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A Report of

District Health System Management

Submitted to

Department of Community Medicine and Public Health

Maharajgunj Medical Campus, Institute of Medicine

Tribhuvan University

Kathmandu

Nepal

Submitted by

MBBS IV Year

Group A3

2014



District Health System Management: Report 2014

DECLARATION AND APPROVAL SHEET

We, the following students of MBBS IV year have produced this report as an outcome ofresidential field program from 25 Falgun 2070 to 26 Baisakh 2071 in Bardiya, Surkhet andRukum districts. We have invested our sincere efforts and consider this work to be original.

Group A3

Roll. No. Name Signature

1221 Bidur Prasad Pandit

1227 Gaurab Tiwari

1238 Prakash Bastola

1265 Santosh Baniya

1267 Subodh Shrestha

1257 Suman Maharjan

1271 Yogesh Subedi

Date:

This report has been accepted and forwarded for final examination.

--------------------------------- ---------------------------------

Coordinator, CBL Unit Head of Department

Date: Date:

Department of Community Medicine and Public Health

Maharajgunj Medical Campus

Institute of Medicine




ACKNOWLEDGEMENTS

We would like to extend our sincere gratitude to the following people, who have beenof great help to us throughout our field.

From Bardiya district, we would like to thank Mr. Achyut Lamichhane (DistrictHealth Oficer), Dr. Raj Bhakta Maharjan and Dr. Arjun Bhatta (Medical Officers), Mr. SanatSharma (Medical Records Officer), Mr. Mohan Kurmar Sharma (Malaria Focal Person), Mrs.Sumitra Khadka (Nursing Incharge) of the District Health Office, Bardiya. We would alsolike to thank Mr. Khem B.K. of Bardiya District Hospital for providing us foodingthroughout our stay.

From Surkhet district, we express our gratitude to Dr. Bhola Ram Shrestha (MedicalSuperintendent) for guiding and assisting us throughout our stay and Mr. Tanka Chapagain

(District Health Officer) from the District Public Health Office. We would like to thank Mr.Yogendra Shahi, Chief co-ordinator of the voluntarily working committee for WasteManagement on Mid-Western Regional Hospital, Surkhet for his guidance and help on thecritical analysis. We are also thankful to Mr. Khumba Bahadur Khadka of Subham Hotel for

providing us lodging facility and Mr. Ganesh Bista for providing food during our stay inSurkhet.

From Rukum district, we are thankful to Mr. Dil Bahadur Giri (HospitalAdministrator) and Dr. Keshav Bhattarai (Medical Officer) from HDCS-CHR Hospital, Mr.Yadu Nath Ghimire (District Public Health Officer). We would especially like to thank Mr.

Prakash Gosain for providing us lodging and food during our stay in Rukum.Lastly, we would like to thank Prof. Dr. Jeevan Kumar Shrestha- Campus Chief, Prof.

Dr. Sharad Onta- Assistant Dean of Institute of Medicine, Prof. Dr. Rajendra Raj Wagle Headof Department: Department of Community Medicine and Public Health, Dr. Archana Amatya(MBBS Coordinator), Mr. Ramesh Sigdel (CBL Unit Coordinator), Prof. Dr. Madhu DixitDevkota, Prof. Dr. Ramjee Prasad Pathak, Prof. Dr. Bandana Pradhan, Associate Prof. ShivaPrasad Sapkota, Associate Prof. Ajay Thakur, Mr. Prem Basel, Assistant Prof. BinjwalaShrestha, Mr. Bishnu Chaulagain, Mr. Ritu Prasad Gartoulla, Mrs. Saraswoti Singh, Mrs.Gita Bhandari, Mr. Rajan Poudel, Mr. Durga Parsad Pahari and Mr. Khadga Shrestha. Weextend our heartfelt gratitude to the department for providing us with the wonderfulopportunity to explore the Mid West Nepal and observe the health system and also forarranging the orientation classes, providing us the logistic supports and for guiding us all theway from the start. We are grateful to Associate Prof. Shiva Prasad Sapkota, Mr. RameshShigdel, Mr. Prem Basel for supervising us during our field stay.

We would like to take this opportunity to thank everyone involved, directly orindirectly, in making this period highly beneficial and productive for all of us.




EXECUTIVE SUMMARY

From nine weeks study on different aspects of district health system management, we

are able to generate this report containing various findings, analysis and conclusions. We

prepared district health profile, a hospital profile and conducted an epidemiological study on

Malaria in Bardiya district based on Bardiya District Hospital; critical analysis on solid waste

management was done in Mid-Western Regional Hospital and a five year plan was prepared

on control of diarrhea in Rukum district.

District Health Profile

Bardiya lies in the Terai belt of our country and is divided into 31 VDCs, 1

Municipality and 4 electoral constituencies. Under DHO, Bardiya consists of 1 district

hospital, 3 PHCCs, 25 HPs and 13 SHPs, 156 PHC-Outreach Clinics, 197 EPI Clinics

supported by 841 FCHVs.

The programs that are being conducted by DHO are EPI, nutrition program, CB-

IMCI, safe motherhood program, family planning program, TB control program, leprosy

control program, malaria control program, mass drug distribution for filariasis control and

program on HIV AIDS.

1 PHC at Swarahawa VDC and 1 HP at Motipur VDC were visited. The study proved

the importance of peripheral centers in providing health services in community level. The

staffing pattern, management body’s formation and the different services provided by the

basic health facilities in the community level were observed and noted.

Hospital profile

Bardiya District Hospital was established in 1991 B.S. and is a 25 bedded hospital

with 21 staffs. Different services provided are OPD service, In-patient service, Emergency

services, Obstetric services, MCH and family planning services, safe abortion services,

ART/VCT clinic, DOTS and DOTS-plus center, immunization services, laboratory services,

training and health awareness program. Hospital is managed by hospital management

committee and quality control committee.

Epidemiological study on Malaria

Malaria is a disease of tropics and subtropics and is a vector borne disease (VBD)transmitted by female Anopheles mosquito. Bardiya is amongst the 13 highly endemic




districts where global fund is actively supporting the government’s intense malaria control

program as Roll Back Malaria due to high case load.

Epidemiological study was performed on Malaria. The disease was studied based on

time, place and person as variables. The Clinical Malaria Incidence was 10 per 1000

population which was decreasing in the last 3 years. Confirmed malaria cases among total

clinical malaria cases were 69 in 2069/70, which was also decreasing in the past 3 years.

Bhimapur SHP was the area diagnosed with highest number of clinical malaria cases (352 in

2069/70) while Baniyabhar SHP and Neulapur HP had no clinical malaria cases. The age

group <5 years diagnosed with clinical malaria was more than the age group >5 years. There

are no reported deaths due to malaria since last 3 years but there is a large disparity between

clinical malaria cases and slide positive cases.

Critical Analysis

Waste management is a top priority issue in any hospital. In Mid-western regional

hospital there was no authorized body for the waste management and amount of the waste

produced in the hospital was not quantified and there were no skilled trained human resources

for the handling of waste management. Furthermore, earthworm farming system was running

in MWRH. So, critical analysis on solid waste management was performed.

With broad topic of collection, transportation, storage, waste disposal site, waste

disposal process, manpower and budgeting, different aspects were critically analyzed using

SWOT table. The main problems were lack of budget allocation for waste management, non-

functional incinerator, disposal sites just behind the emergency block and unavailability of

skillful volunteer for handling of waste. The voluntary committee was successful in

establishing and running earthworm farming and is coordinating with hospital to build a

biogas plant, to bring incinerator, and glass and plastic cutter. Recommendations were given

to maintain strength, improve weakness and address the threat.

Five Year Plan

Diarrheal disease is one of the major public health problems of Rukum district and it

surpasses the incidence of the mid-west region. Diarrheal disease ranks first among diseases

in terms of morbidity in HDCS-Chaurjahari hospital and is among the top five diseases in

Rukum district. Incidence of Diarrhea per 1000 Population in year 2069/70 was 518 and it

seems to have a static trend in the previous three years and it continues to be a significant




problem. So, five year plan on control of diarrhea was prepared based on the data from

HDCS-Chaurjahari hospital.

Five year plan was made in 3 phases- Committee formation and Planning,

Implementation, Re-assessment and Evaluation. The main target was to reduce incidence of

diarrheal disease per 1000 population from 518 to 259 i.e. by 50%. The estimated total

budget was NRs. 54,00,100 , and the sources were government budget and funding from

INGOs and NGOs. Preventive, promotive and curative aspects of Diarrhea were focused.




TABLE OF CONTENTS

Declaration and Approval ii

Acknowledgements iiiExecutive Summary iv

List of Tables viii

List of Figures x

List of Abbreviations xii

Chapter I: Introduction 1

Chapter II: A. District health profile: Bardiya 5

B. Peripheral Institution Visit/ Health Facility Observation 34

Chapter III: Hospital profile: Bardiya District Hospital 37

Chapter IV: An epidemiological study of Malaria in Bardiya district 48

Chapter V: Critical analysis on solid waste management in Mid-western regional

hospital 63

Chapter VI: Five year plan on diarrheal disease control in HDCS-Chaurjahari

hospital 72

Chapter VII: Recommendations and Limitations 91

Chapter VIII: Learning reflections 92

Annex 93




LIST OF TABLES

S.N. Title Page

2.1 Demographic indicators 6

2.2 Number of schools, teachers and students 7

2.3 Categories of Health Facilities 7

2.4 Health indicators 8

2.5 NGOs/INGOs and Private Health Institution 14

2.6 EDP Support 15

2.7 Human resource at DHO, Bardiya 16

2.8 Indicators of malaria 20

2.9 Tuberculosis control programme 21

2.10 Leprosy control programme 21

2.11 Status of rabies in the district 22

2.12 Status of Snake bite in the district 22

2.13 Performance Status FY 2067/68 – 2069/70, National Immunization 23

Programme

2.14 Status of nutrition programme 25

2.15 Status of service delivery sites in the district 28

2.16 Service status in the district 29

2.17 FCHV Performance Status 302.18 PHC-ORC Performance Status 30

2.19 Utilization of laboratory services in Bardiya district 32

2.20 Status of cases registered in the center (from establishment to now) 33

2.21 Age wise distribution of the victims 33

2.22 Human resource of Swarahawa PHCC 35

2.23 Human resource of Motipur HP 36




3.1 Financial Management (in the year 2069/70) 38

3.2 Human resource management in Bardiya district hospital 39

3.3 Obstetrics services provided by Bardiya district hospital 41

3.4 MCH and Family Planning (FP) services 43

3.5 Laboratory Services provided by Bardiya district hospital 45

3.6 Immunization services provided by Bardiya district hospital 45

3.7 Physical facilities available in Bardiya district hospital 46

3.8 Hospital equipments available in Bardiya district hospital 46

3.9 Top 10 diseases in OPD 47

3.10 Top 10 diseases in In-patient department in FY 2069/70 47

5.1 SWOT Analysis 68

6.1 Various types of diarrheal diseases 72

6.2 Phase division 79

6.3 Training activities 82

6.4 Indicators of CDD 836.5 Budgeting of five year plan 84

6.6 Log frame matrix 86




LIST OF FIGURES

S.N. Title Page

2.1 Map of Bardiya District and its Health Facilities 5

2.2 Health Care Delivery System in Bardiya District 13

2.3 Planning function of DHO, Bardiya 17

2.4 Health Management Information System (HMIS) flow in Bardiya 18

2.5 Logistic management in Bardiya 18

2.6 Logistic management information system (LMIS) unit 19

2.7 Status of IUCD, implant and satellite clinic service 27

2.8 Status of contraceptive prevalence rate 28

2.9 OPD Services FY 2067/68 – 2069/70 31

3.1 Morbidity pattern in OPD and Emergency in FY 2066/67 - 2069/70 41

3.2 OPD visits in Bardiya district hospital 42

4.1 Clinical malaria cases with respect to distribution by time 52

4.2 Slide positive cases of P. vivax with respect to distribution by time 534.3 Clinical malaria cases with respect to distribution by place 54

