstetric complications during

delivery is at rise.

• PNC Care

Table 30: Trends of PNC visits

Indicators 064-65 065-66 066-67 067-68 (till chaitra)

% of first PNC (as of

expected pregnancy)

34.1% 33.88% 44.89% 33.27%

The PNC coverage as similar to ANC has also increased in the FY 066/67 but at decrease

in FY 067/68 as shown by the data available up to chaitra. As explained by the Family

Health Section of DHO, the decrease in the coverage could probably be due to over

estimation of target population (MWRA).


• BEOC services

Only basic emergency obstetric care was available in district hospital as well as in

Primary health care centers.

• CAC services

CAC service was available in district hospital and Marie Stopes Center. In the FY 066/67

878 people had received this service.

• PAC services

PAC service was available at the Marie Stopes Center as well as at the district hospital.


Table 31: Problems and constraints of safe motherhood programme

Problems Action to be taken Responsibilities

Poor environment (lack of

physical facilities & others

like blood bank) to provide

quality safe motherhood

services in Health institution.

Provide enabling environment

like physical infrastructure,

furniture and instruments

MoHP,

FHD/RHD/DHO/ all

HIs, HFMC.


3.2.3.3 Disease Control Programme

3.2.3.3.1 Malaria Control

The high risk of getting malaria is attributed to the abundance of vector mosquitoes,

mobile and vulnerable population, relative inaccessibility of the area, suitable

temperature, environmental and socio-economic factors. Currently malaria control

activities are carried out in 65 districts at risk of malaria. The Malaria Control

Programme in Nepal was initiated in 1954. The Malaria Eradication Project that was

launched in 1958 was later reverted to control program in 1978. Roll Back Malaria

(RBM) was launched in 1998. Dhankuta is one of the 52 malaria endemic districts of

Nepal.

Table 32: Service statistics of Malaria control programme

The malariometric indicators in Dhankuta depicts that there are no reported cases of

malaria as shown by the data from FY 064/65 to 066/67. However, hospital record

reported one case of malaria in 2068.

3.2.3.3.2 National Tuberculosis Control Programme

The National Tuberculosis Programme (NTP) is an approach within the national health

system for control of tuberculosis (TB). Tuberculosis (TB) is a major public health

problem in Nepal. DOTS have been successfully implemented throughout the country

Indicators 064/65 065/66 066/67

Annual Blood Examination Rate (ABER) 1.52 0.59 0.19

% of PF among new cases 0 0 0

Malaria Parasite Incidence (per 1000) 0 0 0

Clinical Malaria Incidence 0.33 0.42 0.36

Slide Positivity Rate 0 0 0

Total no. of Malaria cases 0 0 0


since April 2001, for the effective control of TB. Hence, TB Control is also one of the

priority programme for TB control in Dhankuta.

Table 33: Achievements of Malaria control programme

Indicators 064-65 065-66 066-67 Regional National

(065/66)

Case Finding Rate (CFR) 41.5% 27% 33% 64% 75%

Cure Rate 88% 90% 91% 91% 89%

The TB case finding rate in Dhankuta seems lower than that of regional and national

level. However, the cure rate coincides with the regional level.

3.2.3.3.3 Leprosy Control Programme:

Since many decades leprosy has been considered as one of the main public health

problem it has been in top priority of government’s plan and policy so as to eliminate

leprosy from the country. There have been continuous efforts from the DHO, Dhankuta

to reduce its prevalence rate (PR) and eliminate the disease from the country for once and

all.

Table 34: Service statistics of Leprosy control programme

Indicators 064/65 065/66 066/67

New Case Detection Rate 0.16 0.21 0.05

RFT 100% 100% 100%

Prevalence Rate (per 1000) 0.16 0.21 0

Disability Grade 2 0 50% 0

There was only one reported case of leprosy in FY 066/67, Leprosy is eliminated from

Dhankuta district but NCDR was 0.05%.


3.2.3.3.4 HIV/AIDS and STI Control

Nepal is categorized as a “Concentrated” epidemic country in terms of HIV/AIDS.

Dhankuta is one of the HIV/AIDS prone districts of Nepal. Rapid urbanization and

increasing number of seasonal migrants has increased the risks of STIs and HIV/AIDS in

Dhankuta.

Although there were no reported cases of HIV/AIDS during the past years, four new

cases were reported in 067/68, of which 3 were females and 1 was male.

3.2.3.4 Female Community Health Volunteer (FCHV) Programme

The major role of the FCHV is to promote health and healthy behaviour of mothers and

community people for the promotion of safe motherhood, child health, family planning,

and other basic health services with the support of health personnel from the SHPs, HPs,

and PHCCs. Besides the motivation and education, the FCHVs re-supply pills and

distribute condoms, ORS packets and vitamin A capsules; and they also treat pneumonia

cases and refer more complicated cases to health institution.

Table 35: Service statistics of FCHV programme

Indicators 064-65 065-66 066-67

Average no. of people served by

FCHVs

172 217.30 262.31

% of mother group meetings

conducted by FCHVs

78.81% 73.49% 88.15%

% of report received from FCHV 93.25% 93.99% 95.24%

The service statistics on FCHV programme shows a progressive trend. The average no. of

people served by FCHVs in FY 066/67 had increased than the no. of people served

during FY 065/66. The reporting has also increased as compared to previous years.



Table 36: Problems and constraints of FCHV programme

3.2.3.5 Primary Health Care Outreach Clinic (PHC-ORC) Programme

Primary Health Care Outreach clinic (PHC-ORC) program was established in 1994 (2051

BS) with an aim to improve access to some basic health services including family

planning and safe motherhood services for rural households. PHC-ORC clinics are the

extension of HPs and SHPs at the community.

Table 37: Service statistics of PHC-ORC

Indicators 064-65 065-66 066-67 National

(065/66)

Average no. of people served by PHC/ORC 10 11 15 17

% of PHC/ORC held 83.71% 85.9% 81.65% 80%

The average number of people served by outreach clinics although shows a progressive

trend as shown in the table above, it is yet lower than that of the national average. The

percentage of outreach clinics conducted is however similar to the national figure.

Problems Action to be Taken Responsibilities

Aged and drop out FCHV. Replace them with the permission

of Mother Group and train them.

DHO/FHD



Table 38: Problems and constraints of PHC-ORC

Problem constraints Action to be taken Responsibility

Some PHC/ORCs are

not functioning regularly

Reactivate and orient management

committee for regular conduction of

PHC/ORCs with the support of I/NGOs

DHO/HFs

Inadequate supervision

at all levels

Ensure regular supervision as per revised

strategy

DHO/PHO/

HPIs/SHPIs

Inadequate awareness

among the communities

about PHC/ORCs.

Conduct orientation program for community

awareness with the support of I/NGOs

DHO/VDCs

3.2.3.6 Curative Services

3.2.3.6.1 Introduction

The district hospital is the referral apex in the district where patients are referred from

other health facilities. Being part of the district health system, the district hospital is

determined to provide the identified and prioritized essential health packages. Further, it

is concentrated on providing the level of technological medical care that lower levels

cannot provide.

District Health Office in Dhankuta is committed to improving the health status people by

delivering high-quality health services throughout the district. Curative (out-patient, in-

patient and emergency) services are highly demanded component of health services by

the people. The curative health services in Dhankuta were made available at all health

institutions- district hospital, primary health care centres (PHCCs), health posts (HPs),

sub health posts (SHPs) and ayurvedic dispensaries (both zonal and peripheral). Apart


from government institutions, these services were also made available through private

hospitals & clinics.

3.2.3.6.2 Available health services at the District Hospital

• Indoor

• OPD

• Emergency Services (24 hours)

• B/CEOC

• CAC/PAC

• X-ray/ USG Services

• CAC/PAC

Table 39: Service statistics in District Hospital, Dhankuta

Indicators 064/65 065/66 066/67

Total no. of OPD cases 20901 24889 25054

Total no. of emergency cases 2727 3807 5365

Total no. of inpatients discharged 827 855 894

Total no. of delivery conducted 160 190 229

The table as shown above shows that no. of patients served by the district hospital in the

OPD, IPD as well as emergency has increased in the recent years. Moreover, the no. of

delivery attended at the hospital shows an increasing trend.

Table 40: Other service statistics in District Hospital

Indicators 064/65 065/66 066/67

No. of sanctioned beds 50 50 50

No. of available beds 22 22 22

Total OPD visits as % of total population 11.24 11.88 13.25

% of emergency visits (among total visits) 11.54 13.26 17.16

Bed occupancy rate 29.4 32.61 40.21


Delivery conducted (as a % of expected pregnancy) 2.34 2.72 4.13

Death rate (among inpatients) 0.84 0.46 0.44

% of surgery (among in-patients) 2.05 0.93 0.003

Proportion of communicable diseases among in-

patients

17.89 14.03 20.02

Proportion of non-communicable diseases among

in-patients

31.8 33.09 28.41

% of referred among in-patients 14.38 16.84 10.29

Daily average in-patients admitted 2.27 2.37 2.46

The statistics available at the district hospital shows an increasing trend of bed

occupancy. The proportion of communicable diseases in the FY 066/67 has increased as

compared to the previous year. In contrast to this, the proportion of non-communicable

diseases has decreased in last year (FY 066/67).

3.2.3.6.3 Top five causes of morbidity and mortality in District Hospital

• Top five causes of morbidity (FY 066/67)

Pneumonia

Enteric Fever

COPD

Acute Gastroenteritis

LRTI/ ARI

• Top five causes of morbidity (FY 066/67)

COPD-1

Severe Pneumonia-1

Cirrhosis of Liver-1

Fever-1

Total Deaths-4


3.3. Top ten diseases in Dhankuta

Table 41: Top ten diseases in Dhankuta

067-68 (till chaitra) Total New Cases (066/67)

Skin Diseases 15839

ARI 12513

Diarrhoea 9226

Worms 7301

PUO 6520

Gastritis 5325

Sore eye & eye-complaints 4273

Ear infection 3554

Fall/ Injury/ Fractures 2756

COPD 2417

3.4 SWOT Analysis of District Health System

With the SWOT analysis of Dhankuta district health system, specific components are

reviewed with respect to their strengths, their weaknesses, the opportunities they present

for the improvement or health care or betterment of health status, and the potential threats

that may prevail for the system or system component under scrutiny, as well as the threats

that may emanate from the system. The SWOT for the district health system, Dhankuta,

can be presented as follows:

‘SWOT’ Analysis is a useful analytical tool to qualitatively and quantitatively examine and assess a system, such as the district health system with respect to all of its individual system components.



Table 42: SWOT analysis of district health system

SWOT Components Findings/ Attributes

Strengths Service Inputs Sufficient logistics, trained paramedical staffs

available

Service Distribution All outreach clinics functional, paramedical

staffs posted at all health facilities, better

communication

Management &

Organization

Drugs available, regular reporting, referral

facilities available

Weakness Service Inputs Untimely release of budget, Vacant post of EPI

Officer

Service Distribution No ambulance services in PHCC

Management and

Organization

No regular supervision in far flung areas

Opportunities Ecosystem,

Environmental

factors

District hospital is sensitized to the need for

better maternal care (in delivery and abortion

services),support have become available from

NESOG

Co-ordination BNMT that remained dormant for certain

duration is due to re-vitalize

Service Inputs Establishment of blood bank at district hospital

is in the new program


Threats Political factors Political disturbances and strikes affect service

delivery and transport of logistics

Community

Participation

Reluctance of community to participate actively

in programs organized by DHO

System factors Some health facilities are inaccessible in rainy

season.

3.5 Recommendations

The vacant posts in DHO should be fulfilled for efficient and effective

functioning of the DHO.

Ambulance services should be made available at both PHCCs

Continuous supervision should be done irrespective of geographical constraints

and accessibility.

CHAPTER IV

VISITED ORGANIZATIONS


CHAPTER IV

VISITED ORGANIZATIONS

4.1 Peripheral Health Institutions

4.1.1 Dandabazar Primary Health Centre

4.1.1.1 Introduction:

Dandabazar PHCC is one of the two PHCCs of Dhankuta district, located at a distance of

50 km from the district headquarter and 14 km from Vedetar, the southern VDC of the

district. The PHCC established in 2053 B.S. is one of the important centres with varieties

of health services for numbers of VDCs located in the south-west of Dhankuta district.

4.1.1.2 Catchment Areas

Dandabazar VDC Patigaun VDC

Rajarani VDC Maunabudhuk VDC

Singhdevi VDC

4.1.1.3 System Model of Dandabazaar PHCC

4.1.1.3.1 Input Indicators

• Building

The Dandabazar PHCC is currently operating its services from its four different

building. However, three of them were rented. Altogether there were 21 rooms

which were sufficient for delivery of different services through different rooms.

The PHCC also owned a residential quarter. The new PHCC building was under

construction on a walking distance from the currently operating center.


• Logistics:

All the logistics were sufficiently available in the PHCC. There was a separate

store room for the storage of drugs. However, some drugs that were made

available by the district medical store to PHCC were too close to their expiry. No

ambulance services were provided by the Dandabazar PHCC.