4.4 Slide positive cases of P. vivax with respect to distribution by place 55

4.5 Slide positive P. falciparum cases with respect to distribution by place 55

4.6 Distribution of slide positive malaria cases with respect to distribution by

person 56

4.7 Treatment of clinical malaria cases 57

4.8 Trend of clinical malaria incidences over 3 years 57

4.9 Trend of confirmed malaria cases over 3 years 58

4.10 Trend of P. falciparum cases over 3 years 58

4.11 Clinical malaria cases with respect to distribution by time 59

4.12 Clinical malaria cases with respect to distribution by place 60

4.13 Distribution of slide positive malaria cases with respect to distribution by




person 61

6.1 Incidence of Diarrhea/1000 Population 73

6.2 Percentage of severe dehydration among total cases 73

6.3 Proportion of CDD cases treated by FCHV 74

6.4 Proportion of CDD cases treated by VHW/MCHW 74

6.5 Proportion of CDD cases treated by HF 74

6.6 Diarrhea cases treated with Zinc and ORS 75

6.7 Number of <2 months children treated in HFs 75

6.8 Problem tree of high morbidity due to diarrheal diseases 78




LIST OF ABBREVIATIONS

ABER Annual Blood slide Examination Rate

ACT Artemisinin-based Combination Therapy

AFP Acute Flaccid Paralysis

AHW Auxiliary Health Worker

AIDS Acquired Immuno Deficiency Syndrome

ANC Antenatal Care

ANM Auxiliary Nurse Midwife

ARI Acute Respiratory Infection

ART Anti Retroviral Therapy

BC Birthing Center

BCC Behaviour Change Communication

BCG Bacillus Calmette Guerin

BEOC Basic Essential Obstetric Care

CAC Comprehensive Abortion Care

CB IMCI Community Based Integrated Management of Childhood Illness

CBS Central Bureau of Statistics

CDD Control of Diarrhoeal Diseases

CEOC Comprehensive Essential Obstetric Care

CFR Case Fatality Rate

CMI Clinical Malaria Incidence

CPR Contraceptive Prevalence Rate

CS Caesarian Section

DDC District Development Committee

DHO District Health OfficeDoHS Department of Health Services

DOTS Directly Observed Treatment Shortcourse

DPHO District Public Health Office

DPT Diphtheria, Pertussis and Tetanus

EDP External Development Partner

Em Effective micro-organisms

EP Ectopic PregnancyEPI Expanded Programme on Immunization




ER Emergency

FCHV Female Community Health Volunteer

FY Fiscal Year

GIZ Gesellschaft für Internationale Zusammenarbeit

GMCS Global Malarial Control Strategy

GoN Government of Nepal

HA Health Assistant

HDCS Human Development Community Service

HF Health Facility

HIV Human Immuno deficiency Virus

HMIS Health Management Information System

HP Health Post

IEC Information, Education and Communication

IMCI Integrated Management of Childhood Illness

INGO International Non Governmental Organization

IPD In-patient Department

IUCD Intra Uterine Contraceptive Device

JE Japanese Encephalitis

Ka. Sa. Karyalaya Sahayogi

LFA Logical Framework Analysis

LMD Logistics Management Division

LMIS Logistics Management Information System

MA Medical Abortion

MCHW Maternal and Child Health Worker

MO Medical Officer

MoHP Ministry of Health and Population

MoV Means of Verification

MS Medical Superintendent

MWRA Married Women of Reproductive Age

MWRH Mid Western Regional Hospital

Na. Su. Nayab Subba

NCDDP National Control of Diarrheal Diseases Programme

NGO Non Governmental Organization NIP National Immunization Program




OCMC One stop Crisis Management Centre

OPD Out-patient Department

ORS Oral Rehydration Solutions

ORT Oral Rehydration Therapy

OT Operation Theatre

OVI Objectively Verifiable Indicators

PAC Post Abortion Care

PF Plasmodium falciparum

PHC ORC Primary Health Care Out Reach Clinic

PHCC Primary Health Care Centre

RAP Risk Awareness Programme

RBM Roll Back Malaria

RHD Regional Health Directorate

RTAG-M Regional Technical Advisory Group on Malaria

SBA Skilled Birth Attendant

SHP Sub Health Post

SPHA Senior Public Health Administrator

SPR Slide Positivity Rate

API Annual Parasite Incidence

SWOT Strength Weakness Opportunity Threat

TT Tetanus Toxoid

UNICEF United Nations Children’s Fund

USAID United States Agency for International Development

VBD Vector Borne Disease

VCT Voluntary Counselling and Testing

VDC Village Development Committee

VHW Village Health Worker

WHO World Health Organization




Chapter I

INTRODUCTION

1.1 Background

A system can be defined as a set of elements which are arranged in such a way that all of

its components fit together or work together in order to perform a particular function. A health

system can be referred to as the complex of interrelated elements that contribute to health in

homes, educational institutions, workplaces, public places and communities as well as in the

physical and psychosocial environment and the health and related sectors.

A district, being the meeting-point of bottom-up planning (need based) & top-down

planning (for support), is considered to be the focal point for decentralization. District Health

System is an appropriate means of improving the health status of communities where 90 % of

health problems can be addressed at district level. It facilitates interaction and co-ordination

among different governmental departments and NGOs working locally.

District Health System is a self contained segment of the national health system. It

comprises of a well-defined population, living within a clear administrative & geographical area

and includes all institutions (government, non-government, international) providing health care

in the district. In addition it also includes all the traditional and private health care workers and

facilities.

Management, principally, is the task of planning, coordinating, motivating and

controlling; performed to determine and accomplish the objectives by the use of people and

resources. Health Management is a process with which both interpersonal and technical health

services organization are specified and accomplished by utilizing human and physical resources

and technology.

District health system could be regarded as a big container containing many other smaller

and inter-linked groups of containers with interwoven structures, interfaces and channels ofcommunication. The contents of these containers are the people and the programs and services to

them, whereas the structures are community structures and other sector health structures. The

ways and means whereby the containers and contents are arranged so as to be effective and

efficient is the health management which involves management of appropriate hierarchical

arrangement of health facilities for providing easy access to health services to the communities.




The pillars of health system management include organization, planning and

management, community financing and resources allocation, inter-sectored collaboration,

community involvement, development of human resources and health system research.

1.2 Objectives

1.2.1 General Objective

• To acquire knowledge and skills required for the management and development of health

care delivery system.

1.2.2 Specific Objectives

• To understand the existing health care delivery system in the district in terms of

infrastructure, human resources, financial status, management, accessibility and

availability.• To understand the managerial aspect and activities of various health institutions in the

district; including Regional/Zonal/ District/ Private Hospitals, DPHOs, PHCCs, HPs and

SHPs by observation and participation in the activities in and outside these institutions.• To understand the roles / activities of other Government Organizations (GOs) / Non

Government Organizations (NGOs) and alternative health care providers in the health

care delivery of the district and the co-ordination between them.• To develop skills necessary for conducting epidemiological study on a major health

problem of the district.• To develop skills necessary for performing critical analysis on a particular aspect of

health-related facility / activity of the hospital / DHO / DPHO.• To develop planning skills necessary for the maintenance and development of the health

care delivery system and formulate a five year plan on a pertinent health issue in thedistrict.




1.3 Process and preparation

1.3.1 Study AreasBardiya : District Hospital, Gulariya

Surkhet : Mid-Western Regional Hospital, Birendranagar

Rukum : HDCS-Chaurjahari Hospital, Chaurjahari

1.3.2 Study duration Nine weeks (25 Falgun – 26 Baisakh, 2070)

1.3.3 Literature review

1.3.4 Study Toolsa. Observation checklist (for hospital equipment and infrastructures).

b.

Interview guidelines for Senior Public Health Administrator, Medical Superintendent(MS) and other key informants.

c. Note taking during interviews, clinical rounds and observations.

d. SWOT matrix.

e. Logical framework matrix.

f. Photography.

g. Focused Group Discussion (FGD) guidelines.

1.3.5 Study techniquesThe major techniques of the study are as enlisted below:

a. Observation:i. Resources/facilities (adequacy, utilization, etc).

ii. Management (effectiveness, weaknesses, constraints, etc).

iii. Human interaction (e.g. among staffs or between staffs and patients).

b. Participation:i. Health service delivery activities.

ii. Other activities like meetings, discussions, teaching-learning activities and mobile

health programs.

c. Visits and interactions:i. Authorities of health institutions (MS/MO).

ii. District Public Health Office authorities




iii. Others: District Development Committee, I/NGOs, municipality office.

iv. Staff: Hospitals and others.

v. Patients and patient parties

d. Document review:Hospital records, reports, annual reports (national, district, DHO/DPHO)

e. Data collection:The type of data obtained were both qualitative and quantitative and they were

obtained from annual reports, patient record book, store records and hospital records, data

from account section, administrative documents and records.

f. Data processing:The information collected from multiple sources and methods were triangulated

and integrated. The data were analysed to obtain the indicators and describe the situation.

1.3.6 Ethical considerationsThe objectives of the study were explained to the concerned authorities. Informed

consent was taken from the health personnel, patient and the patient parties and other

personnel involved before interview and confidentiality was maintained in all aspects.

1.4 Logistics management

Accommodation was recommended by the campus and a daily allowance was

also provided. In addition transportation cost and stationery were also provided by the

campus.




Chapter IIA. DISTRICT HEALTH PROFILE: BARDIYA

2.1 District Profile

Figure 2.1: Map of Bardiya District and its Health Facilities

2.1.1 IntroductionBardiya district of Bheri zone occupies an area of 2025 square kilometer and has a

population of 434,300 and population density of 211 (persons/sq. km.). Gulariya is the district

headquarter. 37 percentage of its total area is occupied by the Bardiya National Park.

2.1.2 Political and Administrative Division1. Development region: Mid Western Development Region




2. Zone: Bheri Zone

3. Ecological region: Terai

4. District Headquarter: Gulariya

5. Number of electoral constituencies: 4

6. No. of Municipalities: 1

7. Number of VDCs: 31

2.1.3 Population1. Demographic Indicators

Table 2.1: Demographic indicators

Indicators NumberNumber of VDCs 31

Number of Municipality 1

Total Population 434,300

Under 1 Population 10,700

Under 5 Population 50,047

Female married women 15-49

years

86,297

Expected pregnancy 12,488

Under 3 years Population 30,353

Adolescent 10-19 years Population 1,01,285

Annual Population Growth Rate 1.10%

Sex Ratio (males per 100 Females) 92.6

Number of Household 83,176

Average household size 5.13Population Density

(persons/sq.Km.)

211

Total Absent (abroad) Population 25,044

Male Absent (abroad) Population 21,719




Female Absent (abroad)

Population

3,325

(Source: CBS, Census 2011)




2.1.4 Development resources1. Education

Table 2.2: Number of schools, teachers and students

Particulars Primary LowerSecondary

Secondary HigherSecondary

Totalschools652

206 75 44 27

Totalstudents18,494

79,100 38,010 16,280 5,679

Totalteachers-

1352 344 240 30

(Source: DDC, Bardiya)

2. Health

Table 2.3: Categories of Health Facilities

Category NumberDistrict Hospital 1Ayurved Aushadhalaya 1PHCCs 3HPs 25

SHPs 13PHC-Outreach Clinics 156EPI Clinics 197FCHVs 841

(Source: District Population Profile, DHO, Bardiya)

2.1.5 Development indicators

1. Education Total literacy: 76.64%

Male literacy rate: 84.33%

Female literacy rate: 68.72%




2. Health

Table 2.4: Health indicators

Reporting Status 2067/68 2068/69 2069/70

District Hospital 100% 100% 100%

PHCCs 100% 100% 100%

Health Posts 100% 100% 100%

Sub Health Posts 100% 100% 100%PHC/ORC Clinics 91.77% 87.38% 90.92%

EPI Clinics 94.96% 94.17% 99.24%

NGOs 42.19% 34.90% 54.49%

Expanded Programme on Immunization

BCG Coverage 67.71% 66.05% 75.00%

DPT1 Coverage 60.92% 70.03% 76.52%

DPT2 Coverage 71.43% 68.78% 76.64%

DPT-Hep b-Hib 3 coverage 76.86% 69.15 % 76.17 %

Measles coverage 68.33% 65.73% 75.70 %

JE Coverage 75.03% 71.06% 80.58%

% of TT2+ (Pregnant women) coverage 25.16 25.35% 32.84 %

Dropout rate DPT-1 Vs DPT-3 -0.08% 1.25% 0.46 %

Dropout rate BCG Vs Measles -0.01% 0.18% -0.93%

Number and % of unimmunized children 3765(32.29%)

4002(34.15%)

2600(24.30%)

Number of VDCs with <than 90% DPT3

Coverage

28 VDCs 29 VDC 30 VDCs

No. of AFP Cases 8 6 14 No. of Measles cases 65 12 2 No. of Neonatal tetanus Cases 0 0 0Nutrition Programme




New growth monitoring visits as % of<5 years children

54.28% 59.03% 74.41%

Proportion of malnourished children as

% of new growth monitoring (< 5

years)

3.22% 2.66% 3.29%

% of expected pregnant mothers

supplemented with Iron tablets

76.39% 68.25% 71.60%

% of pregnant mothers who received180 iron tablets

40.75% 41.20% 47.28%

% of pregnant supplemented by

Antihelmenthic tablet

69.25% 66.42% 67.14%

% of Postpartum mothers receiving

Vitamin ‘A’

56.00% 55% 54.11%

Vitamin "A" Distribution Coverage

(number and %) 1st (Kartik) round

(6 month to < 5 years children)

46289(92.17%)

43,667(89%)

41908(93.59%)

Vitamin "A" distribution coverage

(number and %) 2nd (Baishakha)

round (6 month to <5 years children)

44518(88.64%)

42,671(87%)

39333(87.84%)

Antihelmenthic tablet distribution

coverage (number and %) 1st

(Kartik) round (1- <5 years children)

41692(94.10%)

38051(88.28%)

37692(95.79%)

Antihelmenthic tablet distribution

coverage (number and %) 2nd

(Baishakha) round (6 month to <5

years children)

40220(90.78%)

38463(89.24%)

34761(88.34%)

Acute Respiratory Infection (ARI)

% of pneumonia among new ARI cases 24.49% 24.17% 21.62%

% of severe pneumonia or very severe

disease among total cases

0.39 % 0.40% 0.25%

Proportion of ARI cases treated by 65.77 65.25 64.55




FCHV

Proportion of ARI cases treated by

AHW/ANM

8.09 7.67 6.85

Proportion of ARI cases treated by HF 26.14 27.08 28.60

Control of Diarrheal Diseases (CDD)

% of severe dehydration among total

cases

0.06 % 3.39 % 0.06 %

Proportion of Diarrheal cases treated by

FCHVs

70.01 70.04 71.80


AHW/ANM

9.55 8.84 7.77


HF

20.44 21.12 20.42

Proportion of diarrhea cases treated withzinc and ORS

91.30 % 93.78 % 98.23 %

Safe Motherhood Programme

Antenatal First visits as % of expected

pregnancies

68.44% 66.72% 68.22%

4 ANC visits as % of 1 st ANC visit 65.07% 66.43% 68.19%

Delivery conducted by SBA at HF as %of expected pregnancy

39.90 % 41.20% 43.64%

Delivery conducted by health worker as

% of Expected Pregnancy

1.09% 0.32% 0.08%

% of institutional delivery amongexpected live births

39.99 41.08 43.54

PNC First visit as % of expected live

birth

49.04 44.91 45.08

Number of CAC & Medical Abortion(MA)

580 242 200

Number of PAC 159 153 162

% of women receiving maternity

incentives among total institutional

100% 100 % 100%




deliveries

% of women receiving 4 ANC

incentives among total institutional

deliveries

33 41 63.57

Met need of emergency obstetric care

(need of EOC is 15% of expected

live birth)

0.1% 9.03% 10.74%

Caesarian Section (CS) rate ( 5% of total

expected birth is the usual CS rate)

0.11 0.03 0.00

Number of Maternal Death, Ratio to

Total delivery

8 7 5

Number of Neonatal Death, Ratio to

Total delivery

98 79 45

Family Planning Programme

Contraceptive Prevalence Rate (CPR) 52.5 53.29 59.66

% of FP new acceptor method mix 12.84 14.22 16.52

FP current users target versus

achievement

102.88 105.55 NA

VSC cases target versus achievement 79.44 77.07 116.67FP (spacing) new acceptor as % of

MWRA

12.82 13.07 15.30

% of services provided by NGOs to total

new acceptors of FP

2.76 N/A N/A

Malaria Control Programme

No of confirmed malaria cases among

total malaria cases

120 124 62

Annual Blood Slide Examination Rate

(ABER) per 100

1.72 1.26 1.67

% of PF among total positive cases 5.61( 6casesout of107)

9.68 (12casesout of124)

9.68(6out

of 62Case




s)Clinical malaria incidences (CMI)

/1,000 risk population

18 13 10

Target versus achievement of blood

slide collection

157.54 108.55 119.45

Reported death due to malaria 0 0 0

percentage of indigenous cases amongtotal positive cases

94.39(101casesout of107)

90.32(112out of124)

90.32(56out

of 62cases

)Tuberculosis Control Programme

Treatment Success Rate on DOTS 78.80 86.34 89.52

Case Finding Rate 73.04 72.8 73.89 No of MDR Cases 0 0 9 (undertreatment

inINF,Bank

e)Leprosy Control Programme

New case DetectionRate(NCDR)/10,000

1.90 2.35 2.12

Registered Prevalence Rate (PR)/10,000 1.45 1.81 1.77Disability Rate Grade 2 Among New

Cases4.49 1.79 5.43

HIV/AIDS Programme

Number of HIV +ve cases 36 12 8 Number of people counseling 6069 10762 11614 Number of persons receiving ART 24 27 34 Number of ART sites 1 1 1 Number of Counseling centres 3 2 3Curative Services

Total OPD New Visits as % of TotalPopulation

89.71 86.46 93.79

Total new female OPD visits as % oftotal OPD visits

56.87 57.97 57.67

% of communicable disease among totalOPD new visit

21.28 17.36 19.33

Average Number of People Served by Health Facilities Per MonthGovernment Hospital 3,209 2,381 2415




NGO/Private Hospitals and other healthinstitutions

3,348 2,396 2524

PHCCs 4,359 4,395 4422Health Posts 11,562 11,666 15627Sub Health Posts 21,605 22,372 18459

EPI Clinics 5,657 5,315 5882PHC/ORC Clinics 5,664 5,374 5437(Source: District Population Profile, DHO, Bardiya)

2.2 District Health System

District heath system comprises of different health care agencies which either act under

the government or independently, to provide preventive, promotive and rehabilitative services to

a defined population living in a district. These agencies act in a coordinated way to improve the

overall health status of the people of the district.

2.2.1 Health Care Delivery System




Fig. 2.2: Health Care Delivery System in Bardiya District

T h a k u r d w a r a S H P

r i S

District Health Office, Bardiya

Public Health Section Hospital Section

R a j a p u r , P H

C = 2

M a g r a g a d h i P H

C

S o r a h a w a P H C

B a g n a h a H P = 2

K h a i r a p u r H P = 2

K h a i r i c h a n

d a n p u r

=

N a y a g a u n H P = 2

N e u l a p u r H

P = 2

P a t a b

h a r H P = 2

S a n o s h r e e H P = 2

D e u d a k a l a

H P = 2

B h i m a p u r S H P

M a n p u r t H P

D h a d a w a r S H

P

J a

u n i P

M a i n a p o .

l i k H

P

S u r y a p a t u

S H P

a t h u r a S H P

o h a

a d S H P

S H P

l t

l

r S

S h i v p u r H P

s

t i

B a n i y a b h

S H P

T a t a t a l S H P

B e l a w a

H P

G o l a S H P

FCHVs:841 PHC/ORC: 156 EPI Clinics: 197




2.2.2 Health Care Providers in Bardiya District Government Supported

o Bardiya District Hospital

o PHC : 3

o HP : 25o SHP : 13

o PHC-ORC : 156

o EPI Clinics : 197

List of NGO/INGO & Private Health Institution

Table 2.5: NGOs/INGOs and Private Health Institution

Name Area of Geographic And Technical SupportReportingStatus Y/N

Institute ofCommunityHealth

Working on HIV/AIDS control in Bardiya in FSW andtheir clients.

Y

BlueDiamondSociety

Working on HIV/AIDS control in Bardiya district inMSM/TG.

Y

NSAARC Working on HIV/AIDS control in Bardiya district Y

FamilyPlanningAssociationof Nepal

Working on Maternal and Child Health Not regular

GeruwaCommunityHealth Center

Working on curative services in Pashupati Nagar VDCof Bardiya

Y

SOSBanshgadhi

Working on Family Health, HIV/AIDS, Malaria, T.B.and other curative services in Motipur, bardiya.

Y

KP PolyClinic Working on family planning and curative services Not regularBardiya PolyClinicSanoshree

Working on family planning and other curative services Not regular




EDP SupportTable 2.6: EDP Support

Name of EDP Types of Support

Technical Logistics FinancialGIZ Technical Financial

Save the children Technical Logistic Financial

Health for Life (H4L) Technicalsupport onsystemstrengthening and

capacity buildingUNICEF Financial

Max Pro Technical

2.2.3 District Health Office (DHO)

The health care delivery system has been decentralized by the Ministry of Health andPopulation. Therefore the health care system is administered on a district level by the District

Public Health Office (DPHO) or the District Health Office (DHO). The governing body

responsible for the preventive, promotive and curative aspect of health care in Bardiya is DHO.

The Senior Public Health Administrator (SPHA) supervises and monitors all components of the

district health system. Mr. Achyut Lamichhane currently holds this post.