• Human Resources

Table 43: Staffing pattern of Dandabazar PHCC

Posts Sanctioned Fulfilled Vacant Remarks

Medical officer 1 1 0

Public Health Officer 1 1 0

Staff Nurse 1 0 1

AHW 2 2 0

ANM 3 2 1 1 contract

Lab-assistant 1 1 0

VHW 1 1 0

Office assistant 2 2 0

• Other Human Resources

EPI clinics: 3

PHC-ORC: 3

FCHVs: 9


4.1.1.3.2 Process

4.1.1.3.2.1 Health Services Provided by Dandabazaar PHCC

• National Immunization Programme

There were 3 EPI clinics for the conduction of NIP. The PHCC was one of the

four cold chain sub-centers of Dhankuta district. Cold chain in Dandabazaar VDC

was maintained using refrigerator. However, the continuous power failure was

one of the challenges for appropriate maintenance of cold chain.

• Nutrition

Dandabazar PHCC was providing continuous nutrition services such as child

growth monitoring, Vit-A supplementation to both post-partum mothers and

children & iron- tablet supplementation to pregnant and post-partum mothers.

• Family Planning & Safe Motherhood Programme

Dandabazar PHCC had been working on various components of family planning

& safe-motherhood programme. The prime services included distribution of FP

devices, FP counseling, routine ANC check-ups, safe delivery services, PNC

services, medical abortion, BEOC and TT immunization.

• Laboratory Services

Dandabazar PHCC was well equipped with laboratory equipments. Hence, it was

thriving in effective delivery of services like sputum test, malaria parasite test and

routine examination of stool & urine.

• Other Services

CB-IMCI

Disease control Program

FCHV Services

PHC ORC Program


4.1.1.3.2.2Managerial Aspects

There was a PHCC management committee in Dandabazar PHCC which was

responsible for planning, decision making and other managerial aspects involved

in PHCC. Training on various aspects was provided by the district on different

times for the PHCC staffs. The recording and reporting were done using HMIS

tools and timely reporting was done to the district.

Waste management in PHCC was done using incinerator.

4.1.1.3.3 Output Indicators

Table 44: Service indicators of Dandabazar PHCC

Indicators Percentage (066/67)

EPI coverage

BCG 107.72%

DPT/ Hep-B III 89.58%

Polio III 82.24%

Measles 97.3%

TT- 2 66.34%

BCG vs Measles drop-out 9.7%

DPT- I vs DPT- III 4.1%

Nutrition Programme

New Growth monitoring 31.68%

% of malnourished (among new visits) 2.48%

ARI Control

ARI Incidence (by PHCC) 794.07/1000

ARI Incidence by community 1190.23

Control of Diarrhoeal Diseases (CDD)

Diarrhoeal Incidence 198.95/1000


Reproductive Health

1st 70.96% ANC visit

4 ANC visits (among first visit) 76.74%

Institutional Delivery 75.61%

Family Planning New Acceptors Current Users

Pills 2.51 2.5

Depo 6.13 7.9

IUD 0.19 0.46

Norplant 0.139 0.19

Contraceptive Prevalence Rate (CPR) 11.06

FCHV & PHC ORC Program

% of report from FCHVs 90.12%

Average no. of people served by FCHVs 130.81

% of mothers group meeting conducted 91.05

% of PHC ORC held 80.13

4.1.1.3.4 Problems and Constraints

• Lack of trained human resource for logistics management

• Cold-chain maintenance problem due to repeated interruption of power supply

• Availability of safe water

• Lack of Ambulance services

4.1.1.3.5 Recommendations

• The person responsible for store management should be trained on logistics

management and LMIS.

• Ambulance services should be made available at the PHCC.

• Alternatives should be managed for cold-chain maintenance during power

failure.


5.2 Pakhribas Health Post

5.2.1 Introduction

Pakhribas HP is one of the 11 Health Posts located in ward no 9 of Pakhribas VDC

which is about 50 metre from highway and 18 kilometers from Dhankuta

Headquarter.

5.2.2 Catchment Areas

Pakhribas Muga,

Falatae, Sanna

Ghorkakharka.

5.2.3 Physical Infrastructures

Pakhribas HP had its own Pucca building with tin roof. It has total of 7 rooms which

were furnished and well ventilated, medical equiped and supply of electricity. 7 room

include 1 store,1 dispensary room,1 ANC/delivery/PNC room,1OPD room,1 dressing

room,1 family planning and counseling,1 vaccine store room and also available of

waiting hall.

5.2.4 Health Activities /Services Provided by Pakhribas HP

Following activities were being conducted regularly by Pakhribas Health Post.

1. OPD service

2. EPI

3. Family planning program

4. Safe motherhood program

5. Nutrition program

6. Disease control

7. PHC/ORC

8. Health Education program


5.2.5 Management aspects

• Planning: Health Post had formulated its own annual work plan according to

the target given for different programs by DHO.

• Staffing

Table 45: Staffing situation of Pakhribas HP

Post Sanctioned

post

Fulfilled

post

Vacant

post

Remarks

Health

Assistant

1 1 0 -

AHW 1 0 0 -

ANM 1 3 0 2 ANM

VHW 1 0 0 -

Peon 2 0 0 -

Total 6 4 0 -

• Meeting

HP, SHP staff meeting

FCHV meeting

FCHVs review meeting.

• Communication: Communication with DHO, SHP and other sector was done

in written form and also verbally in some cases.

• Coordination: Good coordination was found with SHPs of the catchments

area. Similarly coordination with DHO was also found to be quite good. There

were no INGOs and NGOs working in the catchments area of HP.


• Recording and reporting: Recording and reporting of the health activities

was done on regular basis. Report was sent to the DHO office before 7th

of

every month. Immunization chart was properly filled up.

5.2.6 Service Statistics of Pakhribas HP

Table 46: Service indicators of Pakhribas HP

Indicators Percentage (066/67)

EPI coverage

BCG 69.34

DPT/ Hep-B III 54.72

Polio III 59.36

Measles 69.52

TT- 2 30.28

BCG vs Measles drop-out -0.3

DPT- I vs DPT- III 19.2

Nutrition Programme

New Growth monitoring 31.28

% of malnourished (among new visits) 4.57

ARI Control

ARI Incidence (by PHCC) 386.26/1000

ARI Incidence by community 770.15/1000

Control of Diarrhoeal Diseases (CDD)

Diarrhoeal Incidence 648.27/1000

Reproductive Health

1st 49.85 ANC visit

4 ANC visits (among first visit) 34.05

Institutional Delivery 61.11


Family Planning New Acceptors Current Users

Pills 1.59 2.6

Depo 5.30 8.6

IUD - 0.22

Norplant 0.393 0.66

Contraceptive Prevalence Rate (CPR) -

FCHV & PHC ORC Program

% of report from FCHVs 86.85

Average no. of people served by FCHVs 187.60

% of mothers group meeting conducted 83.33

% of PHC ORC held 75.49

5.2.7 Strengths

• Rooms are sufficient as per the need with sufficient space.

• Equipments and drugs were in sufficient amount throughout the year.

• The office and rooms were well furnished.

5.2.8 Constraints

• Poor access of the HP services to the people due to geographical difficulty.

• Dispensary room was not managed properly.


5.3 Parewadin Sub-Health Post

5.3.1 Introduction

Parewadin Sub-Health Post established in 2050 BS was one of the 24 SHPs in

Dhankuta district. It was located at ward no. 5 of Parewadin VDC. The sub-health

post was situated in its own building.

5.3.2 Catchment Areas

Parewadin VDC Tankhuwa VDC

Murtidhunga VDC Hattikharka VDC

Aangdim (Terathum)

5.3.3 Infrastructures

• Building:

Parewadin sub health post has its own well constructed building with well

ventilated rooms covering in a healthful environment. Separate rooms were

allocated for OPD check up, MCH services, store, injection and dressing. The

building was further in the phase of maintenance.

• Drugs/Store:

Drug required in the SHP level was found to be sufficient in quantity and quality.

• Human resources:

All the post sanctioned in SHPs were fulfilled.


5.3.4 Health Activities /Services Provided by Parewadin SHP

Following activities were being conducted regularly by Parewadin Sub- Health Post.

1. Daily patient check up.

2. Injection/Dressing and Dispensing drugs.

3. ANC/PNC/NC services.

4. EPI services.

5. FP services (condom, pills and depo.)

6. PHC/ORC (clinics/month.)

7. EPI –Clinics (clinics/month)

8. Nutrition programs

• Growth monitoring.

• Vit. A Distribution and deworming.

9. Disease control:

• IMCI Programme

• TB and leprosy control programme.

5.3.5 Management aspects

• Planning:

No annual and monthly planning system was found. Annual target provided by

DHO is available.

• Organization:

Organizational structure is as per national health policy 1991.

• Direction:

Direction of DHO through verbal on direct meeting and sometimes written

through formal letters.


• Staffing:

All staffs are fulfilled.

• Co-ordination:

Vertical co ordination with Illaka Health Post Tankhuwa and DPHO. Horizontal

co ordination with VDC office, Schools, etc.

5.3.6 Problems and Constraints

• Over-expectation of health services from the clients.

• Poor management of store.

• Untimely availability of budget.

5.3.7 Recommendations

• PHC/ORC should be conducted regularly by utilizing staffs with proper

coordination

• Store room should be properly arranged


4.2 Supporting Organizations

4.2.1 Nepal Red Cross Society (NRCS)

4.2.1.1 Introduction

NRCS is one of the largest humanitarian organizations established with district

chapters in each of the 75 districts of the country. NRCS, Dhankuta was

established in 2038 B.S. It has been serving the people of Dhankuta district with

its 4 sub-branches, 30 sub chapters, 2 Youth Red Cross Circles and 57 Junior Red

Cross Circles.

4.2.1.2 Vision

To improve the health status of the vulnerable people

4.2.1.3 Mission

NRCS is committed to deliver quality services for improving health status of the

vulnerable people by mobilizing its nationwide network of volunteers and staffs,

and in partnership with communities and other stakeholders.

4.2.1.4 Objectives

• To provide health service to the people, whenever they are in need

• To provide rescue operation in disaster condition

• To assist in social services.

4.2.1.5 Major Activities

• Ambulance Services

• Emergency relief services

• First-aid treatment services

• Health Education

• Training & Awareness on HIV/AIDS & FP

• School Based Disaster Management Program


• Construction of Latrines

• Community Empowerment by providing training on improved stoves

4.2.1.6 Strengths, Weakness, Opportunities & Challenges

Strengths

Nationwide network of volunteers and staffs

High community acceptance

• Weakness

Problems of funding

No proper blood transfusion services due to lack of blood bank in the

district.

• Opportunities

Partnership with other organizations in specific projects (ADRA in

awareness & training in HIV/AIDS)

• Challenges

Geographical hurdles

Political instability

4.2.1.7 Recommendations

• NRCS need to take initiatives to establish blood bank within the district


4.2.2 Society for Local Volunteer’s Effort (SOLVE)


Society for Local Volunteer’s Effort was established in 1989 with its central office

in Dhankuta and contact office in Subidhanagar in Kathmandu. It is based on the

volunteer concept of an active youth, established with the purpose of alleviating

poverty among various unprivileged and excluded communities in line with prime

objectives of National Planning Commission.

4.2.2.2 Vision

• To envision Nepalese communities which are equitable and capable of meeting

their basic needs with their resources.

4.2.2.3 Mission

• To work with groups to empower people and encourage capacity growth in

communities.

4.2.2.4 Key Activity Areas

• Conducting micro-finance for poor women households

• Developing agriculture and micro-irrigation

• Developing micro-enterprise

• Rural water supply and sanitation

• Maternal and Child Health

• Environment and renewable energy

• Developing community literacy

• Child education and rights

• Building nation and governance

• Building peace and management of peace

4.2.2.5 Reporting System

Monthly reporting to BBC


4.2.2.6 Strengths, Weakness & Challenges

• Strengths

Need based program

Community participation

• Weakness

Programs guided by donor agency

Lack of competent manpower

• Challenges

Political influences


• Competent staffs should be recruited.


4.2.3 Family Planning Association Nepal (FPAN)


FPAN, Dhankuta was established in 2035 B.S. It implements its program in

partnership with large number of NGOs, CBOs, DHO and other line agencies of

government for the implementation of sexual and reproductive health program in

Dhankuta.

4.2.3.2 Mission

FPAN is committed to improve the quality of lives of individuals through SRH

information and services especially for poor, marginalized and vulnerable people in

under-served areas. It defends to the right of all young people to enjoy their sexual

lives free form ill health, unwanted pregnancy, violence and discrimination, to

empower women to exercise their SRH rights to terminate unwanted pregnancies

legally and safely at affordable cost, and to eliminate STIs and to eradicate

HIV/AIDS.

4.2.3.3 Objectives

• To increase access of gender sensitive STI services and STI & HIV/AIDS

education to vulnerable population.

• To increase the access of safe abortion services.

• To strengthen recognition of SRHR, including policy and legislation, which

promotes, respects, protects and fulfils these rights.

• To increase availability of gender sensitive SRH information and services

including family planning in rural setting.

4.2.3.4 Program Activities

• Family Planning services

• MCH services and education

• Advocacy on SRHR


• STI services

• VCT services

• HIV prevention, care and support

• Safe abortion services

• Capacity building training

4.2.3.5 Problems & Constraints

• Resource constraints

• Reluctance of health personnel to work in remote areas

• Out migration of adolescents and youths in rural VDCs

• Need of additional training on sexual and reproductive health


• Incentives scheme should be provided for health personnel working in remote

areas so as to motivate them to work.