2.2.3.1 Human resource

Table 2.7: Human resource at DHO, Bardiya

S.N. Posts

Government Currently Available

Sanctionedpost

(in number)

Fulfilled

(innumber)

Amonggovernmentsanction (innumber)

Local andotherresources (innumber)

Technical Staffs 1. Sr. Public Health 1 1 1 02. HA/Sr.AHW 2 2 2 03. Statistics Supervisor 1 1 1 04. Family Planning 1 1 1 05. EPI Supervisor 1 1 1 06. Health Education 1 1 1 07. TB Leprosy 1 1 1 08. Public Health Nurse 1 1 1 09. Vector Control 1 1 1 010. Malaria Inspector 2 2 2 011. Lab Technician 1 0 0 012. Computer Operator 1 1 1 013. Cold Chain Assistant 1 1 1 0

14. ANM 2 2 2 015. Lab Assistant 2 2 2 016. Typist 1 1 1 017. Driver 1 1 1 0Administrative Staffs 1. Na. Su. 1 0 0 02. Accountant 1 0 0 03. Kharidar 1 0 0 04. Sub Accountant 1 0 0 0

5. Ka .Sa. 4 4 4 0

(Source: DHO, Bardiya)




2.3 Management Functions of DHO

2.3.1 Planning

Figure 2.3: Planning function of DHO, Bardiya

Planning begins from the district level and progresses upwards. The MoHP formulates

programs and sets targets each year. Resources are allocated accordingly based on meetings held

at various levels of the health system management structure.

2.3.2 Supervision and Monitoring

There is a regular system of integrated supervision and monitoring (S & M) of all

existing health related activities. For S & M, a tentative schedule of the whole year is prepared

and followed accordingly. There is supervision in each Primary Health Care Center (PHCC),

Health Post (HP), and Sub Health Post (SHP) at least once a month by the DHO.

District Performance Review meeting at DHO (in Kartik)

Program Review meeting at DDC (in Falgun)

Regional level of Performance meeting

National Level Performance meeting

National Planning Commission Ministry of Finance

Ministry of Health

Programs and targets fixed for DHO / PHCC / HP / SHP

Budget Allocation




2.3.3 Recording and Reporting System

Figure 2.4: Health Management Information System (HMIS) flow in Bardiya

The reporting status from SHP, HP, PHCC and District Hospital is 100% in the last 3

years.

2.3.4 Logistic management

Figure 2.5: Logistic management in Bardiya

Logistic Management Division

Regional Medical Store

District Store Local Purchase as per need

Donor Agencies

PHCCSHPHP

DHO

FCHVs

12 t day of every month

7t day of every month

HP / PHCC

SHP

3rd day of every month

1st day of every month

Regional Health Directorate / Department of Health Service / HMIS Section




2.3.5 Financial management (FY 2069/70)

As per the data obtained from DHO, Bardiya,The total budget allocated was NRs. 69,27,000 for the FY 2069/70.

The total budget released was NRs. 55,71,830.

The total income for the FY 2069/70 was NRs. 34,81,621 and expenditure was NRs.

37,40,838.

2.3.6 Evaluation

Performance of staff is evaluated using a Performance Evaluation Form. The use of the

performance evaluation form is done on yearly basis.

Programs were evaluated through review meetings held once a month in each illaka .

Quarterly, half yearly and annual reviews are also held for each program. The evaluation of the

other NGOs working in the health was not in practice.

2.4 Health programs of DHO

2.4.1 Disease control programa. Malaria

Annual blood slide examination rate in 2069/70 is 1.67 percent among total malarious

population which is more than previous year 2068/69. Number of confirmed malaria case has

decreased to 61 in 2069/70 from 124 in 2068/69. Total number of PF case has also decreased.

SHP, HP, PHCC

Logistic management system, DHO

DOHS, LMD

LMIS Unit

3 monthly report

3 monthly report

Figure 2.6: Logistic management information system (LMIS) unit: Logistic planning forneed based procurement, storage and distribution of all health care logistics.




Due to expansion of Lab service and TOT of Malaria for health institution in-charge, clinical

malaria has decreased to 10/1000 population.

Table 2.8: Indicators of malaria

Indicators 2067/68 2068/69 2069/70

No of confirmed malaria cases among total

malaria cases

120 124 62

Annual Blood Slide Examination Rate (ABER)

per 100

1.72 1.26 1.67

% of PF among total positive cases 5.61( 6 casesout of 107)

9.68 (12 casesout of 124)

9.68(6out of

62Cases)Clinical malaria incidences (CMI) /1,000 risk

population

18 13 10

Target versus achievement of blood slide

collection

157.54 108.55 119.45

Reported death due to malaria 0 0 0

Percentage of indigenous cases among total positive cases

94.39(101cases out of

107)

90.32(112 outof 124)

90.32(56out of

62cases)

b. Lymphatic Filariasis

The coverage was very low in fiscal year 2068/69 which was only 51.01 percent. Rumors

of people dying from taking prophylaxis against lymphatic filariasis originated from Banke

district spread very quickly and thousands of effort and strategies failed to stop that storm and

people did not accept drugs distributed in mass campaign but in fiscal year 2069/70, it wasradically increased than previous year (75.41%) due to mass communication, awareness, hard

work of health workers and public understanding of advantage of program.




c. Tuberculosis (TB)

Tuberculosis is a major public health problem in Nepal. T.B. patients are being treated

with Directly Observed Treatment Short Course. The case finding in 2069/70 is 73.89 percent in

Bardiya district which is a little bit more than the year 2068/69. Treatment success rate has also

been increased to 89.52 percent in 2069/70 from 86.34 percent in 2068/69. All these indicators

meet the WHO standards.

Table 2.9: Tuberculosis control programme

Tuberculosis Control Programme 2067/68 2068/69 2069/70

Treatment Success Rate on DOTS 78.80 86.34 89.52

Case Finding Rate 73.04 72.8 73.89

No of MDR Cases 0 0 9 (undertreatmentin INF,Banke)

d. Leprosy

The new case detection rate has declined very slowly. In 2069/70, it was 2.12 per 10,000

populations whereas in 2068/69 it was 2.35. Although the prevalence has decreased, it is more

than 1 per 10,000 population. In 2069/70 it is 1.77 per ten thousands population which exceeded

the elimination level and disability grade 2 is 5.43 which indicates the late detection of new

cases.

Table 2.10: Leprosy control programme

Leprosy Control Programme 2067/68 2068/69 2069/70

New case Detection Rate(NCDR)/10,000 1.90 2.35 2.12

Registered Prevalence Rate (PR)/10,000 1.45 1.81 1.77

Disability Rate Grade 2 Among New Cases 4.49 1.79 5.43




e. RabiesRabies is a significant problem in Bardiya district. The number of animal bites in the year

2069/70 was 707 out of which 674 people were treated for post-exposure prophylaxis of rabies.

However, there was no death due to rabies.

Table 2.11: Status of rabies in the district

Indicators 2069/70

Total number of animal bites (species wise) 707

Number of persons treated for post-exposure prophylaxis of rabies 674

Vaccine (vial) expenditure 2601 vial

Number of deaths due to rabies (hydrophobia) 0

f. Snake biteSnake bite is a problem in Bardiya district in summer and rainy season. The total number

of snake bites in the year 2069/70 was 46 out of which only 6 required anti-snake venom serum.

Only 1 person died of snake bite in the year 2069/70.

Table 2.12: Status of Snake bite in the district

Indicators 2069/70

Total number of snake bite 46

Number of persons treated for poisonous snakebite 6

Anti snake venom serum expenditure 38 vial

Number of deaths due to snake bite 1

2.4.2 Child HealthThe Child Health and Nutrition Section of the DHO is responsible for conducting the

following programs: Expanded Program on Immunization (EPI), School Health and Nutrition

Program, Integrated Management of Childhood Illness (IMCI) program, Control of Diarrheal

Diseases (CDD) and Acute Respiratory Illness (ARI), Community Responsive Antenatal,

Delivery and Life Support project for mothers and newborn.




a. Immunization

The National Immunization Program (NIP) is a high priority program (P1) of

Government of Nepal and is provided free of cost. Immunization is considered as one of the

most cost-effective health interventions. It has significantly contributed to reduce the burden of

vaccine preventable diseases and child mortality. The Regional Health Directorate (RHD) acts as

a facilitator between the Central and the District levels. It is the responsibility of the DHO to

ensure that a successful immunization program is implemented at the district and below level.

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

implement immunization programs in their respective municipalities and Village Development

Committees (VDCs) by extending the EPI clinics.

In Bardiya district immunization services has been providing from all the health facilities

including 197 EPI clinics. There are 4 to 7 EPI clinics in each VDC as the national references it

is estimated 3 to 5 EPI clinics in each VDC.

Table 2.13: Performance Status FY 2067/68 – 2069/70,

National Immunization Programme

S.N. Indicators 2067/68 2068/69 2069/701. BCG Coverage 67.71 66.05 75.002. DPT-Hep B-Hib 3 coverage 76.86 69.15 76.173. Measles coverage 68.33 65.73 75.704. % of TT2+ (Pregnant

women) coverage25.16 25.35 32.84

5. Dropout rate DPT-1 VsDPT-3

-0.08 1.25 0.46

6. Dropout rate BCG VsMeasles

-0.01 0.18 -0.93

7. Number and % ofunimmunized children

3692(32.29%)

4012(34.15%)

2600(24.30%)

8. Wastage rate by antigenBCG 81 81 80.96DPT Hep B 1 2 11.35Polio 17 16 17.18Measles 60 60 62.06J.E. 29 33 36.42TT 24 23 17.14

9. No. of VDC with <90% 28 VDCs 29 VDCS(only 30 VDCs (Only




DPT3 coverage (Belawa,Jamuni andKalika Havemore than 90)

Belwa and jamuni have>90%Coverage)

Belwa VDC has >90 % coverage)

10. No. of AFP Cases 8 6 9

11. No. of Measles cases 65 12 212. No. of Neonatal tetanusCases

0 0 0

(Source: Annual Health Report, DHO, Bardiya 2069/70)

b. Nutrition Program

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

Nepal. National nutrition program aims to improve the overall nutritional status of children,

pregnant women, women of child bearing age. This is implemented through the control of

general malnutrition and prevention and control of micronutrient deficiency disorder.

In Bardiya district the overall nutritional status of children and pregnant women, women of child

bearing age, the following programs are under intervention:

Community based Management of Acute Malnutrition (CMAM)

Infants and Young Child Feeding (IYCF) program

Growth monitoring under 5 children

National Vitamin A program and Anti-helmenthic tablet distribution to under 5 years

children (Kartik to Baisakh) Iron distribution to pregnant mothers

Anti-helmenthic tablet distribution for pregnant mothers

Vitamin A distribution for post partum mothers

Celebration of world breast feeding week (first week of August)

Celebration of Iodine month (February)

Celebration School health and nutrition week (Jesth 1 to7)

De-worming program for government school children Baal-vita program for 6 months to 23 months children




Table 2.14: Status of nutrition programme

S.N. Nutrition Programme 2067/68 2068/69 2069/70

1. New growth monitoring visits as % of <5 yearschildren

54.28% 59.03% 74.41%

2. Proportion of malnourished children as % of new

growth monitoring (< 5 years)

3.22% 2.66% 3.29%

3. % of expected pregnant mothers supplemented with

Iron tablets

76.39% 68.25% 71.60%

4. % of pregnant mothers who received 180 irontablets

40.75% 41.20% 47.28%

5. % of pregnant supplemented by Anti-helmenthic

tablet

69.25% 66.42% 67.14%

6. % of Postpartum mothers receiving Vitamin ‘A’ 56.00% 55% 54.11%

7. Vitamin "A" Distribution Coverage (number and

%) 1st (Kartik) round (6 month to < 5 years

children)

46289

(92.17%)

43,667

(89%)

41908

(93.59%)

8. Vitamin "A" distribution coverage (number and %)

2nd (Baisakha) round (6 month to <5 years

children)

44518

(88.64%)

42,671

(87%)

39333

(87.84%)

9. Anti-helmenthic tablet distribution coverage

(number and %) 1st (Kartik) round (1- <5 years

children)

41692

(94.10%)

38051

(88.28%)

37692

(95.79%)

10. Anti-helmentic tablet distribution coverage

(number and %) 2nd (Baishakha) round (6 month

to <5 years children)

40220

(90.78%)

38463

(89.24%)

34761

(88.34%)

(Source: Annual Health Report, DHO, Bardiya 2069/70)

c. CB-IMCICommunity Based Integrated Management of Childhood Illness (CB-IMCI) Program is

an integrated package of child-survival programs and addresses major 5 killer diseases like

Pneumonia, Diarrhea, Malaria, Measles, and Malnutrition in 2 months to 5 year children and




basic new born care in holistic approach. CB-IMCI also includes management of infection,

jaundice, hypothermia and counseling on breastfeeding for young infants less than 2 months of

age. With the implementation of this package children are diagnosed early and treated

appropriately for major childhood diseases at the health facility and community level. At the

community level FCHVs play key role to increase community participation.

The objectives are to

reduce frequency and severity of illness and death related to ARI, Diarrhea, Malnutrition,

Measles and Malaria.

contribute to improved growth and development.

Impacts of the Program

Institutional delivery is found to be increased.

Infectious new born cases are being treated in the community level.

Treatment procedure is similar all over the district.

FCHVs are happy because government is providing incentives for new born care.

Community people are satisfied due to low/no cost for the treatment.

Saving of time of community people because of availability of treatment in community.

It enhanced the level of knowledge, skills of health workers and FCHVs.

It developed precise and easy protocol.

It has decreased neonatal and child morbidity and mortality because early management incommunity level.

2.4.3 Maternal and Child Health/Reproductive Healtha. Family Planning Program

The main thrust of the National Family Planning Program is to expand and sustain

adequate quality family planning services to communities through the health service network

such as hospitals, 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. The policy also aims to encourage public private partnership. Female community

health volunteers (FCHVs) are to be mobilized to promote condom distribution and re-supply of




oral pills. Awareness on FP is to be increased through various IEC/BCC intervention as well as

active involvement of FCHVs and Mothers Groups as envisaged by the revised National Strategy

for Female Community Health Volunteers program. In this regard, family planning services are

designed to provide a constellation of contraceptive methods/services that reduce fertility,

enhance maternal and neonatal health, child survival, and contribute to bringing about a balance

in population growth and socio-economic development, resulting in an environment that will

help the Nepalese people improve their quality of life.

Status of IUCD, Implant and satellite clinic service sites:

Fig. 2.7: Status of IUCD, implant and satellite clinic service

The graph shows the sites of the long term methods. These numbers of sites cannot cover

the total MWRA. Implant demand is high but sites and trained human resources are not

sufficient. All existed sites cover very small area of the district. The diagram shows that CPR in

the fiscal year 2069/70 is 59.66 percent which is 6 percent more than fiscal year 2068/69 which

is very good and the district is very near to Millennium Development Goal of 67 percent by

2015. Percentage of new acceptor, both method mix and spacing FP method are also in

increasing trend in the last three years. According to the given target the achievement of the VSC

is in increasing trend though the number of client of VSC is going to be decreased every year.




Fig. 2.8: Status of contraceptive prevalence rate

b. Safe Motherhood Program

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

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

complications of pregnancy and childbirth. In Bardiya, safe delivery incentive program provides

NRs. 500 for transportation to a health facility.

Table 2.15: Status of service delivery sites in the district

Indicators 2067/68 2068/69 2069/70

No of functional BEOC sites 3 3 4

No of functional CEOC sites 1 1 0

No of Safe abortion sites 3 3 3

Ratio of BEOC/CEOC sites to Population(Population/No. of sites)

1:117100 1:118933 1:108575

No of birthing centers and Ratio to EP (No.EP/No. BC)

17 17 17




Table 2.16: Service status in the district

S.N. Indicators 2067/68 2068/69 2069/70

1. ANC 1 st visit as % of expected pregnancy 68.44% 66.72% 68.22%

2. ANC 1st visit as % of expected live birth 76.03% 74.27% 75.79%

3. 4 ANC visits as % of 1 st ANC visit 65.07% 66.43% 68.19%4. Delivery conducted by SBA as % of expected live

births39.90 41.20 43.64

5. Delivery conducted by health worker as % of Exp.live birth

1.09 0.32 0.08

6. % of institutional delivery among expected live births

39.99 41.08 43.54

7. PNC 1 st visit as % of expected live birth 49.04 44.91 45.088. No of CAC (Surgical and Medical Abortion, MA) 580 242 2009. No of PAC 159 153 16210. % of women receiving maternity incentives among

total institutional deliveries100 100 100

11. % of women receiving 4 ANC incentives amongtotal institutional deliveries

33 41 63.57

12. Met need of emergency obstetric care (need ofEOC is 15% of expected live birth)

0.1% 9.03% 10.74%

13. Caesarian Section (CS) rate ( 5% of total expected birth is the usual CS rate)

0.11 0.03 0.00

14. Number of Maternal Death 8 7 515. Number of Neonatal Death 98 79 45

2.4.4 Female Community Health Volunteers (FCHV) Program

Recognizing the importance of women's participation in promoting health of the people,

GoN initiated the Female Community Health Volunteer (FCHV) Program in FY 2045/46

(1988/1989) in 27 districts and expanded to all 75 districts of the country in a phased manner.

The major role of the FCHV is to promote health and healthy behavior of mothers and thecommunity. Besides the motivation and education, the FCHVs re-supply pills and distribute

condoms, ORS packets and vitamin A capsules; and in IMCI program districts, they also treat

pneumonia cases and refer more complicated cases to health institution. Similarly, they also

distribute iron tablets to pregnant women.




Table 2.17: FCHV Performance Status

Indicators 2067/68 2068/69 2069/70

Proportion of Pills cycles distribution byFCHVs among total distribution

51.23 43.58 46.56

Proportion of Condoms distribution byFCHVs among total distribution

51.03 47.88 48.73

Proportion of ORS distribution by FCHVsamong total distribution

64.14 NA NA

Number of maternal death reported by FCHV 0 0 0 Number of newborn death reported by FCHV 0 0 0% of Mother's Group Meeting held 73.34 75.48 77.18Total Loan Mobilized from FCHV Fund (Rs.) 11,408,256 10,558,439 10,13,244

2.4.5 Primary Health Care-Outreach Clinic (PHC-ORC) Program

PHC/ORC program was launched in 1994 by the Government of Nepal 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 an extension of HP & SHP at the community

level. VHW & MCHW or ANM provide basic PHC services (FP & ANC services/HE/minor

treatment) to communities (2-5 catchment areas per VDC) at a pre-arranged place on a

predetermined date once a month.

Table 2.18: PHC-ORC Performance Status

Indicators 2067/68 2068/69 2069/70

Number and % of PHC/ORC conducted withrespect to targeted

1718(91.77)

1635(87.34)

1700(90.81)

Number of People Treated by First Aid 15558 14658 10829

No. of women who received ANC Services 10301 9933 8098

% of growth monitoring through ORC (to totalgrowth monitoring)

51.53 51.16 52.80




2.4.6 Free Health Services

The interim constitution of Nepal 2063 has emphasized that every citizen shall have the

right to basic health services free of cost as provided by the law. As a result, the free health

service is provided in all sub-health posts and health posts. This service has also been extended

to PHC and government hospitals with capacity of 25 beds in 35 districts. Essential drugs (33 in

PHCC, 24 in SHP/HP, 41 in District Hospital) including basic lab investigations are also

provided free to the patients. Family Planning, Immunization, Nutrition, Malaria, Filaria, TB,

Leprosy treatment and interventions are provided free.

The percentage of targeted groups receiving free indoor service among total discharge

patients was 2.54 in 2068/69 and 3.62 in 2069/70 (Source: Annual Health Report 2069/70, DHO,

Bardiya).

2.4.7 OPD-IPD CAREThe OPD, IPD and ER are essential components of the health service. Essential health

care services (emergency and inpatient) are provided free of cost to the poor, disabled, seniorcitizens and FCHVs in 25 bedded district hospitals; and PHCCs and emergency service to allcitizens at SHP/HP level. Curative services aim to reduce morbidity, mortality and to providequality health services by means of early diagnosis; adequate as well as prompt treatment andappropriate referral if necessary.

Fig. 2.9: OPD Services FY 2067/68 – 2069/70




The above diagrams shows that people’s visit in HFs are increasing in fiscal year 2069/70

compared to previous year 2068/69. The percentage of female patients is similar in the last three

years and percentage of communicable disease has increased slightly (2 %) in the year 2069/70

than previous year 2068/69.

2.4.8 Health Education, Information and Communication Program

IEC is the most important and valuable program of health system which helps and promotes

to have a healthy life and promotes positive behavior change in community people. It enhances

the accessibility of people to utilize health services. The DHO is actively involved conducting

various programs that produce and distribute IEC materials such as posters and pamphlets. In

this program, major activities are conducted like- FM broadcasting, interaction with community

people, printing and distribution IEC material, health promotion campaign, different health daycelebration.

2.4.9 Laboratory Services

Table 2.19: Utilization of laboratory services in Bardiya district

FYParasitology/Bacteriology Virology Hematology Histopathology Biochemistry

Immunology/Serology

OtherTests

2067/68

6740 8890 1451 2768 13

2068/69

4888/8165 16202 4162 6129 1111

2069/70 5353/12040 2979 20767 537 5160 8731/ 5

Above table shows that laboratory services are in increasing trend. It is due to expansion

of lab service in health facilities in Bardiya.

2.4.10 OCMC : One stop Crisis Management Centre

OCMC is a center to provide all the care needed in one place, including treatment of

injuries, shelter, psychological counseling, rehabilitation, negotiation with the family, legal




advice and protection. Basically, it is a patient centered management place because officers from

all relevant agencies will come to provide assistance once they are called.

Hospital based OCMC was established at District Health Office Bardiya in 2068/8/16

before inauguration of the centre. District co-ordination committee was formed in the

chairmanship of Chief District Administrator and also case management committee was formed

on guidelines developed by Ministry of Health and Population.

Table 2.20: Status of cases registered in the center (from establishment to now)

S.N. Type of Crime Numbers 1. Rape 292. Physical Assaults 273. Burns by others 5

Total 61

Out of the total 61 cases, three were cases of F/Y 2070/71. The data shows that rape case

in Bardiya is high as compared to others.

Table 2.21: Age wise distribution of the victims

Age interval Fiscal Year Number

2068/69 2069/700-5 0 0 06-10 2 2 411-20 7 7 1421-30 6 17 2331-50 0 13 1351 + 0 4 4Total 15 43 58

Table shows that age group 11-50 is mostly affected.