4.2.4 Britain Nepal Medical Trust (BNMT)


Britain Nepal Medical Trust is a service oriented NGO established in 1967. The

major areas of BNMT are TB and Leprosy control, community empowerment for

community health development & drug management for sustainability of

availability of drug in the community. BNMT has been operating its program on TB

control in Dhankuta district since 1970. However it begun its co-ordination with the

DHO in various other priority health programmes in the district only in 2003.

4.2.4.2 Vision

• Improved health status of people of Nepal

4.2.4.3 Mission

• Helping the people of Nepal to improve their health through supporting

sustainable health services, capacity building and people’s empowerment.

4.2.4.4 Goal

• Improved ability of communities in the Eastern Development Region to manage

and address their basic right to health.

4.2.4.5 Objectives

• Strengthen the capacity of local institutions

• Empowering communities

• Develop innovative models and approaches

• Completing handover of existing programmes


4.2.4.6 Strategies

• Capacity building and strengthening partners

• Community based program

• Poverty and equity

• Addressing emerging health need

4.2.4.7 Program activities

BNMT has been helping Dhankuta in the following priority (P1) programmes of

Nepal Government.

• TB control programme

• HIV/AIDS & STI programme

• Essential Drug Programme

• Reproductive Health- Safe Motherhood

• Infectious diseases- ARI & Diarrhoea control

4.2.4.8 Problems & Constraints

• Lack of funding by donor agency

• At the verge of insolvency


• BNMT should appeal for support so as to rejuvenate its activities in the district.

CHAPTER V

EPIDEMIOLOGICAL STUDY


CHAPTER V

EPIDEMIOLOGICAL STUDY ON PNEUMONIA

5.1 Introduction

Pneumonia is a common illness in all parts of the world. It is a major cause of death

among all age groups. In children, many of these deaths occur in the newborn period. The

World Health Organization estimates that one in three newborn infant deaths is due

to pneumonia. Over two million children under five die each year worldwide. WHO also

estimates that up to 1 million of these (vaccine preventable) deaths are caused by the

bacteria ''Streptococcus pneumoniae'', and over 90% of these deaths take place in

developing countries.

5.2 Objectives

5.2.1 General Objectives

• To study the epidemiology of pneumonia among IPD cases in Dhankuta District

Hospital.

5.2.3 Specific Objectives

• To study the magnitude of pneumonia in Dhankuta.

• To find the distribution of pneumonia by person and time.

5.3 Rationale

• Pneumonia is a leading killer disease under five children in Nepal.

• High incidence of Pneumonia was evidenced by the three year data trend among IPD

cases of District Hospital from FY 064/65 to 066/67.

• Pneumonia control among under five children is a national priority programme that has

been effectively conducted in Dhankuta through all levels.

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5.4 Methodology

• Study area: District Hospital was selected as the area of our epidemiological

study.

• Study population: Indoor patients of district hospital who were diagnosed as

Pneumonia cases were studied to explore the magnitude and distribution of

pneumonia within the district

• Study Design: Retrospective study was done in which 3 years information was

reviewed.

• Study technique: Secondary data review was done from indoor patient register.

• Source of data: The data was made available from medical record section of

district hospital.

5.5 Study variables:

• Time Variables: Month/year

• Place variable: There were no clear data available to study the distribution of

Pneumonia with respect to geographical locations. Hence we couldn’t explore the

place-wise distribution of pneumonia in Dhankuta.

• Person variables: Age and Sex

5.6 General Epidemiological Characteristics of Pneumonia

5.6.1 Agent Factors

• Common Bacteria

H. Influenza

S. Pneumoniae

Staphylococci species

• Common Viruses

Adenoviruses

Enteroviruses

Influenza A,B,C


• Other Agents

Mycoplasma pneumoniae

5.6.2 Host Factors

• Small children can succumb to the disease within a matter of days and

case fatality rates are higher in young infants and malnourished children.

• Adult women experience more illness than men, probably because of more

exposure to children.

5.6.3 Environment Factors

• Cold climatic conditions, poor housing, poor nutrition

• Intense indoor air pollution

5.6.4 Mode of Transmission

• By air borne route via person to person contact.

5.7 Findings and Discussions

5.7.1 Time Distribution

This diagram shows the monthly trend of ARI of 2064/65 to 2066/67 in district hospital

indoor. Although no clear trend was observed, in Dhankuta district hospital the number

of cases were higher during Mangsir and Falgun. However, during the FY 065/66 the

pneumonia cases were higher during Bhadra. This was due to the epidemic of pneumonia

during that period.


Figure 1: Time Distribution of Pneumonia

5.7.2 Sex- Distribution

The bar graph shows the sex wise distribution of Indoor Pneumonia cases in Dhankuta

district hospital in which male were more affected and admitted in indoor then the female

since last three years. This may be due to high mobility pattern of male then female in our

society due to high chance of exposure with risk factor of Pneumonia.

Figure 2: Sex Distribution of Pneumonia

05

101520253035404550

064/65

065/66

066/67

57.58%50.80%

62.16%

42.42%49.20%

37.84%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

064/65 065/66 066/67

Male

Female


5.7.3 Age-distribution

The diagram given below shows the most of the cases of pneumonia affects children than

other age groups. In Dhankuta district hospital, the proportion of pneumonia cases in

children of less than five years were about two-third times greater than the total sum of

rest of age group in all three fiscal years.

Figure 3: Age Distribution of Pneumonia

5.8 Conclusion

The epidemiological study revealed that pneumonia was higher during winter season

(Mangsir and Falgun). Male were more prone to pneumonia in Dhankuta. Infants

were highly suffered from pneumonia as compared to other age-groups.

5.9 Recommendations

• Further study on epidemiological features regarding pneumonia is necessary to

explore more comprehensive picture of pneumonia distribution within the district.

• Complete records on district hospital should be made available.

0

10

20

30

40

50

60

<1 yrs 1-4 yrs 5-14 yrs 15-59 yrs 60+ yrs

064/65

065/66

066/67

CHAPTER VI

CRITICAL REVIEW


CHAPTER VI

CRITICAL REVIEW

6.1 Critical Review on Logistics Management

-Prabesh Ghimire

6.1.1 Introduction

The logistics management system is a management activity which includes the total flow

of products (commodities, essential drugs, vaccines, contraceptives, medical equipments

and instruments, HMIS/LMIS forms/ formats/ registers and other allied materials) from

the acquisition of raw materials to the delivery of finished goods to the users, as well as

the related flow of information that both controls and records the movement of those

products.

An efficient management of logistics is crucial for effective and efficient delivery of

health services as well as ensuring rights of citizens of having quality of health care

services. The objective of logistic management in Dhankuta is to plan and carry out the

logistics activities (including maintenance) for the uninterrupted supply of essential

medicines, vaccines, contraceptives, equipments, HMIS/LMIS forms and allied

commodities for the efficient delivery of healthcare services from all governmental health

institutions in the district.

6.1.2 Rationale

• An essential aspect of district health management

• The topic of interest

6.1.3 Objectives

• To review the logistics management system of Dhankuta district.

• To study the logistics management information system in Dhankuta.


6.1.4 Methodology

• Study Type: Cross-sectional descriptive study was done to

review the logistics management system of

district.

• Study area: Store section of District Health Office as well as

peripheral institutions was selected for the study.

• Study Duration: The study was done for 3 days.

• Data collection tools: Secondary Data Review Format

Interview Guidelines

• Data collection techniques: Data review was done for collection of information.

Interview was also done with storekeeper on

logistics system.

6.1.5 Findings

• Logistics flow system

All varieties of logistics ranging from essential drugs and vaccines to contraceptives,

medical equipments, instruments and commodities are supplied to the District Health

Office, Dhankuta by Logistics Management Division (LMD) under Department of

Health Services via Regional Medical Store in Biratnagar. These logistics are supplied

by the District Store to the peripheral institutions based on PULL system.


Port

Central Warehouse (Teku)

Regional Medical Store

(Biratnagar, Koshi)

District Store(DHO, Dhankuta)

PHCCs SHPsHPs

Community Health Workers

Clients/ Consumers

Logistic Management Division (DOHS)

Regional Health Directorate (Dhankuta)

Figure 1: Logistics Flow System

• Store Management

The storage of logistics in the district store was done using FEFO mechanism. The

stock of logistics in the district store as well peripheral institutions was maintained

with EOP and ASL. EOP for district store and peripheral institutions is 3 months and 1

month respectively. However the ASL is 5 months and 3 months respectively.

• Recording reporting

The recording and reporting of logistics were done using various forms like entry

form, dispatch form and order form. Reports of every received commodities and

supplied logistics are sent by peripheral institutions to the district store trimesterly


using various LMIS and audit forms. The district sends a report to RMS as well as

LMD every three months and the feedback is sent by LMD to regional and district

logistic management section.

Regional Medical Store (Biratnagar)

District Medical Store(DHO, Dhankuta)

Sub-Health PostsHealth Posts PHCCs

Logistics Management Division(Teku)

Supervision

Reporting

Figure 2: Logistics Management Information System in Dhankuta

• Supervision

There is a periodic supervision of PHCCs regarding logistics management. However,

there are no provisions of supervision for HPs and SHPs from DHO.

• Training

The in-charge of the district store has been trained for the logistics management.

Moreover, the heads of all peripheral institutions have also been trained on effective

logistic management & PULL system.


6.1.6 Observation Findings

During our observation of the district store, we found that the time being for the supply of

logistics to the peripheral health institutions, the packaging and store seemed unmanaged.

The physical condition (temperature) was also not adequate for drug storage. However,

the inventory system was well maintained. There was a good recording and reporting

regarding logistics management.

Regarding the transportation, there is only one vehicle for the use by DHO, DH as well as

peripheral health services. Hence, the shortage of vehicle was experienced time and

again.

6.1.7 SWOT on Logistics Management

Strengths

• Pull system was on practice.

• 100% reporting was found on logistics management.

• Timely supply of logistics.

• ASL & EOP were well maintained at the district.

Weakness

• Poor maintenance of store.

• Limited vehicle for logistics supply.

• Lack of supervision for HPs and SHPs.

Opportunities

• Established of new DHO building.

Threats

• Nepal bandha affected logistics supply time and again.



• The number of vehicles for DHO should be increased

• There should be provisions of supervision also for the health posts and sub-health

posts.

• Store should be maintained according to the standard guidelines.


6.2 Critical Review on Integrated Management of Childhood Illness

-Rabina Kumari Rajak

6.2.1 Introduction

Community Based Integrated Management of Childhood Illness (CB-IMCI) is an

integrated package of child-survival programmes and addresses major killer diseases like

pneumonia, diarrhoea, malaria, measles, malnutrition in under 5 year children. The goal

of CB-IMCI programme is to reduce the morbidity and mortality among children under-

five age. CB-IMCI programme in Dhankuta was first implemented in fiscal year 2059/60.

It was implemented with the objectives to improve the utilization and behavioral

practices of the community and family for early referral and treatment of sick newborn

and child.

6.2.2 Rationale

• CB-IMCI is an integrated programme that addresses five major killer diseases.

• The diarrhoea incidence has increased to maximum in FY 066/67 (165.13/ 1000)

as compared to previous years.

• ARI incidence has been increasing in Dhankuta.

• Growth monitoring coverage has been decreasing in Dhankuta.

6.2.3 Objectives

• To review the CB-IMCI programme in Dhankuta.

• To identify the possible reasons increasing incidence of diarrhoea.

• To analyze the causes associated with the high incidence of ARI.

• To seek the hindrance factors for the coverage of growth monitoring.

6.2.4 Methodology

• Study Type: The critical appraisal on CB –IMCI was done using

cross-sectional descriptive study design.

• Study area: The study was done in the IMCI section of DHO.


• Study Duration: The study was performed for 2 days.

• Data collection tools: Secondary data review format and interview

guidelines were used for collection of data.

• Data collection techniques: Data review

Interview with IMCI supervisor

• Source of data: Monthly monitoring and annual performance

review worksheet was used

6.2.5 Findings

Table 47: Data trends on ARI Incidence

Indicators 064/65 065/66 066/67 National

ARI Incidence by HF (per 1000) 289 412 450.55 340

ARI Incidence by Community

(VHW/MCHW/FCHV) per 1000

616 648.56 895.25 660

% of new Pneumonia 55.2% 55% 52.30% NA

The above table shows that reported cases of ARI by both health facility and community

had increased in 066/67 than that of past two years. The reported incidence seemed

higher than that of the national figure. This increase could either be due to improvement

in the recording and reporting system or an actual increase in the cases of ARI.

Despite the increase in ARI incidence, the percentage of new pneumonia cases has

decreased from 55.2% in FY 064/65 to 52.30% in FY 066/67. This could have happened

possibly because much of the people are well familiar with pneumonia. So, they arrive

early to health centers. However, other ARI diseases are still unfamiliar. Hence, ARI

incidence could have increased.


Figure 3: Trends of Diarrhoeal Incidence

The reported incidence of diarrhea by both health facility and community shows an

increasing trend. The maximum incidence of ARI was evidenced in Budhabare HP

(2142.86 per 1000). According to the IMCI section, the increase as shown by the data

trend is not actually the true one. It has actually been due to two main reasons.

• Out-migration of target population (U5 children)

• Over-estimation of target population of Dhankuta district.