About 7% victims are below 10 years age. In the fiscal year 2068/69, only 15 victims

were registered in the center because the center started the work late in the fiscal year. In fiscal

year 2069/70, 43 cases were registered and managed in the centre.




B. PERIPHERAL INSTITUTION VISIT/ HEALTH FACILITY OBSERVATION2.5 Visits to Different Health Facilities

2.5.1 Swarahawa PHCC

a. IntroductionIt is located in Swarahawa VDC. This PHCC can be reached by a motorable road in

about thirty minutes from Gulariya District Hospital and kachhi road link with Highway. It was

established in 2032 B.S. in the form of HP and it was upgraded to PHCC in 2052 B.S. The

catchment areas of the PHCC include 7 VDCs which are:

Swarahawa

Jamuni

Mainapokhari

Motipur Belawa

Kalika

Deudakala

b. Resources

Physical r esour ces

The PHCC has 2 buildings: Administrative building

Service providing building.

The administrative building has store room, administrative room and two computer

rooms along with separate office.

The service providing building has registration room, emergency room, TB/Leprosy

(DOTS clinic), Laboratory, Dressing room, VCT counseling room and MCH (Family Planning,

ANC).The PHCC has capacity of three beds: one for labor and two for emergency. The PHCC

also provides the comprehensive abortion care service by trained nursing staffs upto 8 weeks.

Within the PHCC premises is also the quarter capable of accommodating three families.




H uman resource

Table 2.22: Human resource of Swarahawa PHCC

S.N. Post Sanctioned Fulfilled

1 Medical officer 1 02 H.A. 1 1

3 Sr. AHW 1 1

4 Staff Nurse 1 1

5 AHW 2 2

6 ANM 3 3

7 Lab. Assistant 1 1

8 VHW 1 1

9 Peon 1 1

Total 12 11

2.5.2 Motipur HP

a. Introduction

Motipur HP was established in Asar, 2050 BS as a SHP and was promoted to HP in Asar

7, 2070 BS. It is located in Bansgadi, Bardiya. Its catchment areas include ward no. 6 of Belawa

VDC, ward no. 3, 5 and 9 of Deudakala VDC.

b. Resources

Physical Resour ces

It has got 2 buildings; one storied each, one with 3 rooms and the other with 2. The

buildings have:

1 Office which also works as OPD

1 Dressing room 1 Store room

1 Labor room / Birthing centre

1 Employees room

The health post has 2 beds for examination.




H uman resource

All posts sanctioned for SHP were fulfilled.

Table 2.23: Human resource of Motipur HPS.N. Post Sanctioned Fulfilled

1. HA 1 1

2. AHW 3 2+1

3. ANM 2 1+1

4. Peon 1 1

Total 7 5+2




Chapter III

HOSPITAL PROFILE: BARDIYA DISTRICT HOSPITAL, BARDIYA

3.1 IntroductionBardiya District Hospital was established in 1991 B.S. Total area of this hospital is above

6 bighas. Though the hospital’s catchment area is whole district, because of its geographical

location it has been able to provide service to municipality and only few VDCs.

11 VDCs of Bardiya district are located on the other side of Geruwa river. So during

rainy seasons, accessibility to the hospital is difficult and people go to nearby hospitals. Because

of the close proximity to Nepalgunj and India, majority of the people seek health services in

Nepalgunj and Lucknow.

3.3 Capacity of the HospitalThe hospital was initially 15 bedded. During fiscal year 2061/62, hospital support

committee ( sahayog samitee ) was changed to hospital development committee and additional 10

beds were approved making the hospital 25 bedded.

3.4 InfrastructureThe hospital premises houses the following buildings:

a. Main hospital building (2 Block, New and Old)The main hospital building houses Emergency department, OPD, Dressing rooms,

DOTS centre, ART clinic, In-patient department, Labour room, Radiology room

and Operation Theatre

b. MCH building

c. Nepal Red Cross building

d. Store building

e. Laboratory building

f. Post mortem building

g. Staff buildings- 3 (2 Doctor quarters and 1 Nursing quarter)




3.5 Management and Other Facilities

3.5.1 Bardiya District Hospital Development Committee, Bardiya

A. Hospital Management Committee

President – Khem Prasad PoudelMembers – Officer of DAO (G PRa ka)

NRCS President

LDC Officer

Chief of Municipality

President of Chamber of Commerce

DEO officer

Nursing in-charge

Medical Superintendent

Female Representative from ward or nominated by president

B. Quality Control CommitteePresident – District Health Officer

Members – Medical Superintendent / Representative of Hospital

Nursing Incharge

Lab Technician (DHO)

HA, Public health nurse (DHO)

Statistical Assistant (DHO)

Consumers’ forum

NGOs of District / Nursing Home members

District Health Officer/Supervisor (DHO)

3.5.2 Financial Management (in FY 2069/70)

Table 3.1: Financial Management (in the year 2069/70)

Programme/ Activities BudgetAllocated

2069/70

Budget Released2069/70

BudgetExpenditure

2069/70Development

Committee- 34,81,621 37,40,838

Sadharan Anudan 13,17,000 14,01,967 14,01,967




3.5.3 Human Resource ManagementHuman resource and its management is the integral part of health care delivery system.

Local resource utilization is an important aspect in health care delivery system especially in the

peripheral areas where the manpower is usually lacking. Below is the list of human resources

working in Bardiya District Hospital.

Table 3.2: Human resource management in Bardiya district hospital

S.N. POSTS

GOVERNMENT CURRENTLY AVAILABLE

Sanctioned post

(in

number)

Fulfilled

(in

number)

Amonggovernmentsanction (in

number)

Local and otherresources

(in number)

Technical Staffs1. Medical Superintendent 1 0 0 02. Medical Officer 1 1 0 43. HA/Sr. AHW 1 1 1 04. Staff Nurse 4 4 4 05. Medical Recorder 1 1 1 06. Lab Technician 1 1 1 07. Radiographer 1 0 0 08. AHW 2 2 2 09. Lab assistant 1 1 1 010. ANM 2 2 2 011. Dark Room Assistant 1 0 0 0

Administrative (Non-Technical)1. Na.Su. 1 0 0 02. Kharidar 1 1 1 03. Ka. Sa. 9 4 4 0




3.6 Services Provided by the Hospital

The hospital provides following services:

a. OPD service

The OPD service is provided by the hospital 6 days a week from 10:00 am – 2: 00 pm.

The tickets for the OPD are available from 9:00 am – 12:00 pm. The price of ticket is NRs. 5.

The OPD is functioning in 3 different rooms and there is separate OPD service to the HIV/AIDS

patients through ART/VCT clinic. There are 2 separate dressing rooms.

b. Indoor service

There are 25 beds in the hospital out of which 6 beds are separated for malnutrition, 6 for

post-partum mothers and 2 for delivery. Remaining 11 beds are used as per the flow of patient in

the hospital.The admission charge is NRs 30, and patients are not charged for further stay in the

hospital.

c. Emergency service

The hospital provides 24 hour emergency service run by 6 staffs:

Emergency Room In-charge : Senior AHW

Senior AHW : 2

AHW : 3

HA : 1

There is a provision for 24 hour on call service by the medical officer who is the first

duty on call and there is no separate emergency lab but the lab assistant also works on call. There

are 8 beds altogether. The charge for the emergency admission is NRs 10.

d. Obstetrics services

This service is provided by the hospital for 24 hour throughout the week. The hospital

provides the service of normal vaginal delivery, vacuum delivery, forceps delivery and

Caesarean Section. There is an adequate supply of equipment and drugs for different procedures.There are 2 beds for delivery and 6 for post-partum mothers.




Table 3.3: Obstetrics services provided by Bardiya district hospital

Particulars 2066/67 2067/68 2068/69 2069/70

Total no. of deliveryconducted

669 916 857 718

No. of normal delivery 421 557 503 416

No. of Caesarian Section 248 359 354 302

Total live births 660 905 851 712

Total maternal deaths 1 0 1 0

(Source: MCH records, Bardiya District Hospital)

Service Deliverya. Morbidity pattern in OPD and Emergency

Fig. 3.1: Morbidity pattern in OPD and Emergency in FY 2066/67 - 2069/70

(Source: Annual report 2069/70, Bardiya District Hospital)

Number of patients in Emergency is in increasing trend in first three fiscal years and

slightly decreased in the last one. This is due to a number of reasons like increasing awareness

about health related problems in people, private hospitals reluctant to admit critical cases,

increasing Road traffic accidents, increased population, increasing popularity of essential health

30344

25757

22028

19369

3122 4089 4529 4050

0

5000

10000

15000

20000

25000

30000

35000

2066/67 2067/68 2068/69 2069/70

N o

. o

f p a t i e n t s

Fiscal Year

OPD

ER




care services, etc. The number of patients coming to OPD is decreasing primarily due to better

facilities available in nearby areas like Banke district and Lucknow, India.

Fig. 3.2: OPD visits in Bardiya district hospital

(Source: Annual Report 2069/70, Bardiya)

Most of the OPD cases are new one among which most are females. Fraction ofcommunicable disease is about one-fifth of total OPD new visit.

b. Mortality pattern among In-patients

2067/68 2068/69 2069/70 Trend( - or + )

Total Hospital Deaths 10 2 1-

The cause of death of patient in 2069/70 was COPD.

89.71

56.87

21.28

86.46

57.97

17.36

93.79

57.67

19.33

0

10

2030

40

50

60

70

80

90

100

Total new OPD visits as % oftotal OPD visits

Total new female OPD visits as% of total OPD visit

% of communicable diseaseamong total OPD new visit

2067/68 2068/69 2069/70




3.6.3 Institutional Services

a. MCH and Family Planning (FP) services:There is a separate building for MCH/FP service in the hospital, which provides services

in the working days. The services provided on different days are as follows:

Table 3.4: MCH and Family Planning (FP) services

Days Services

Sunday andMonday

ANC, TT, Counseling.

Tuesday Child immunization, HE, Nutrition and Counseling

Wednesday toFriday

FP (Temporary), HE and Counseling

b. ART/VCT Clinic:ART clinic was established in B.S. 2067, Mangsir. There are 3 staffs – ART counselor,

DAC co-ordinator and focal person (staff nurse), in ART clinic. The clinic runs for 10 am to 5

pm and is closed on Saturdays and public holidays. The services of the clinic are ART, VCT, STI

and PMTCT. The clinic has provided ART therapy to 48 HIV positives (till March 2014) out of

which 36 are currently under medication, 5 males died, 2 females died, 2 females were

transferred out and 1 male and 2 females discontinued therapy for unknown reasons.When patient is found ELISA positive he/she is referred to Nepalgunj for CD4+ count. If

CD4 count is low, medication is started and the patient is kept under observation for 15 days in

Nepalgunj. Then the patient is referred back to the ART clinic for the continuation of

medication.

c. DOTS and DOTS plus center:

There are two staffs in DOTS center – DOTS center incharge and focal person (AHW).

This center runs every day from 10 am to 5 pm. Both of these clinics are within the hospital

premises. Patients can receive TB treatment free of cost as instructed by the Ministry of Health.

National Tuberculosis Program started DOTS plus project for the treatment of MDR cases since

B.S. 2070, Magh. The DOTS plus center also provides service to the Leprosy patients.