Figure 4: New Growth Monitoring Coverage in Dhankuta

472.24506.69

624.76

129

123.7165.13

0

100

200

300

400

500

600

700

064/65 065/66 066/67

CDD Incidence (by HF & Community)CDD Incidence (by HF)

0%5%

10%15%20%25%30%35%40%45%

064/65 065/66 066/67 067/68 Regional National

32.90%30.18%

24.92%17.15%

44.04% 44.81%New Growth Monitoring (coverage)


The percentage of new growth monitoring shows a decreasing trend. This is possibly

because of the improvement in the recording system. The repeated entry of same children

which could occur during previous years has been minimized by recording them in the

same recording sheet.

6.2.6 SWOT analysis of IMCI programme

Strengths

• Good community participation

• Highly motivated FCHVs

• Good reporting on IMCI indicators

Weakness

• Delayed release of budget

• Lack of public awareness

Opportunities

• Support of NGOs

• Implementation of CB-NCP

Threats

• Geographical hurdles


• Adequate & timely release of budget should be done.

• Community awareness about IMCI should be focused.


6.3 Critical Review on National Immunization Programme (NIP)

-Shreetina Keshari Tuladhar

6.3.1 Introduction

The National Immunization Programme (NIP) is a priority program of Nepal

Government. EPI is considered as one of the most cost effective health interventions

since the beginning of the service. The overall goal of the EPI is to reduce child

morbidity and mortality associated with Vaccine Preventable Diseases (VPDs). The

target population for BCG, DPT, OPV and Measles are infants under one year (12

months) of age.

6.3.2 Rationale of the study

• BCG Vs Measles dropout rate Dhankuta was higher i.e. 14.16%.

• Immunization coverage was lower i.e. BCG coverage was 75.13%, DPT/Hep.3

was 65.27 %, Polio3 70.11% and Measles was 72.26% as compared to the national

achievement.

• It was one of the priority programs of Nepal.

6.3.3 Objective of the study

• To find out current status of immunization coverage

• To find out the factors behind low immunization coverage

• To find out the factors behind high dropout rate of immunization

• To analyze EPI in terms of SWOT i.e. Strength, Weakness, Opportunity and

Threat


6.3.4 Methodology

• Study method: Descriptive and explorative study was used

to critically appraise the status of NIP in the

district.

• Data Collection Techniques: Secondary Data Review and Interview with

EPI Supervisor was done so as to collect the

information

• Data Collection Tools: Secondary Data Analysis Format

Interview Guidelines

• Study Duration: The study was carried out for three days.

6.3.5 Findings and discussion

Table 48: Four years trend analysis on immunization

Program Activities Programme Output (Coverage percentage)

2064/65 2065/66 2066/67 2067/68

BCG 83.95% 85.85% 86.21% 84.18%

DPT3 36.06% 44.02% 27.47% 9.53%

Polio-3 39.30% 45.48% 37.55% 27.47%

Measles 72.78% 73.47% 75.20% 75.37%

The table presents the immunization coverage of BCG, DPT3, OPV3 and Measles in

Dhankuta from F/Y 2064/65 to 2067/68 (till chaitra). The four-year trend analysis shows

the coverage of all immunization were below the national level. In the F/Y 2066/67 the

BCG coverage was 86.21%, which decreased to 84.18% in the F/Y 2067/68. The

coverage of DPT3 and OPV3 were also in decreasing order from F/Y 2065/66 to

2067/68. However, the coverage of Measles had slightly increased in F/Y 2067/68 than

that of 2066/67.


The immunization coverage was lower in four years trend as compared to the national

coverage. The low coverage of immunization shows the inaccessibility of immunization

services to the target population. However, during the discussions on the subject it was

found that target population estimated by Government of Nepal on NIP was higher with

regard to the actual population receiving the NIP services. While looking at the health

institution wise NIP coverage it was found that the coverage was also below the target

level.

Table 49: Immunization Drop-out Rate

Immunization 064/65 065/66 066/67 067/68

(till chaitra)

National

(065/66)

BCG vs Measles 8.9% -0.47% 3.82% 14.16% 11.3%

DPT 1 vs DPT 3 1.6% 0.06% 7.89% -4.91% 2%

The above table depicts that the BCG vs Measles drop-out rate is highly increased from

066/67 to 067/68. However DPT I vs DPT 3 drop-out is decreasing in 067/68.

6.3.6 SWOT Analysis of EPI Program

Strength

• Sufficient logistic supply in the DPHO

• Timely distribution of vaccines and other logistics from DPHO to other institutions

Weakness

• Some refrigerators & deep-fridge were non-functional at cold-chain centre.

• Vacant Post of EPI Supervisor.

Opportunities

• Support of FCHVs in National Immunization Day.

• Community participation in EPI.


Threats

• No electric back-ups during power cut.


• Vacant post of EPI supervisor should be fulfilled

• Non-functional deep fridges and refrigerators should be maintained

• DHO should find the alternatives during power-cuts


6.4 Critical Analysis on Recording and Reporting

-Naresh Bhatta

6.4.1 Introduction

Before the integrating of all health programs in 1993 various vertical projects were using

their own recording and reporting system. More than 110 different forms, cards, registers

and reports formats were on use. There is lack of standardization, duplication and

collection of unnecessary information.

During the fiscal year 1986/87, all the vertical programs were integrated at the district level

but information system was not integrated till 1993. During the fiscal year 1993/94, the

ministry of health was restricted and department of health reinstated. A central MIS section

was established in order to develop integrated health management information system at all

levels for better coordination, planning, monitoring and evaluation of ongoing program

integrated at various levels. Government has established a systematic channel for recording

and reporting. Record is kept in different forms and registers likewise; reporting is done in

different formats from periphery to center in timely basis.


• Essential functions of management.

• Decreasing reporting status on lower level health facilities.

• Topic of personal interest.

6.4.3 Objectives

• To find out the actual recording and reporting status of DHO and different

institutions.

• To explore the Problem, obstacles for timely recording and reporting task.


6.4.4 Methodology

• Study design: Descriptive study was done so as to review the

recording and reporting status of the district.

• Study area: The study was done in the statistical section of

DHO.

• Study duration: The study was performed for 3 days.

• Data collection technique: Record review and interview with DHO,

statistician, in-charge of health institutions and

storekeeper was done to review recording and

reporting status within the district

• Data collection tools: Interview guidelines designed to interview

statistician was used for the collection of

information.

6.4.5 Findings and Discussions

Table 50: HMIS reporting form different institutions

Institutions Reported percentage in fiscal year

065/66 066/67 067/68 (Up to chaitra)

Hospital 100 100 100

PHCC 100 100 100

HP 100 100 100

SHP 100 100 95.7

PHCC/ORC 89 82 57.7

FCHV 94 95 67

EPI 92 93 86


Table 51: HMIS reporting status of different organizations

Institutions Timely Reporting percent

065/066 066/67 067/68 (up to

chaitra)

Dandabazar PHC 75 92 100

JitpurPHC 33 75 75

Belhara HP 67 83 50

Tankhuwa HP 67 92 100

Hattikharka HP 58 83 87.5

Chanuwa HP 50 83 62.5

Pakhribas HP 25 92 87.5

Ankhisalla HP 17 83 37.5

Ahela HP 50 67 62.5

Budhimorang HP 83 100 100

Maunabadhuk HP 50 100 75

Atharasaya HP 50 67 75

Budhabara HP 50 67 25

Hospital 87.5

6.4.6 Discussion

The recording and reporting status of only few HIs were found to be satisfactory. The

reporting from SHP, PHC-ORC, EPI clinics and FCHV has decreased in FY 067/68 as

compared to FY 066/67. The Timely recording and reporting varied markedly among

different health institutions and months. Budhimorang HP had the highest (100%) timely

recording and reporting status.

Vacant post in peripheral HIs showed to have affected the whole recording and reporting

process. The recording and reporting process from lower level health workers (VHWs and


FCHVs) is still at questions of validity and reliability. The private sector health institutions

are still beyond the coverage of HMIS system.

6.4.7 SWOT analysis

Strength

• There is one statistician working in the district and good recording and reporting

in the district health office.

• Computer application in the district office in coordination with hospital in spite of

computer illiteracy of statistical assistant

• Quarterly and annual review meeting in the district in which reports are also

verified up to HP level.

• Monthly monitoring sheets are filled and used in DHO and some HFs.

Weakness

• Lack of formalized performance based appraisal system.

• Lack of training in LMIS and staffs of peripheral health facilities are not aware

about the importance of timely reporting.

• Not covering the private sector health institution of the HMIS system

Opportunity

• Strengthen integrated supervision and formation of subcommittee of district

supervisor to facilitate the function of SHP, HP and PHC.

• Community participation through strengthened HF management committee.

• Different NGOs are interested to work in coordinated manner with DHO in the

section of reporting and data use.


Threats

• Geography and communication system

• Transparency gap of programs

• Political interference


• HMIS and LMIS training should be given to root level i.e. HP and SHP.

• Initiation of covering the private sectors HIS within HMIS by regulating the

licensing and renewal of such health institutions.

• Performance based appraisal system needs to be strengthened for monitoring the

health workers for recording and reporting system.


6.5 Critical Review on Staffing Situation

-Uttam Gautam

6.5.1 Introduction

The staffing function of management is concerned with people. People as human

resources are vital for achieving the goals of any health institutions. The institutional

performance largely depends on the individual performance of each and every health

worker at each level.

Staffing is a process of acquiring, developing, utilizing and maintaining an effective

workforce. It fills up the slots in the organizational structure of any institutions.

The main aim of district health system to provide preventive, promotive and curative

services to the people living in the district is only fulfilled if there are right numbers of

people in the right place at right time having right skills and right motivation and

attitudes.


• There is difference in staffing situation between health institutions in highway

areas and other areas of the district.

• Unmanned and vacant posts in health institutions.

• A subject of interest to self.

6.5.3 Objectives

• To find out the present staffing situation under DHO, Dhankuta.

• SWOT analysis of staffing situation.

• To explore the obstacles in fulfilling the staffs in health institutions.

6.5.4 Methodology

• Study type: The staffing situation in Dhankuta was reviewed

using descriptive and cross sectional study design.


• Study area: The study was done in administration section of

District Health Office.

• Study duration: The study was done for the duration of 2 days.

• Data collection tools: Interview guidelines

Secondary data format

• Data collection techniques Interview was done with DHOr and Nayab Subba.

Review of Attendance Register of staffs was also

done.

6.5.5 Findings

Table 52: Post wise staffing situation

Posts Sanctioned Fulfilled Vacant

Public Health Administrator 1 1 0

Medical Superintendent 1 0 1

Medical Officer 4 3 1

District Supervisors 8 7 1

Staff Nurse 6 5 1

Lab Technician/ Assistant 1 1 0

Radiographer 1 0 1

HA/ Sr. AHW 16 16 0

AHW 41 41 0

ANM 21 20 1

MCHW 24 23 1

VHW 37 28 9

6.5.6 Discussion

The staffing situation of DHO, Dhankuta was found to be satisfactory because only 10%

of the total sanctioned posts were vacant. Sanctioned posts were vacant mainly in remote


areas. Posts of malaria inspector, EPI supervisor in public health section and radiographer

in hospital were remained vacant since long period of time affecting the quality of

services.

There were no special provisions of incentives and other facilities for health workers in

remote areas due to which some of the health workers were reluctant to go in such areas.

6.5.7 SWOT Analysis

Strengths

• About 90% of the sanctioned posts were fulfilled

• All the sanctioned posts of HA/ Sr. AHW were fulfilled

Weakness

• Staff placements were not done systematically (untimely transfer and untimely

deputation).

• Long time vacant posts in DHO (malaria inspector, EPI supervisor) and hospital

(radiographer).

• No incentives for health workers at far-flung areas.

Opportunities

• Community participation in health institution management committee

Threats

• Geographical difficulties

• Political influence


• DHO should ensure the management of the vacant and unmanned posts.

• There should be provision of special incentives and other opportunities like training

for health workers at far-flung areas.


6.6 Critical Analysis on Case finding in National TB Programme

-Anu Gomanju

6.6.1 Introduction

Tuberculosis is one of the major public health problems in Nepal. About 45 percent of the

total population is infected with TB, out of which 60 percent are adult. In Nepal,

introduction of treatment by Directly Observed Treatment Short Course (DOTS) has

already reduced the number of death. Expansion of this cost effective and highly

successful treatment strategy i.e. DOTS, which already has proven its efficacy in Nepal,

will have a profound impact on mortality and morbidity. The national tuberculosis

programme’s (NTP) long term goal is to reduce the transmission of TB to such a level

that it is no longer a pub;ic health problem. The NTP has coordinated with the public

sectors, private sectors, local government bodies, I/NGOs, social workers, educational

sectors and oher sectors of the society in order to expand DOTS and sustain the present

significant results achieved by NTP.

At district level, the district health office/district public health office is responsible for

planning and implementing of the NTP activities within the district. For proper

monitoring of the programme different indicators has been developed by NTP. Case

detection ratio is one of the indicators. Case detection ratio is the number of new

pulmonary smear positive cases detected, expressed as percentage of the estimated new

smear positive cases. It provides a measure of case finding coverage. The national target

is to achieve a case detection ratio of 70% and it was below national targets in Dhankuta

district.

6.6.2 Rationale

• With respect to the national target, the case detection ratio of Dhankuta district is

low.

• Despite adequate training and logistic supply program achievement is weak in this

indicator.


6.6.3 Objectives

• To find out root causes of low case finding of TB in Dhankuta district..

• To analyze the problem in terms of SWOT i.e. strength, weakness, opportunity

and threat.

• To recommend the DHO, Dhankuta regarding action to be taken to improve the

situation.

6.6.4 Methodology

• Study method: Descriptive method was employed to review case

finding status of National TB Programme.

• Study duration: The study was conducted for 3 days.

• Data collection techniques: Secondary data analysis from TB register and

HMIS 32 was done. Interview was also done with

TB/Leprosy supervisor and HP/SHP in charges

• Data collection tools: Formats for secondary data review and interview

guidelines were used for collection of information.

• Data Sources: Monthly monitoring sheet was used as the source

for collection of information.

6.6.5 Findings and discussion

• The case detection ratio of district was continuously lower than national target

for last ten fiscal years.


Figure 5: Year wise TB Case Detection Ratio

• There was cent percent DOTS coverage in Dhankuta district. Ninety-one percent

of health worker in district had taken DOTS modular training.

• There were 3 DOTS treatment centers with microscopy, 11 DOTS treatment

centers and 24 DOTS treatment sub-centers. Among treatment centers in district,

those with microscopy facility (Jitpur PHCC, Dandabazar PHCC and Dhankuta

hospital) had achieved case detection ratio near national target level.

• About 56% of total new smear positive cases were registered in DOTS treatment

centers having microscopy facility.

3230

27

55

37

3537

43

28

33

0

10

20

30

40

50

60

57/58 58/59 59/60 60/61 61/62 62/63 63/64 64/65 65/66 66/67

Case Detection Ratio


Table 53: DOTS treatment centre wise case detection ratio (FY 2066/67)

DOTS treatment

centres

Estimated new

smear positive

cases

Detected new

smear positive

cases

Case detection

ratio

Chanuwa HP 8 1 11.8

Jitpur PHCC 9 6 67.0

Hattikharka HP 4 2 53.7

Pakhribas HP 13 3 23.3

Tankhuwa HP 13 3 23.3

Aankhisalla HP 16 1 6.40

Belhara HP 4 1 77.5

Aahale HP 6 1 17.7

Dandabazar PHCC 6 4 68.0

Budhimorang HP 4 0 0.00

Maunabudhuk HP 6 1 16.8

Atharasaya HP 7 9 41.6

Budhabare HP 1 0 0.00

Dhankuta hospital 14 10 73.00

Total 112 36 32.14

• The reported incidence of new smear positive cases in F/Y 2066/67 was found

higher among young age (about 20% in 0-24 years age group) indicating

transmission of TB not decreasing.

• Preparation and movement of slide for AFB test was not well functioned mainly

due to the geographical difficulties.


6.6.6 SWOT analysis

Strength

• Modular training was provided to most of the health workers.

• Sufficient budget and logistic supply.

• Quarterly review meetings were regular.

Weakness

• Inadequate number of microscopy centre.

• Lack of regular HMIS feedback in TB program.

Opportunity

• Good support of DDC and I/NGOS (BNMT)

• Committed DPHO team.

• DOTS committee at different level.

Threats

• Geographical and climate factors

• Political instability


• DOTS treatment centre with microscopy need to be expanded.

• Vaccine mobilization date and staff review meeting days can be used as

opportunities to use slide transportation

• Regular feedback from DHO in TB control program should be given.


6.7 Critical Analysis on Primary Health Care Outreach Clinics Programme

-Dinesh Rupakheti

6.7.1 Introduction

Primary Health Care- Outreach Clinics (PHC-ORC) are the extension of Primary Health

Care Centers (PHCCs), Health Posts (HP), and Sub Health Posts (SHP) at the community

level. Primary Health Care outreach Clinics (PHC/ORC) were established in 1994 (2051

BS) with an aim to improve access to some basic health services including family

planning and safe motherhood services for rural households. VHWs and MCHWs or

ANMs provide basic PHC services (FP/ANC) services / Health Education/ Minor

Treatment) to a pre- arranged place close to communities (two to five catchment areas per

VDC) on a predetermined day once in a month. In principle, then clinics will be held at

locations not more than half an hour’s walking distance for the population residing in that

area.

6.7.2 Rationale

Only 81.6% PHC/ ORC clinics were conducted in FY 2066/067 compared to 85.9% in

FY 2065/066. The conduction of PHC/ORC is in decreasing trend in Dhankuta district.

6.7.3 Objectives

• To find out the current status of PHC/ORC programme.

• To find the factors affecting PHC/ ORC programme.

• To analyze the PHC/ORC programme in terms of SWOT i.e. strength, weakness,

opportunities, and threats.

• To recommend the DHO for improving PHC/ORC programme.

6.7.4 Methodology

• Study design: Descriptive and analytical study design was used

for critical analysis of PHC/ ORC programme.

• Study area: Dhankuta district was selected as the area of study.

• Study duration: The study was done for the period of 3 days.


• Data collection technique: Record review and in depth interview with DHOr,

District supervisor, HIs incharge, VHW, MCHWs,

ANMs was done.

• Data collection tools: Record review format and interview guidelines

were used for review of information.

6.7.5 Findings

Table 54: Trends in PHC/ ORC conducted in Dhankuta district

Indicators 064/65 065/66 066/67

Total no. of PHC/ ORC held in a year

1326 1371 1264

% of PHC/ORC held

83.71% 85.90% 81.65%

Average no. of people served by PHC/

ORC

13742 15334 18965

Total no. of people served by

PHC/ORC

10 11 15

• The table shows the decreasing trend of conduction of PHC/ORC and increasing

trend of average number of people served by them.

• Supervision of PHC/ORC was only 1.82% in FY 2066/067.

• No any funds collected since last three years through registration fees from users.

• Altogether, five posts of VHWs were vacant in districts.


6.7.6 SWOT analysis of the PHC/ORC Programme

Strength

• The percentage of PHC/ ORC conducted is higher than national level.

• The average number of people served by PHC/ ORC is in increasing trend.

Weakness

• Supervision of the PHC/ ORC clinic is inadequate.

• There are irregularities in conducting PHC/ ORC clinics.

• There is no equity in incentives among health worker conducting PHC/ORC.

• Vacant posts of VHWs in some VDCs.

• The community based organization (CBOs) and other local resources are not

mobilized.

Opportunities

• VDC can be involved for support.

• The dissemination of Revised PHC/ORC Strategy can help to make the program

effective.

Threats

• The difficult terrain has hindered the overall success of the programme.

• Many people are still unaware of the actual services provided by PHC/ORCs.

• Many people still prefer specialized services.


• The supervision of the PHC/ORC needs to be increased.

• There should be equity in incentives among health workers conducting

PHC/ORC.

• The vacant posts of the VHWs need to be filled.


6.8 Critical review on Integrated Supervision

-Anil Dhungana

6.8.1 Introduction

Supervision is a process by which workers are helped by a designated staff member to

learn according to their needs to make the best use of their knowledge and skills, and to

improve their abilities so that they do their jobs more effectively and with increasing

satisfaction to themselves and the agency. -Margaret William

It is the process of assisting, supporting and monitoring for the purpose of increasing

skills and performance of the staffs for achievement of organizational goal.

Without supervision, even the best planned operations do often achieve only limited

results. Supervision keeps the planned action on the right track, identifies and corrects

deviations, addresses the problems as they arise at the implementation itself, informs the

responsible officials about the actual status of programme implementation, energizes

staffs to carry on with their good work, and supports them for enhancing their

performance.

Integrated supervision is a process of guiding, supporting, motivating and monitoring of

all programs at once for the purpose of improving skills and performance of staffs.

Integrated supervision is one of the new concept and priority programs of Ministry of

Health, Government of Nepal which has been practicing from fiscal year 2052/53 where

the entire programme could be supervised at once. It is one of the crucial parts of

managerial function which guides, supports, motivates and monitors all programs at once

for the purpose of improving skill and performance of the staff.

In the district, supervision schedule should be planned at all levels before the programme

implementation. Necessary supervision trainings need to be provided to the staffs from

time to time for maintaining integrated supervision.


Table 55: Routine supervision strategy in district level From To Times in a year/unit

District PHCC/HP 12

PHCC/HP SHP 12

SHP Wards 12


• Integrated supervision being one of the priority programs of MOH, Government

of Nepal.

• Integrated supervision to peripheral institutions was poor (PHC-60%, HP-33%,

SHP-5%, ward-0 % in 063/064).

• Compulsory recording and reporting of checklist not maintained.

6.8.3 Objectives

6.8.3.1 General Objective

• To identify critical points associated with low status of integrated supervision in

the district

6.8.3.2 Specific Objectives

• To document the key findings in integrated supervision

• To analyze the integrated supervision in terms of SWOT

• To identify critical points and provide possible suggestions for bringing

desirable changes in supervision status of the district

6.8.4 Methodology:

• Study area: Overall Dhankuta district was selected as the area of

study.


• Study method: Descriptive study design was used for critical

review of supervision status.

• Study unit: DHOr, District Supervisor, Health Institution in-

charges.

• Data collection techniques: Secondary data analysis and interviews with

programme supervisors and HP/SHP in- charges

was done.

• Data collection tools: Data review format and interview guidelines were

designed to collect information.

• Study duration: The study was done for 3 days.

6.8.5 Finding and discussion

Table 56: Supervision status of the district

Institution/HWs

supervised

Times/unit

No. of

HI/HWs

Required

times/year

No. of supervision

Times/year % of required

time/year

64/65 65/66 66/67 64/65 65/66 66/67

PHCC

12 2 24 24 27 52 100 112.5 216.7

HP

12 11 132 89 120 81 67.4 90.9 61.3

SHP

12 24 288 112 181 181 38.9 62.8 62.8

EPI clinic

12 149 1788 2 4 12 0.11 0.2 0.7

PHC/ORC

12 128 1536 1 11 28 0.1 0.7 1.8

FCHV 12 315 3780 0 56 66 0 1.5 1.7


The table shows that the frequency of supervision has been increasing but the status of

the supervision seems poor below illaka level. The supervision schedule was not

followed properly in peripheral region as the provision incentive for supervision(TADA)

was provided if the distance of the HIs were more than 6 miles. Though the supervision

schedule and checklist was prepared by DHO, they were not followed properly. Also the

supervision checklist was not fully able to meet the need of the district. Due to no regular

orientation and training to supervisors, the integrated supervision was affected resulting

poor implementation of integrated supervision.

Thus, the supervision was poor not only in quantity and but also in quality below the

illaka level.

6.8.6 SWOT Analysis

Strength

• Feedback mechanisms

• Regular supervision

• Annual budget allocation

• Supervision schedule prepared by DHO

Weakness

• Poor supervision in far-flung areas

• Implementation of Integrated supervision not effective

• Supervision scheduled not followed below illaka level

• Post supervisory meeting not regular

• No regular training and orientation on integrated supervision to all staffs

Opportunities

• Provision of TADA allowances


Threats

• Nepal Banda

• Geographical hurdles


• Integrated supervision checklist should be strictly used during supervision.

• Adequate training and orientation to supervising staffs for the clarity of its

concept, purpose, supervisory roles and responsibilities.

• Post supervisory meetings should be conducted regularly.

CHAPTER VII

MINI- ACTION PROJECT


CHAPTER VII

MINI ACTION PROJECT

7.1 Introduction

Mini action project is a miniature form of project that is usually conducted in the short

interval of time with a maximum utilization of locally available resources and technique in

the district. This type of exercise is beneficial in developing skills in real situation of

problem where the required resources may not be available, and it also helps to develop

consistence and self-reliance of an individual.

During the field study, the issue of recording and reporting was raised in many instances

from time to time in different level of health care delivery system in the district. We

decided to conduct Min Action Project on improving recording and reporting status of the

district. Criteria of identifying the subject were based on the experiences shared by

statistician Mr. Purna Shekhar Shrestha that most of the people responsible for recording

and reporting have not obtained refresher training for a long time and some of them are

unwilling to report timely to the district. Finally we decided to organize an orientation

program in recording and reporting.

7.2 Rationale

• One of the major health management components reflecting the performance of the

overall district

• Reluctance of some health workers in timely reporting

• Non- reporting from private hospitals and few NGOs.

• Interest of DHO staffs.

7.3 Objectives

7.3.1 General objective

• To strengthen the recording and reporting status of the health institutions in

Dhankuta


7.3.2 Specific objectives

• To aware the health workers about the situation of recording and reporting.

• To explore possible causes responsible for reluctance among health workers in

reporting.

• To identify the reasons for non-reporting from private hospital and NGOs.

• To update the health workers on revised version of Integrated HMIS tools.

• To find out the possible solutions.

7.4 Date Venue and Time

• Date: 2068-

• Venue: Seminar hall of District Health Office, Dhankuta

• Time: 10:30- 12:15

7.5 Methodology

• Methods: Mini-lecture and Group discussion

• Media: Pen, Paper, Newsprint papers, revised manual of HMIS

tools, Laptops

• Resource Persons: DHOr, Statistician

• Facilitators: Team members

• Participants: 18 participants from district hospital, Sub health posts

(Bhedetar, Chungmang and Faksib)


7.6 Plan of Action

Table 57: Plan of Action of MAP

Activities Date

Prioritization of problem 11/02/068

Discussion with DHOr and Statistician to finalize the subject for MAP 11/02/068

Planning for the MAP 12/02/068

Implementation 13/02/068

Evaluation 13/02/068

Figure 1: Phases of MAP


7.7 Activities

According to our planning we had conducted a workshop with health workers of district

hospital and few other peripheral institutions in co-ordination with statistician Purna

Shekhar Shrestha.