There are 35 TB patients and 2 Leprosy patients. 3 out of 35 TB patients are MDR TB.




d. Safe abortion services:

2066/67 2067/68 2068/69 2069/70

Number of CAC Services Provided 7 63 102 81

3.6.4 Radiology and DiagnosticsX-ray and USG services are available in the hospital. There is 1 X-ray machine operated

by dark room assistant and 1 USG machine used by the General Practioner.

3.6.5 LaboratoryThe laboratory service is provided by the hospital in a separate building. Most of the

essential investigations are available. The service is provided throughout the week and sample is

collected from 10:00 am to 3:00 pm. Emergency investigation service is provided 24 hours a dayon call. The investigations available in BDH are as follows:

a. Biochemical Investigations

Na +, K +, Blood Sugar, Urea, Creatinine, Uric Acid, Total Bilirubin and Direct Bilirubin

b. Serological and Immunological Investigations:

Widal slide agglutination test, Blood HBs Ag test, VDRL test, TPHA test, RA factor test

and CRP test.

c. Hematological Investigations:

Total Count, Differential Count, Hemoglobin, Erythrocyte Sedimentation Rate, Platelets,

Blood grouping and Malarial Parasite test (free)

d. Other Investigations:

Routine and microscopic examination of urine and stool, Urine Pregnancy Test and

Sputum test (free)

Laboratory Equipments:

a. Microscope – 3 b. Water Bath – 1c. Hot Air Oven – 1d. Incubator – 1e. Colorimeter – 2f. Balance – 1g. Centrifuge – 2h. Shaker – 1




Table 3.5: Laboratory Services provided by Bardiya district hospitalS.N. Health Laboratory Services on Type ( in

Total Number ) 2066/67 2067/68 2068/69 2069/70

1. Parasitology/Bacteriology 1842 3751 3847 2448

2. Virology - 46 563 16863. Hematology 5918 6119 5846 45814. Microbiology 861 - - -5. Histopathology - - - -6. Biochemistry 955 737 1537 6387. Immunology/Serology 1625 842 919 9448. Other Tests - 7 66 5

(Source: Annual Health Report 2069/70, DHO, Bardiya)

3.6.6 Preventive and Promotive Facilitiesa. Immunization:

It is provided according to the national policy on immunization .

Table 3.6: Immunization services provided by Bardiya district hospital

S.N. Particulars No. ofDoses

Recommended Age

1. BCG 1 At birth or first contact

2. DPT, HEP B, Hib 3 6, 10, and 14 weeks of age

3. Polio 3 6, 10, and 14 weeks of age

4. Measles 1 9 months of age

5. TT 2 All Pregnant women Note – 5 doses of TT vaccine

during a woman’sreproductive life

6. JE 1 12 to 23 months

b. FP

c. Safe motherhood

d. TB DOTS and Leprosy centree. ART/VCT Centre

3.6.7 Post-mortem Services and Medico-legal ServicesBDH provides post mortem examination of medico legal cases as recommended by the

district police office. The post mortem is performed by a MO on duty. The toxicological samples




are sent to the forensic lab in National Academy of Science and Technology, Kathmandu for

further examination.

3.7 Physical Facilities

Table 3.7: Physical facilities available in Bardiya district hospitalNo. of sanctioned beds 25

No. of available beds 25

Functioning ambulance 1

Electric supply Inadequate because ofloadshedding(generatoravailable)

Water supply Adequate

Other essential facilities No ICU, CCU, NICU

General services Yes

Orthopedic services No

Medical services Yes

Surgical services Yes

Gynae/Obs services Yes

Pediatric services Yes

Dental services No

Pathology services No

Operation theatre Yes (1 minor and 1major)

3.8 Hospital EquipmentTable 3.8: Hospital equipments available in Bardiya district hospital

Equipment Number Equipment NumberX-ray 1 Refrigerator 3

Microscope 3 OT table 2Oxygen concentrator 2 OT lights 2Oxygen cylinder 8 Incubator 1ECG machine 2 Suction machine 2USG machine 1




3.9 Top 10 diseases in OPD (in terms of morbidity, FY 2069/70)

Table 3.9: Top 10 diseases in OPDS.N. Disease Percentage

1. Upper Respiratory Tract Infection 6.97%2. Impetigo/Boils/Furunculous 6.16%3. ARI/Lower Respiratory Tract Infection 4.82%4. Gastritis (APD) 4.81%5. Headache 4.36%6. PUO 3.94%7. Typhoid (Enteric Fever) 3.78%8. Intestinal Worm 3.39%9. Amoebic Dysentery 3.38%

10. Fungal Infection 3.17%(Source: Annual report 2069/70, Bardiya)

3.10 Top 10 diseases in In-patient department (in terms of morbidity)

Table 3.10: Top 10 diseases in In-patient department in FY 2069/70

S.N. Cases No.1. Incomplete abortion 812. Acute Gastroenteritis 803. COPD 564. PUO 395. Pneumonia 356. Enteric Fever 287. Severe Malnutrition 178. Burn 109. Chest Infection 710. Abdominal Pain/APD 5

(Source: Annual report 2069/70, Bardiya)




Chapter IV

AN EPIDEMIOLOGICAL STUDY OF MALARIA IN BARDIYA DISTRICT

4.1 IntroductionMalaria is a disease of tropics and subtropics all over the world. It is a vector borne

disease (VBD) transmitted by female Anopheles mosquito. Only 10 districts of Nepal are malaria

free so far and hence is still an endemic disease of Terai of Nepal. Bardiya is amongst the 13

highly endemic districts where global fund is actively supporting the government’s intense

malaria control program as Roll Back Malaria due to high case load.

It is caused by 4 different species of plasmodium, viz P. vivax, P. falciparum, P.

malariae and P. ovale . P. vivax is the predominant malarial parasite (approximately 10 times

more common than P. falciparum ) found in Nepal over the past few years (national malarial

treatment protocol, November 2004, Epidemiology and Disease Control Division). However the

exact proportion of this parasite species varies from place to place and air to air. P . malariae is

not so common in Nepal. P. ovale is found mainly in Africa.

P. falciparum causes a potentially fatal disease (cerebral malaria). Clinical condition of

the patient suffering from P. falciparum malaria suddenly deteriorates within 24 hours of

presentation of febrile illness. However, so is not the case with P.vivax which runs a relatively

benign course of the disease.Resistance of P. falciparum against currently available anti malarial drugs is an

increasing problem worldwide. Malaria control program in Nepal was initiated in 1954 through

the Insect Borne Disease Control Program, supported by USAID. In 1958 Malaria Control

Program, the first national public health program in the country was launched with the objective

of eradicating malaria from the country. Later it was reverted back to Malaria Control Program

in1978.

After intense reviews, the strategies were revised in accordance with the WHO Global

Malarial Control Strategy (GMCS) in 1983. Following the call of WHO to revamp the Malarial

Control Program in 1998, RBM initiative was launched to address perennial problem of malaria

in hard core forested, foothills, and inner Terai and valley areas of the hills, where more than 70

percent of total malarial cases in the country prevail. RBM was operational in 12 priority districts

and currently malaria control activities are carried out in 65 districts at risk of malaria. The




global fund is actively supporting Malaria Control Program in the high endemic 12 districts since

2004.

4.2 Case Definition1. Clinical Malaria: a person from malaria endemic area who presents with fever or history

of fever during last 3 days after the exclusion of other causes of fever.

2. Imported Case: a person with malaria who has a travel history to India in the past 6

months.

3. Indigenous case: a person with malaria who has not travelled to India in the past 6

months.

4. Relapse: a person with laboratory proved malaria showing symptoms of malaria after

completion of full course of treatment.

4.3 Indicators




4.4 National Treatment Protocol 2010/11Antimalarial drugs will be provided free of charge from all public sector health facilities.

Antimalarial drugs will be provided free of charge through the Female Community

Health Volunteer (FCHV) network in high risk area ( stratum 1 VDCs) and moderate risk area

( stratum 2 VDCs) according to national treatment guidelines.

Artemisinin-based combination therapy (ACT) will be provided for confirmed falciparum

malaria cases throughout the country (according to national treatment guidelines).

Chloroquine will be provided for confirmed vivax cases and suspected malaria cases

(according to national treatment guidelines).

Primaquine will be provided for the radical cure of confirmed vivax cases (according to

national treatment guidelines).

National malaria treatment guidelines will be reviewed regularly and revised as

appropriate based on the findings of drug resistance surveillance.

National malaria treatment guidelines (and any revisions to them) will be implemented at

all public sector health facilities throughout the country within one year of ratification by the

Regional Technical Advisory Group on Malaria (RTAG-M). Recommended antimalarials,

including ACT, will be incorporated into the essential drug list.

National malaria treatment guidelines (and any revisions to them) will be communicated

to private sector health care providers throughout the country within one year of ratification by

RTAG-M (through drug regulatory authority).

4.5 Rationale of the study

1. Malaria is one of the major public health problems in 65 districts of Nepal.




2. Bardiya is one of the 13 high endemic districts of malaria where global fund is assisting

RBM program.

3. Malaria Control Program is a national priority program.

4. Ecological determinants like hot and humid climate, low altitude, forest areas, frequent

flooding and stagnant water favoring breeding of the vectors of Malaria.

5. Being one of the border districts with India, there is high chance of cross border

importing cases.

6. An effective intervention carried out in the district has resulted in drastic decrease of case

load, morbidity and mortality.

4.6 Objectives of the study

4.6.1 General Objectivesa) To describe the epidemiological trend of malaria in Bardiya district.


a) To find out the magnitude of the disease in the district.

b) To describe disease in terms of time, place and person.

c) To describe the trend of the disease in the past 3 years.

d) To describe the clinical malaria cases in terms of time, place and person of 2070/71.

4.7 Methodology

1. Study area: DHO, Bardiya district

2. Study design: Retrospective study

3. Study duration: 3 weeks

4. Study technique:

a) Secondary data review

b) Entry register review

c) Interactions with the Vector Control Officer and Malaria Inspector in

DHO Bardiya

d) Interaction with medical officers in BDH

5. Study tools: observation check list, guidelines for interviews and discussions, format for

secondary data analysis




6. Data collection: source

a) Reports on malaria control, Vector Control Office, DHO, Bardiya

b) Discharge register review BDH

7. Data processing: manual processing, analysis and interpretation

8. Validity and reliability:

a) Consultation with − Mr. Bishnu Vaisya (Vector Control Officer, DHO,

Bardiya)

Mr. Balkrishna Sharma (Malaria Inspector, DHO,

Bardiya)

9. Study area:

a) Total population in district – 434,300

4.8 Findings and Analysis

The findings of secondary data analysis of Bardiya district are presented below.

4.8.1 Distribution by time

Fig. 4.1: Clinical malaria cases with respect to distribution by time

The above figure shows that the clinical malaria cases are high during rainy season.

738

1252

729

262 208115 75 93

197 171 198 257

N u m

b e r

Clinical Malaria Cases in 2069/70




Fig. 4.2: Slide positive cases of P. vivax with respect to distribution by time

Malaria parasite slide positivity is also seen more during rainy season.

5

6

8

1

3

1

0

6

5 5

6

9

N u m

b e r

Slide Positive Cases of P. vivax in 2069/70




4.8.2 Distribution by place

Fig. 4.3: Clinical malaria cases with respect to distribution by place

The highest number of clinical malaria cases was detected in Bhimapur SHP, whereas inBaniyabhar SHP and Neulapur HP the case detection was zero.