• Welcome speech and objective clarification: by our team member.

• Introduction: the workshop was started with the introduction from the participants

and ourselves

• Issues of discussion: by our team member.

• Information about revised Integrated HMIS tools: by Purna Shekhar Shrestha

• Raising of issues related to HMIS tools, problems and constraints in recording and

reporting: by Participants

• Discussions for possible solutions: by Purna Shekhar Shrestha and team members

• Compiling the common views raised in the presentation

7.8 Results

• Direction was given from DHOr to record properly and to report timely.

• Constraints and possible solution regarding recording and reporting were sorted out.

• Major misunderstandings were clarified from the group discussion.

• Commitment of DHO, statistician and all participants for timely reporting,

improving reporting status and properly recording.

7.9 Evaluation of Mini Action Project

• Active participation of resource persons & participants.

• Positive feedback from DHOr and statistician

• Commitment to conduct monthly review meetings from incharge of Sub-health

posts.


7.10 Sustainability of MAP

Sustainability of the MAP was assured through commitment from DHOr for the

allocation of the sufficient budget for the monthly review meetings and for the proper

monitoring of the progress.

CHAPTER VIII

FIVE YEAR PLAN


CHAPTER VIII

FIVE YEAR PLAN ON SAFE MOTHERHOOD

8.1 Introduction

The goal of the National Safe Motherhood Programme is to reduce maternal and neonatal

mortalities by addressing factors related to various morbidities, death and disability

caused by complications of pregnancy and childbirth. Global evidence shows that all

pregnancies are at risk, and complications during pregnancy, delivery and the postnatal

period are difficult to predict.

Within the health sector, safe motherhood has been a national priority programme for the

last decades, and is highlighted in all major health related policies and plans. The

Eleventh Plan, the Second Long Term Health Plan and the NSMLTP (2002- 2017) all

highlight the need to improve the maternal health. The Millennium Development Goals

(MDG) specifies a two thirds reduction in the under-five mortality rate and 75 percent

reduction in the maternal mortality ratio by the year 2015. The NHSP-IP draws on the

Millennium Development Goals, with the stated purpose of improving the health status of

the Nepalese population through utilization of essential health care services (EHCS),

specifying maternal mortality and infant and child mortality reduction among other

essential health care indicators. Since safe motherhood and newborn health are not purely

health issues, they warrant a multi-sectoral approach, and the role of other sectors is

particularly important in enhancing access and promoting equity.

This plan on Safe Motherhood outlines strategic directions and defines the major inputs,

outputs and general areas of activity, with a specific set of activities and detailed costing.

8.2 Rationale

The rationale for developing five year plan in Safe Motherhood was as follows:

• First ANC visit as percentage of expected pregnancy is 62.4% which is lower than

that of national average.

• Only 17.58% deliveries are conducted by HW & SBAs.


• Still large proportion (42%) of deliveries is conducted at homes.

• It is the most priority programme of Nepal Government.

• It is also matter of equity and social justice.

• Safe Motherhood is a matter of concern of DPHO.

8.3 Process of Developing the Plan

Developing a comprehensive five year plan was one of the objectives of our field visit.

After the analysis of health service statistics of Dhankuta district, we prioritized Safe

Motherhood for developing five year plan.

Improving maternal health and survival is a complex issue. However, a vision was

needed in terms of where Dhankuta needs to reach in the near future. Therefore realizing

this; we initiated an effort with expertise and involvement of DHOr, program supervisor

in SM and in guidance of other program supervisors to develop a SM plan for the period

2010-15. This plan is mainly based on the above-mentioned facts, however it is a more

comprehensive document since it draws from the National Safe Motherhood Plan (2002-

2017) as well. This plan gives a vision of where Dhankuta should be in the next 5 years.

Preparations for the plan began with several meeting with program officer on SM and

participatory discussions were conducted at May 25-27 2011 to come up with a plan for

safe motherhood. During the discussions we reviewed the current strategies discussed

achievements, problems and drawbacks and lessons for the future, which were the key

elements for consideration while formulating the various levels of objectives and

indicators.


8.4 Plan Format

The Log Frame Matrix has been used to lay out the various level outputs and activities.

The matrix consists of four columns. The first column shows the hierarchy of objectives,

the second column of the matrix identifies the indicators in the base line and sets time

bound targets. It also identifies how the progress is to be measured through means of

verification in the third column. More importantly it outlines the assumptions and the

risks, which help program implementers to identify the constraints beforehand. However

the plan is not without its limitations. The neonatal component has not been addressed

although improving neonatal health and survival is one of the important components of

safe motherhood.

8.5 Goals and Objectives

8.5.1 Overall Goal

The overall goal of the plan is to improve maternal health and survival of women in

Dhankuta district.

8.5.2 Objectives

• To increase the percentage of women seeking ANC visits

• To increase the deliveries attended by SBAs

• To increase the percentage of institutional deliveries

• To increase the percentage of women completing PNC visit (1 visit)

• To provide training to all health workers regarding SM

• To increase the no. of institutions providing safe abortion services

• To increase the percentage of women receiving emergency obstetric care


8.6 Targets

By the year 2011,

• To increase the percentage of women seeking ANC (1st

• To increase the percentage of women seeking ANC (4 visits) from 56.75%.

(among first visits) to 80%

Visit) from 62.47% to

85%.

• To increase the deliveries attended by SBAs from 11.4% to 40%

• To increase the institutional deliveries from 57.86% to 80%.

• To increase the percentage of women completing PNC Visit (1 visit) from

44.89% to 65%

• To provide training to cent percent health workers working in SM

• To provide safe abortion services through all PHCCs


8.7 Safe Motherhood Plan in Logical Framework Approach

Table 58: Safe Motherhood plan in log-frame approach

Narrative Summary Objectively Verifiable Indicators Means of Verification Assumptions/ Risks

1 GOAL

Improved maternal

health and survival

• Increase in percentage of women

seeking ANC visits

• Increase in no. of delivery attended

by SBAs

• Increase in institutional delivery


completing PNC visit (1 visit)

• No. of training received by health

workers regarding SM

• Increase in no. of institutions

providing safe abortion services

• Percentage of women receiving

emergency obstetric care

• Annual Report; DHO,

Dhankuta

• Annual Report; DOHS

• Monthly monitoring and annual

performance review worksheet

• Records and reports from HIs

• Overall environment

(social, political &

economic) is stable

• Political situation

remains stable and

peaceful


2 PURPOSE

Sustained increase in

utilization of quality

maternal health

services


seeking ANC (1st

2012- 65%

Visit) from

62.47% in 2011 to 85% in 2016

2013-70%

2014-75%

2015-80%

2016-85%

• Increase in % of women seeking

ANC (4 visits) from 56.75%.

(among first visits) in 2011 to 80%

in 2016

2012- 60%

2013-65%

2014-70%

2015-75%

2016-80%

• Increase in percentage of delivery

by SBAs from 11.4% in 2011 to

40% in 2016

2012- 15%

• Regular HMIS reports from

peripheral HIs

• Records and report from

District Hospital

• Annual Report; DHO,

Dhankuta

• Annual Report, DOHS

Monthly Monitoring Sheets;

DHO

• The private hospitals

and birthing centers

increases

• Political situation

remains stable and

peaceful

• DDC & VDCs are

functional

• Overall environment

(social, political &

economic) is stable


2013- 20%

2014- 26%

2015- 33%

2016- 40%

• Increase in percentage of deliveries

at health institutions from 57.86%

in 2011 to 80% in 2016


completing PNC Visit (1 visit)

from 44.89% in 2011 to 65% in

2016

2012-47%

2013-52%

2014-56%

2015-60%

2016-65%

• Training to cent percent health

workers working in SM

• All PHCCs provide safe abortion

services by 2016


3 OUTPUTS

• Enhanced and

equitable provision of

quality SM services

-focused ANC

-delivery by SBAs

-new born care

-PNC

-CAC/PAC

-referral services

• 1st

• 4

ANC coverage achieved to 85%

by 2016 th

• All HPs providing normal delivery

services & newborn care.

ANC coverage among first

visits achieved to 80% by 2016

• Increased number of SBAs

available for safe delivery

• Women receiving PNC (1visit)

increased to 65% by 2016

• Provision of BEOC including

newborn care and CAC at all

PHCCs by 2016

• Adequate provision for referral of

all complicated obstetric cases to

higher institutions by 2016

• Sustainability of CAC/ PAC

services in the District Hospital.

• Administrative records (DHO,

Dhankuta)

• Periodic supervision report

• Annual Report; DHO

• Annual Report; DOHS

• Study/ Survey reports

• Monthly monitoring sheets

• Referral sheets

• Continuing national

commitment and

resources for SM as a

priority

• Commitment and

resources for capacity

building of peripheral

institutions in health

management

• Development of safer

and effective way of

working in critical

areas

• NESOG continues to

support on SBA

training


4 INPUTS

• Budget

Improve sustainable

financing system for

SM services

• Increased share for SMNH in

district annual budget

• District Budget

• Records from account section,

DHO

• Audit Reports

• Timely release and

disbursement of

budget

• Human Resources • District hospital, all PHCCs and

HPs fully staffed by SBAs (with

skill mix, both number and type)

• Increase in number of technical

and administrative human

resources required for SM

• Training to all staffs responsible

for Safe Motherhood Program

• Human resource records from

administration section, DHO

• Records from training section,

DHO

• HURIC data

• Records on human

resources are available

• Physical

Infrastructures, assets

and procurement

-Adequate physical

resources for SM

services an year

round availability of

SM related drugs and

supplies

• Number of health posts with fully

equipped birthing centers

• All PHCCs with fully equipped

BEOC facilities sustained

• Fully equipped CEOC facility at

district hospital enhanced

• Annual report, DOHS

• Annual Report, DHO

• LMIS report, DHO

• Study/ Survey reports by

different institutions

(professional and educational)

• Level of resources

remain the same as

planned


• Year-round availability of SM

drugs and commodities (SDKs,

EOC kits, Iron tablets, Vit-A

capsules, etc.)

• Free health schemes implemented

as stated

• Co-ordination and

Public Private

Partnership

• Number of SM services related

contracts

• Annual health plans developed by

DDC that cover SM

• Records from DHO

• DDC plan

• Conducive policy

environment for

partnership with

I/NGO, CBOs and

private sectors

• DHO remains

committed to concept

of public private

partnerships


8.8 Major Activities

Table 59: Major activities in safe motherhood plan

Major Activities Assumptions

1 ANC Services

• Regular ANC services (examination: BP, Weight & FHR), birth

preparedness and complication readiness, TT immunization,

Iron supplementation, deworming, malaria prophylaxis) by all

peripheral institutions.

• Make existing PHC Outreach Clinics functional

• Conduct mothers’ Group meetings by FCHVs on a regular basis

• Health education and counseling for birth preparedness and

complication readiness

• Provide support for transport

• Pregnant women will have active

participation in ANC services.

• There is a policy that directs the DHO to

provide such services free

2 Safe Delivery Services

• Improving physical infrastructures for safe delivery (birthing

centre)

• Adequate supply of physical resources for safe delivery services

(SBK, EOC kits, etc.)

• Promotion of institutional deliveries

• Continuity of incentive schemes for institutional deliveries

• Orientation to mother groups

• Pregnant mothers go to the health facilities

for delivery & SBA are available in the

health facilities.

• The provisions of incentives for

institutional delivery are sustained and

continued.

• No bands and strikes


• Strengthening and expansion of safe delivery services to all

HPs, PHCCs, in a phased manner

• Decision making power relies on women

3 PNC Services

• Regular services available at all HIs for physical examination of

mother and newborns (to detect complications, provide

treatment and referral)

• Promotion of exclusive breast-feeding

• Regular immunization services to newborn

• Postnatal, FP counseling to all mothers utilizing PNC services

• Postnatal Vit A. and iron supplementation

• Institutional deliveries are increased

• Mother’s group is aware of safe

motherhood activities

• Mobilization of FCHVs is ensured

4 Training

• SBA training for HWs

• Orientation to all staffs of all peripheral HIs on RH and SM.

• Training on recording and reporting

• Orientation to mothers groups regarding SM practices

• Identify gaps in the existing BEOC in-service curriculum and

adapt in-service SBA training

• Develop generic (27 core skills) competency based SBA

training package

• Train doctors on C/S

• NESOG continues to support on SBA &

CAC/PAC training

• Availability of budget & resource persons

• Co-ordination & co-operation of DPHO

with RHTC and NHTC

• Curriculum development


5 EOC services

• Providing BEOC services through all PHCCs

• Sustaining and strengthening CEOC services available at the

district hospital on a 24 hour basis

• EOC kits made available to all health facilities

• Improving the functioning of referral system by developing

simple referral protocols, orientating HWs and ensuring 24 hrs.

availability of services

• Developing and implementing need based planning and

monitoring system and a phased expansion on B/CEOC sites in

the district hospital and PHCCs

• Health facilities have enough space and

trained human resources for BEOC will

retain in HIs.

6 Safe Abortion

• Strengthening CAC/PAC services in district hospital and Maire

Stopes center

• Develop CAC/PAC services to all PHCCs

• Encourage private/NGO sectors to expand CAC services in line

with CAC policy

• Decision making power relies on women

7 Behaviour Change Communication (BCC)

• Promote SM related healthy behaviours, including birth

preparedness by conducting BCC activities and using right

based approaches

• Conflicts does not limit the mobility and

gathering of people at district level and

below


• Develop and implement research based communication

interventions to reach disadvantaged and vulnerable groups

• Update and implement integrated SMNH communication

strategy, including standardizing messages and making them

available at all level

• Awareness campaign on SM

• Establishment and maintenance of IEC corners at all HIs

• Co-ordinated effort to implement BCC

activities

• Communities are willing to participate in

SM BCC program

8 Information Management

• Develop strategy to incorporate key SM information within an

integrated matrix (disaggregated by ethnicity, caste and wealth)

• Orientation and training on effective recording and reporting

using HMIS tool

• Design and implement research for generating additional

information that is not incorporated in HMIS

• Increase access to SM information at all levels (community to

district)

• Comprehensive HMIS is feasible

• Regular review to respond for change in

HMIS regarding SM needs

• Load shedding is reduced so that

motivation to enter computer data is not

lost.

9 Physical Assets and Procurement

• Develop an inventory of SM services, facilities, equipment and

instrument

• Establish data based for drug and commodities

• Political instability does not affect

implementation activities

• Situation allows monitoring of physical


• Strengthen the quarterly LMIS reporting system for

consumption of SM related drugs and other commodities

• Timely and adequate supply of SM related logistics

• Develop mechanism for replenishment of RH kits (e.g. use

money raised from deliveries for SM drugs and supplies)

• Ensure proper use of RH kits

facilities construction

• Fund commitment remains at least the

same

• Government is committed to establish

transparent procurement mechanism

10 Supporting Activities

• Regular review meetings with all related HIs

• Develop mechanism for reward and punishment

• Coordination between DHO, hospital and RTC for management

issues

• Good co-operation from all HIs

• Fair evaluation for reward and punishment

• Roles and responsibilities of PHO,

hospitals, RTC clearly defined and applied

for smooth functioning

11 Human Resource Management

• Identify requirements (placement in District Hospitals and PHCs

with BEOC but without doctors)

• Advocate for and implement a system whereby the EOC

competent staff (midwife, doctor) are retained


8.9. Targets for Safe Motherhood Programme

Table 60: Targets for safe motherhood programme

Activities Target Unit 2012 2013 2014 2015 2016

1 First ANC visit 28713 Person 5634 5699 5747 5799 5834

Fourth ANC visit 20124 Person 3381 3704 4023 4349 4667

Health Institution Delivery 14248 Person 2028 2408 2816 3262 3734

Post Natal Visit 14248 Person 2028 2408 2816 3262 3734

2 Logistics Supply

Supply of essential drugs and vaccines 15 Times 3 3 3 3 3

Supply of SDKs 5 Times 2 - 1 - 1

Supply of EOC kits 5 Times 2 - 1 - 1

Supply of IEC materials 5 Times 1 1 1 1 1

Supply of forms and registers 5 Times 1 1 1 1 1

3 Trainings and Orientations

SBA training to MOs, SN & ANM 36 Person 12 - 12 - 12

Gender sensitivity training to HA/ HW 75 Person 25 - 25 - 25

Orientation to FCHVs, VHWs & MCHWs 400 Person 150 - 130 - 120

Training on recording and reporting 300 Person 120 - 100 - 80

4 Infrastructures

Construction & maintenance of BEOC and

birthing centers

7 Health centers 3 2 - 2 -

Repair & Maintenance 18 Health Centers 8 - 5 - 5


5 Awareness campaigns using BCC 6 Times 3 - 2 - 1

6 Meetings

DRHCC meeting 15 Times 3 3 3 3 3

Review meeting of C/BEOC centre & birthing

centers

10 Times 2 2 2 2 2

FCHV review meeting 5 Times 1 1 1 1 1

7 Incentive Schemes

Incentives for four ANC visits 20124 Person 3381 3704 4023 4349 4667

Incentives for institutional delivery 14248 Person 2028 2408 2816 3262 3734


8.10 Budget Plan

Table 61: Budget plan for safe motherhood programme

Activities Unit 2012 2013 2014 2015 2016 Total

Target Budget Target Budget Target Budget Target Budget Target Budget

1 First ANC visit Person 5634 5699 5747 5799 5834

Fourth ANC Visit Person 3381 3704 4023 4349 4667

Health Institution

Delivery

Person 2028 2408 2816 3262 3734

Postnatal visit Person 2028 2408 2816 3262 3734

2 Logistics Supply

Supply of essential

drugs and vaccines

Times 3 75000 3 84000 3 87000 3 90000 3 93000 429000

Supply of SDKs Times 2 50000 - 1 28000 - 1 30000 108000

Supply of EOC

kits

Times 2 40000 - 1 23000 - 1 25000 88000

Supply of IEC

materials

Times 1 15000 1 16500 1 18000 1 19500 1 21000 90000

Supply of forms

and registers

Times 1 10000 1 13000 1 15000 1 18000 1 20000 76000


3 Trainings and

Orientations

SBA training to

MOs, SN & ANM

Person 12 72000 - 12 72000 - 12 72000 216000

Gender sensitivity

training to HA/

HW

Person 25 50000 - 25 50000 - 25 50000 150000

Orientation to

FCHVs, VHWs &

MCHWs

Person 150 52500 - 130 45500 - 120 42000 140000

Training on

recording and

reporting

Person 120 60000 - 100 50000 - 80 40000 150000

4 Infrastructures

Construction of

BEOC and

birthing centers

Health

Centers

3 900000 2 600000 - 2 600000 - 2100000

Repair &

Maintenance

Health

Centers

8 400000 - 5 250000 - 5 250000 900000

5 Awareness

campaigns using

BCC

Events 3 15000 - 2 10000 - 1 5000 30000


6 Meetings

DRHCC meeting Times 3 13500 3 13500 3 13500 3 13500 3 13500 67500

Review meeting

of C/BEOC centre

& birthing centers

Times 2 100000 2 115000 2 125000 2 140000 2 148000 628000

FCHV review

meeting

Times 1 141750 1 151200 1 157500 1 163800 1 173250 787500

7 Incentive

Schemes

Incentives for four

ANC visits

Person 3381 1352400 3704 1481600 4023 1609200 4349 1739600 4667 1866800 8049600

Incentives for

institutional

delivery

Person 2028 2028000 2408 2408000 2816 2816000 3262 3262000 3734 3734000 14248000

Grand Total 5375150 4882800 5369700 6046400 6583550 28257600

CHAPTER IX

OTHER ACTIVITIES


CHAPTER IX

OTHER ACTIVITIES

9.1 District Presentations

9.1.1 First District Presentation

9.1.1.1 Date, Time and Venue

• Date: 2068/02/12

• Time: 1:15 P.M. - 3:20 P.M.

• Venue: District Health Office, Dhankuta

9.1.1.2 Participants

• 24 people attended the presentation

• District Health officer & other programme officers

• Statistician

• Representative from DACC

• Members from District Hospital

• Field Supervisor from VCTS

9.1.1.3 Main objectives of the programs

• To present the district profile

• To discuss about the district health system

• To present about the supporting organizations on the basis of our findings.

9.1.1.4 Subject matter we discussed

• District Profile

• Health Profile of the district

• District Health System (in system model)

• Health Programs in the districts (trend analysis of achievements)

• Findings about supporting organizations


9.1.1.5 Details of the program

• Welcome speech:- Anil Dhungana

• Objectives of the program:- Anu Gomanju

• Dissemination of the action plan:- Uttam Gautam

• Presentation of findings:

Shreetina Keshari Tuladhar

Prabesh Ghimire

Dinesh Rupakheti

Naresh Bhatta

• Feedback from:-

Senior Public Health Administrator Mr. Jhalak Sharma Poudel

(DHOr, Dhankuta)

Prof. Chitra Kumar Gurung (Institute of Medicine)

• Thanks giving:- Rabina Kumari Rajak

9.1.2 Final presentation

9.1.2.1 Date, Time and Venue

• Date: 2068/02/18

• Time: 11:30 A.M. – 12:15 P.M.

• Venue: Seminar Hall, DHO

9.1.2.2 Participants

• About 18 people participated at our final presentation

• Section officer, Program Officers (CB-IMCI, Safe motherhood, family

planning, Malaria, AIDS)

• Statistician, Store keeper, Medical Recorder (district hospital)

• Members from district hospital (Medical doctor, Staff nurse, ANM)

• Representative from DACC


9.1.2.3 Objectives

• To present the overall information about our comprehensive field practice

• To overview our activities performed during the field practice

• To present the comprehensive five year plan on Safe Motherhood

• To thank people for their support during our study and obtain feedback of

our study.

9.1.2.4 Activities:

• The programme was conducted informally with no chairmanship.

• The specific objectives of our field practice were clearly stated prior to the

beginning of the program.

• The chief activities performed during field visit were stated.

• The five year plan was briefly presented in a log-frame approach.

• We thanked everyone for their valuable co-operation, suggestions and

valuable inputs that was provides to us during the course of our study

• Feedback from:-

Ram Narayan Shrestha: Section Officer, Dhankuta

Purna Shekhar Shrestha: Statistician

Akshay Lal Yadav: Programme Officer (CB-IMCI)

Balkumari Gurung: Programme Officer (Safe Motherhood)

Toya Nath Ghimire: Programme Officer (Family Planning)

Indu Nepal Yonjan: District Aids Co-ordination Committee


9.2 Participated Programs

9.2.1 Interaction on Comprehensive Abortion Care in District Hospital

Dhankuta: Issues and Challenges

The interaction program with doctor, nurses and paramedics was held in DHO,

Dhankuta on the issues and challenges for comprehensive abortion care in

District Hospital, Dhankuta. Five members of our team participated in the

interaction program and gained valuable in-sights on the problems and issues

regarding the CAC services provided by the hospital.

• Date: 27/01/2068


• Time: Duration: 45 minutes

• Key Persons:

Dr. Joji Baral (NESOG)

Mr. Jhalak Sharma Poudel (District Health Officer, Dhankuta)

9.2.2 International Nursing Day

All of our members participated in the Nursing Day Programme organized by

the nursing council of Dhankuta. We were benefitted by the valuable speeches

from the key stakeholders of Dhankuta district on the importance of health

services & roles of health professionals in providing all forms of care and

support to the patients and the community. We were really glad to see Chhori

Shrestha, (District Hospital, Dhankuta) being honoured for her indefatigable

contributions for 32 Years in the nursing services in Dhankuta.

• Date: 12/05/2011



9.2.3 Orientation on Disaster Management

We also participated and interacted actively in a brief orientation programme on

Disaster Management given by Nepal Red Cross Society. We could acquire

helpful information on the public health importance of disasters, their effects

and impacts. We were also oriented briefly on the cycle of disaster

management.

9.2.4 Orientation to the members of District Population Co-ordination

Committee.

We got the opportunity to participate as an observer in the orientation of

members of District Population Co-ordination Committee on 2nd

of Jestha 2068.

We obtained the prospect to know the various population programmes due to

commence within a month time in Dhankuta district. The programme was

organized under the chairmanship of LDO Baburam Gautam and attended by

heads of most of the government line agencies operating in Dhankuta district as

well as by the heads from different educational institutions.

CHAPTER X

LEARNINGS AND

RECOMMENDATIONS


CHAPTER X

CONCLUSIONS AND RECOMMENDATIONS

10.1 Conclusions

Comprehensive field practice on management of district health system is actually a

learning process. Hence, it was really proved to be a platform for us to bring all the

theoretical aspects of our learning into actual field situation.

Through the close look to the overall district health managerial patterns and the

service system, by remaining there at the district itself, we could able to comprehend

how District Health System really works.

Some of the conclusions that we could cumulate during our field practice are as

follows:

• District health profile

Keeping quality record/ proper recording is a great job.

Just compilation of data doesn’t give any meaning. It’s review, analysis and

discussion and use at the local level is the most.

• Critical Review

Breaking problems into various critical points and striking on most

appropriate point is the way of bringing change.

Same problem can be studied through different perspectives, and finding

their solution in the existing condition of the district setting is important.

• Epidemiological study

Health workers should follow the standard operational definition of diseases

for diagnosing a problem.

Gender based differences on health seeking behaviour and service utilization

pattern widely exists so it needs to be addressed by empowerment.


• Mini action project

Without the motivation and participation of district health supervisors and

peripheral health workers, no programme becomes success.

• Five year plan

Geographical patterns and other difficulties in the districts and VDCs must

be considered while preparing operational plans.

For realistic and implementable plan, district supervisors and peripheral

health workers must be involved actively.

• Group dynamics and others

For the success of any project, the mathematics of teamwork is –“Sum the

ideas, minus the differences, multiply the unity and divide the

responsibilities”.

No task is difficult when there is unity among diverse ideas, experiences and

leanings of the group members.

Learning to adapt in every situations- may it be different or difficult

situation, by maintaining team spirit inspite of individual variations to

accomplish a predetermined goal.

Learning to offer help to a team or take help from a team for a team in the

spirit of team approach.


10.2 Recommendations

• To DHO Dhankuta

The vacant posts in DHO should be fulfilled for efficient and effective

functioning of the DHO.

Health information and resource center should be established in DPHO.

Ambulance services should be made available at both PHCCs

Continuous supervision should be done irrespective of geographical

constraints and accessibility.

• To Campus

The schedule for the field was not at appropriate time because it was the end-

time of financial year. Hence, DHOr including all program supervisors were

busy completing their activities that were to be completed within that fiscal

year.

Orientation classes were done but all those were proven theoretical in actual

field settings. Hence, the orientation classes should be made more

comprehensive and practical.

The schedule for supervisory visits should be arranged timely.

Appropriate guidelines should be provided for report writing so as to

maintain uniformity.

BIBLIOGRAPHY


BIBLIOGRAPHY

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ANNEX I

LIST OF INDICATORS

Immunization Main Indicators Numerator and Denominator 1 Immunization coverage Number of children under one year of age immunised

with specific dose of antigen x 100 Total estimated number of children under one year of age

2 Immunization coverage for TT2+ vaccine

Number of pregnant women immunized with TT2+ x 100 Total estimated number of pregnant women

3 Measles drop-out rates (BCG vs. Measles

vaccine)

Number of children received BCG - Number of children received measles vaccine x 100 Number of children received BCG

4 Vaccine Wastage Rate Number of vaccine doses received - Number of vaccine doses used x 100 Number of vaccine doses received

Nutrition

1 Growth-monitoring coverage

Number of visits x 100 Number of targeted visits

2 Proportion of malnourished children (weight for age)

Number of children (0-36 months) under low growth curve for 1st visit x 100 Number of children (0-36 months) new cases

3 Postpartum Vitamin A coverage

Number of Postpartum women supplemented with vitamin A capsule x 100 Total number of Expected pregnancies

4 Deworming coverage Number of children (1-5 years) receiving deworming tablets twice a year x 100 Number of children of 1-5 years

Control of diarrhoeal disease 1. Morbidity rate due to diarrhoea Total diarrhoeal new cases in specified time x 1000

Target population (under-fives) 2. Mortality rate due to diarrhoea Total number of diarrhoea-related deaths x 1000

Target population (under-fives)

ARI

1 Under-five child mortality due to ARI-related causes

Total deaths due to ARI in one year x 1000 Total <5 yr. population in the same year

2 Annual incidence of ARI among under-five children

Total no. of ARI cases in one year x 1000 Total no. of <5 yr. population in the same year

3 Annual incidence of pneumonia among under-fives

No. of pneumonia cases in a specified year x 1000 Total no. of <5 yr. population in same year

Family Planning

1 Contraceptive Prevalence Rate (CPR)

Number of current users of modern FP methods x 100 Married Women of Reproductive Age (MWRA)

2 Method-specific new acceptors as a percent of MWRA

Number of method specific New Acceptors x 100 Married Women of Reproductive Age (MWRA)

Safe Motherhood

1 ANC service coverage No. of ANC first visits x 100 Expected no. of pregnancies 2 Percentage of 4 ANC visit No. of 4 time ANC visit x 100 No. of 1st ANC visits 3 Delivery service coverage by

health Total no. of delivery services provided by health workers x 100

Workers Total no. of expected pregnancies 4 Postnatal service coverage Total no. of first postnatal visits x 100 Total no. of expected pregnancies 5 Maternal mortality ratio Total maternal deaths x 100,000 Total live births

Malaria

1 Annual Blood Examination Rate

Total no of slides examined x 100

(ABER) Total population at risk of malaria 2 Slide Positivity Rate (SPR) Total no of positive slides x 100 Total slides examined

Tuberculosis

1. Treatment outcomes Cure rates Completion rates Failure ratess Death rates

The number of new smear- positive cases having that outcome * 100 The number of new smear- positive cases registered in that quarter

2. Smear conversion rate at 2 (3) months for new smear- positive cases, relapses, and failure cases

The number of smear- positive cases (new, relapse or failure cases) which are smear- negative at 2(3) months of treatment x 100 The number of smear- positive cases (new, relapse, or failure cases) registered during the quarter

3. Case detection ratio of new pulmonary smear- positive cases

The number of new smear- positive cases registered during a year x 100 The number of new smear- positive cases estimated to occur during the year in that population.

4. Positivity rate for smear positive cases

The number of smear- positive cases detected during a quarter x 100 The number of TB suspects examined by smear microscopy in that quarter

Leprosy

1 Registered Prevalence Rate Total number of leprosy cases registered at the end of year x 10,000 Total Population

2 New Case Detection Rate ( NCDR)

Total number of new cases detected for leprosy x 10,000

Total population

OPD/ In-patients care

1 Percentage of OPD new Total number of OPD new visits (cases) x 100 Total population of catchment areas 2 Ten leading OPD cases on district

basis 1st ten leading OPD new cases

3 Top five leading causes of hospitalization

1st five leading cause of hospitalization

4 Death Rate among in- patients Total number of inpatient deaths x 100 Total number of in-patients admitted 5 Average length of stay Total In patients days Total no. of discharges 6 Bed occupancy rate Total inpatients stay in a hospital x 100

365 (days) x Total no. of beds available 7 Bed turnover interval 365 (days) – (Average length of stay x Throughput) Throughput

Others

Main Indicators Numerator and Denominator 1.Average no of people served by FCHV

No of people served by FCHV

Total no of FCHV 2.% of PHC/ORC clinics held by month

Total number of clinics held x 100 Total number of clinics to be held

3.No. of people served per clinic

Number of people served by clinics x 100

Total no. of clinics held

4.% of Mothers group conducted meeting

Number of Mothers Group meeting conducted x 100 Total no. of Mothers group

ANNEX II

INTERVIEW GUIDELINES FOR DHO

1. Administrative Management

A) Planning

1. How do you prepare the district health plan?

2. What is planning process of PHCC/HP/SHP?

3. Have you prepared training schedule of district annually?

4. How do you set the target and activities of different programs for different

health facilities?

B) Organization

1. What is the organizational structure of DHO?

2. What is the networking system of different organizations in the district?

C) Staffing

1. What is staffing pattern in DHO?

2. How do you determine training needs in district?

3. How do you appraise the program of your subordinates?

4. How often do you have staff meetings in your office?

D) Directing

1. What is the decision-making system of DHO?

2. Is there any reward and punishment system in DHO/PHCC/HP/SHP?

3. What types of authorities are delegated to your sub-ordinates during your

absence in office?

4. How do you circulate the information with your subordinates?

E) Communication

1. How do you communicate within and in between the office?

F) Coordination

1. How do you coordinate with PHC/HP/SHP?

2. How do you coordinate among INGOs, NGOs and GOs?

3. Could you explain about the role of management committee in different

health institutions?

4. Are you facing any problem in coordination?

G) Supervision

1. Do you have supervision schedule of PHC/HP/SHP?

2. How often do you supervise?

3. Do you have feedback system after supervision?

4. What is the process of supervision?

5. Is there any supervision of DHO from higher level authorities?

H) Recording and reporting

1. How is recording and reporting system running in PHCC/HP/SHP and

other health organizations?

2. How do you maintain and use reports made available at the district?

3. Have you faced any problem during recording and reporting?

4. Do you have any provision of refresher training for your staffs regarding

recording and reporting?

I) Budgeting

1. How do you plan a budget in the district?

2. What are the basic components of budgetary allocation?

3. How do you manage the appropriate recording process of income and

expenditure of budget?

4. Have you felt any problems in accountancy?

J) Evaluation

1. How do you evaluate the peripheral institution?

2. What method is used for the evaluation?

K) Administrative activities

1. How do you manage performance appraisal of your staffs?

2. How do you manage all administrative works in your office?

3. Do you have monthly meeting in DHO?

4. Are you facing any administrative problems?

2. Logistic Management

1. How do you demand logistic from RMS?

2. How do you supply medical / logistic to the peripheral level HI?

3. Whether the demand logistic is sufficient for the district?

4. How do you manage logistic for special situation like epidemic?

5. What audit form is used for recording and reporting?

6. When do the peripheral level HI and hospital report to district?

7. Whom do you use to look the stock level?

8. How do you place logistic in store?

9. When and how do you recheck the recording system?

10. Do you have feedback system after reporting?

11. How do you records and reports to the higher level?

12. Do you buy medicine in district?

13. What do you do to the expired drugs and few months remained to expired?

14. Do you have system of returning medicine which is not used from HI?

3. Budgeting system

1. How do you plan budgeting in the district?

2. What are the steps of budgeting allocation?

3. Can we know about the budget release and expenditure?

4. How do you manage if allocated budget is not sufficient?

5. Who do control the finance of the district?

6. How do you use the income of hospital?

ANNEX III

INTERVIEW GUIDELINES FOR PROGRAM/ SECTION

1. What is your job description?

2. What is the supervision and monitoring system?

3. When and how do you supervise your subordinates?

4. Who supervises you?

5. What is the reporting system?

6. What are the problems and constraints in the section?

7. What are the actions need to be taken to solve the problems/constraints?

Who are the responsible people?

ANNEX IV

GUIDELINE FOR GOs/ INGOs/ NGOs VISITS

1. General introduction of organization.

2. Goal and objectives of organization.

3. Areas of conducting programs.

4. Focus group of implemented programs.

5. Target, achievement and reporting system of program.

6. Coordination system with DHO, DDC and other agencies.

7. Duration of program.

8. Community involvement in programs.

9. Problems and constraints of program

ANNEX V

OBSERVATIONAL CHECKLIST FOR THE PHCC/HP/SHP VISITS

Condition Yes No

• Well constructed building • Adequate ventilation/lighting • Adequate furniture/tables • Adequate laboratory equipments. • Separate rooms for separate services. • Comfortable waiting place for the

patients. • Daily diary maintenance. • Complete registers maintenance • Condition of the stores. • Presences of dispensary rooms • Cold chain maintenance • Presence of IEC corners. • Presence of ORS corner • Proper use of safety box • Healthful environment institution • Good water supply system • Proper use of toilet • Proper waste disposal system

ANNEX VI

CHECKLIST FOR THE STORE

Condition Yes No

Infrastructure • Well constructed building • Adequate ventilation/ lighting • Cleanliness • Adequate space

Stock level maintenance

• EOP maintained • ASL level maintained • FEFO maintained • Updated records

Cold chain

• No.s of refrigerators........... • Presence of generator for power supply • Fuel Stock • Separate place to store opened and un-

opened vials Waste management

• Burning of cartoon • Separate provision for collection of

hazardous and non hazardous drugs

ANNEX VII

SECONDARY DATA REVIEW FORMATS

Dhankuta District Profile

S. no Features 1 Geography

Boundaries • East • West • North • South

Topography • Area • Region • Latitude • Longitude • Altitude (with range)

2 Socio-economic Occupations

Religions

Language

Ethnic groups

3 Political divisions Electoral Constituencies Municipalities VDCs

4 Climate

5 Natural Resources Rivers/ streams Forests

Minerals

6 Organizations NGOs INGOs Clubs

8 Communication Postal Services Newspapers/ magazines

9 Tourist areas/ Heritages

Educational Profile of Dhankuta

S no Levels Government Private Total 1 Primary 2 Lower Secondary 3 Secondary 4 Higher Secondary 5 Higher Level

Total

Health Institution Profile

S no Features 1 Primary Health Care Centre

2 Health Posts

3 Sub-Health Posts

4 EPI Clinics

5 PHC ORC

6 FCHVs

7

Human Resource Profile in Health Institutions of the District

S no Health institution Sanctioned post

Filled post

Unmanned Post

Vacant post

Fazil Post

1 DPHO 2 District Hospital 3 PHCC 4 HPs 5 SHPs

Total

Demographic Profile

S no Indicators District National 1 Population

• Male • Female • Total

2 Sex Ratio (M:F) 3 Dependency Ratio

• Child dependency • Old dependency • Total

4 Total Households 5 Average Family Size 6 Population Density 7 Fertility Status

• Crude Birth Rate (CBR) • General Fertility Rate (GFR)

8 Mortality • Crude Death Rate (CDR) • Neonatal Mortality Rate (NMR) • Infant Mortality Rate (IMR) • Under -5 Mortality Rate (U5MR)

9 Morbidity • Incidence Rate

• Disability Rate

10 Population Change • Rate of natural increase

PHOTO GALLERY

PHOTO GALLERY

Photo 1: Meeting with District Health Officer

Photo 2: Preparation for data collection

Photo 3: Review of Monthly Monitoring Sheet

Photo 4: Data collection from section officer

Photo 5: Data collection from Koshi Zonal Ayurvedic Aushadhalaya

Photo 6: Data Collection from Pakhribas Health Post

Photo 7: Observation of District Medical Store

Photo 8: Critical Review

Photo 9: Data Analysis

Photo 10: Preparation for First Presentation

Photo 11: Mini Action Project

Photo 12: Preparation of Comprehensive Five Year Plan

Photo 13: Preparation for Final Presentation

Photo 14: Final Presentation

Photo 15: College Presentation

Photo 16: Group members with DHOr and Campus Chief & BPH Co-ordinator during supervision

Comprehensive Field Practice

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Transcript of Comprehensive Field Practice