2027

334246

6168696974

9092

115121121

127131133135137

139142

166171

238261264

275276

300352

Rajapur PHCSorhawa PHC

Padanaha SHPDaulatpur HP

Taratal SHPDhadhawar SHP

Jamuni HPKhairi Chandanpur HP

Sivapur HPGola SHP

Thakudwara SHPMotipur SHP

Belawa HPMagaragadi PHC

Pasupatinagar SHP Nayagaun HP

Manau SHPBaganaha HPKhairapur HP

Mathura Haridawar SHP

Manpur Tapara SHPDeudakala HP

Suryapatawa SHPSanoshree HP

Patabhar HPDhodhari SHP

Kalika SHPBadalpur SHP

Mahamadpur SHPMainapokhar SHP

Bhimapur SHP

Clinical Malaria Cases in 2069/70




Fig. 4.4: Slide positive cases of P. vivax with respect to distribution by place

Slide positive P. vivax cases in health centers other than those in fig 4.4 were nil.

Fig. 4.5: Slide positive P. falciparum cases with respect to distribution by place

11

2

3

3

4

5

5

9

11

11

Belawa HP Nayagaun HP

Deudakala HP

Magaragadi PHC

SoS Medical Center

Jamuni HP

Rajapur PHC

Sanoshree HP

Patabhar HP

Baganaha HP

Neulapur HP

Slide Positive P. vivax cases in 2069/70

1 1 1 1

2

Magaragadi PHC Sorhawa PHC Neulapur HP Bardiya Hospital Rajapur PHC

N u m

b e r

Slide Positive P. falciparum Cases in 2069/70




There is disparity of clinical cases and slide positive cases between VDCs. Though high

number of clinical cases were found in Bhimapur SHP, slide positive cases were maximum in

Neulapur, Baganaha and Patabhar HPs.

Only a small proportion of the slide positive cases (6 out of 69) were caused by P.

falciparum. A 4 year old boy and 25 year old male were imported P. falciparum cases detected in

Ashwin and Mangsir respectively.

4.8.3 Distribution by person

Fig. 4.6: Distribution of slide positive malaria cases with respect to distribution by person

There is a huge burden in the age group 10-20 years and 20-30 years followed by 30-40.

The slide positive cases are higher in male population.

5

1312

9

6

5

2 2

1 1 1 1

2

01

00

2

4

6

8

10

12

14

0 - 10 1 0 - 20 20 - 30 30 - 40 40 - 50 50 - 60 60 - 70 70 - 80

N u m

b e r

Age and Sex wise Distribution of Slide positive Malaria(2069/70)

Male

Female




b) Trend of confirmed malaria cases over 3 years

Fig. 4.9: Trend of confirmed malaria cases over 3 years

The confirmed malaria cases have significantly declined over past 2 years.

c) Trend of P. falciparum cases over 3 years

Fig. 4.10: Trend of P. falciparum cases over 3 years

Only a small proportion of total slide positive cases were caused by P. falciparum.

120 124

69

0

20

40

60

80

100

120

140

67/68 68/69 69/70

N u m

b e r

Confirmed Malaria Cases Among Total Malaria Cases

612

6

120 124

69

67/68 68/69 69/70

N u m

b e r

P. falciparum Among Total Slide Positive Cases

P. falciparum cases

Total cases




4.9 Analysis of malaria cases in Bardiya district from Shrawan 2070 to Falgun 2070

A total of 913 clinical malaria cases in Bardiya district from Shrawan 2070 to Falgun 2070 were

taken from the district health office. The information gathered was then analyzed on the basis of time,

place and person.

a) Distribution by Time

Fig. 4.11: Clinical malaria cases with respect to distribution by time

Alike previous years, the clinical malaria cases are higher during rainy season (Shrawan,Bhadra and Ashwin).

401

211

123

6933

12 8

56

Shrawan Bhadra Ashwin Kartik Mangsir Poush Magh Falgun

N u m

b e r

Clinical malaria cases in 2070




b) Distribution by Place

Fig. 4.12: Clinical malaria cases with respect to distribution by place

This year more clinical malaria cases are identified in Dhodhari SHP followed by

Bhimapur SHP. Like previous years, clinical malaria cases are found to be high in Bhimapur

SHP.

343

1583

55

2239

414

5722

6140

44142

3587

79

113

0 20 40 60 80 100 120 140 160

Padanaha SHPKhairi Chandanpur HP

Sivapur HPGola SHP

Motipur SHPThakurdwara SHP

Belawa HPPasupatinagar SHP

Nayagaun HPManau SHP

Beganaha HPKhairapur HP

Mathura Haridwar SHPManpur Tapara SHP

Surayapatawa SHPDhodhari SHP

Kalika SHPBadalpur SHP

Mahamadpur SHP

Bhimapur SHP

Clinical Malaria Cases in 2070 Shrawan - Falgun




c) Distribution by Person

Fig. 4.13: Distribution of slide positive malaria cases with respect to distribution by person

This year there is high burden of confirmed malaria cases in age group 30-40 years and

20-30 years. Still confirmed malaria cases are higher in male population.

4.10 Conclusion

The annual slide collection is increasing (6801 in 068/69 to 7167 in 069/70).

Clinical Malaria Incidence is 10 per 1000 population which is decreasing in the last 3

years.

Confirmed malaria cases among total clinical malaria cases is 69 in 2069/70, which is

also decreasing in the past 3 years.

Bhimapur SHP is the area diagnosed with highest number of clinical malaria cases (352

in 2069/70) while Baniyabhar SHP and Neulapur HP have no clinical malaria cases.

There is a predominance of slide positive malaria in male population over female

population both with P. vivax and P. falciparum.

2

3

7

11

3

0

3

0 01 1

01

00

2

4

6

8

10

12

0 - 10 1 0 - 20 20 - 30 30 - 40 40 - 50 50 - 60 60 - 70

N u m

b e r

Age and Sex wise distribution of Slide positive Malaria cases (2070Shrawan - Falgun)

Male

Female




The age group <5 years diagnosed with clinical malaria is more than the age group >5

years.

The percentage of P. falciparum among total slide positive cases is 10.90% which is

almost same as that of previous years.

The percentage of indigenous cases among total slide positive cases is 90.32% which is

also same as that of previous years.

There are no reported deaths due to malaria since last 3 years.

There is a large disparity between clinical malaria cases and slide positive cases.

4.11 Limitations

Data were not well-managed which caused a major problem for the study.




Chapter V

CRITICAL ANALYSIS ON SOLID WASTE MANAGEMENT IN MID-WESTERNREGIONAL HOSPITAL

5.1 IntroductionSolid waste management is the generation, prevention, characterization, monitoring,

treatment, handling, reuse and residual disposition of solid wastes. Medical waste is one of the

most problematic types of wastes for a solid waste authority. When such wastes enter the

municipal solid waste stream, pathogens in the wastes pose a great hazard to the environment

and to those who come in contact with the wastes.

Ideally, these types of waste should be separated. However, separation is possible only

when there is significant management commitment, in-depth and continuous training of personnel, and permanent supervision to ensure that the prescribed practices are being followed.

Otherwise, there is always a risk that infectious and hazardous materials will enter the common

waste stream.

5.2 Rationale

Amount of the waste produced in the hospital is not quantified and there are no skilled

and trained human resources for the handling of waste management.

There is no authorized body for the waste management in such a regional hospital.

Unmanaged waste inside the hospital premises is itself a source of diseases.

Waste management is a top priority issue in any hospital.

There is no incinerator in Mid-Western Regional Hospital for management of hazardous

solid waste.

Though there isn’t any authorized body, a voluntary committee is working f or the waste

management and hospital cleanliness.

Since 2068/69 the voluntary committee is successful in establishing and running

earthworm farming in MWRH.

The hospital is putting special efforts in bringing glass cutter, plastic cutter and

incinerator in near future.




The committee in co-ordination with hospital is building biogas plant in the new hospital

building for the management of waste produced within the hospital.

5.3 Objectives5.3.1 General Objectives

To study the various aspects of solid waste management system in MWRH and critically

analyze the findings.


To identify the existing infrastructure and human resources for the solid waste

management at MWRH.

To identify various problems present and look for possible causes.

To obtain information regarding the training and expertise acquired by the working

personnel.

To analyze the impacts of waste management within the hospital premises.

To provide the recommendation to MWRH based on our critical analysis.

5.4 Methodology

Study Area: Mid-Western Regional Hospital, Birendranagar, Surkhet

Study Design: Descriptive

Study Duration: 3 weeks

Study Techniques:

a. Identification of Problem

Techniques ToolsObservationPhotography

Note KeepingCamera

Verify and Establish as a Critical Problem1. Further observation of waste disposal site2. Interview with the waste management in-

charge and medical superintendent

1) Observation Checklist2) Interview Guidelines/ Semi-

structured Questionnaire




b. Identification of the Underlying CauseTechniques Tools

Observation Observation Checklist/ Photography

Interview with MS/Involved Manpower Semi-structured Questionnaire

c. Identification of SolutionTechniques ToolsObservation Note KeepingInterview Interview GuidelinesDiscussion with hospital staff Discussion Guidelines

5.5 Sources of Information

1. In-charge of waste management committee and other members

2. Medical Superintendent

3. Sweepers and helpers of the hospital

4. In-charge of Emergency, In-patient, Out-patient, OT, Laboratory, Labor room and

Canteen

5. Other staffs

5.6 Findings

In this hospital, the categorization of solid waste is done as follows:

1. Combustible waste

2. Bio-degradable waste

3. Non-combustible and non bio-degradable waste

5.6.1 Sources of wasteWaste collected in the hospital comes from the following sources:

1. Wards, OPDs, Emergency, OT and laboratory.

- Sharps, glasses, dressings and bandages.

2. Operation theater and labour room

-Pathological wastes such as human tissues, placenta, body parts, dressings and band




3. Hospital canteen, patient parties

- Daily general waste (remains of food, paper, plastics, etc.)

5.6.2 Collection of wasteAll the solid waste generated within the hospital premises is collected in dust bins with

specific color coding system implemented by hospital for the last 3 years. These dust bins are

kept in each and every ward, OPDs, emergency, laboratory, pharmacy, OT, and around the

hospital premises.

Color coding of the dust bins:

Color Type of WasteRED Hazardous waste other than sharps and syringesGREEN BiodegradableBLUE Combustible

The hospital uses SAFETY BOX for the collection of the sharps and syringes which is

provided by the government of Nepal. If safety box is not available then the hospital uses the

Yellow color bins for the collection of these wastes.

5.6.3 Transportation of waste

The wastes collected were taken to the disposal site manually, by the sweepers and peonsof the hospital once daily at the end of the day or as soon as the dust bins get full.

5.6.4 Storage of waste

Since wastes were taken at the end of each shift and disposed off, no such provision for

storage was in place.

5.6.5

Disposal of wasteThe wastes produced by the hospital are disposed off according to the type of the waste.

1. Combustible waste

There is an open pit of size 10x10x10 cubic feet where all the combustible wastes are

dumped and burned up.




2. Bio-degradable waste

The disposal of bio-degradable wastes goes through specially designed earthworm

farming. This system is in use since 2 years. Approximately 2000 earthworms were

bought at the beginning which has now increased to more than 20,000 in number.

There are 8 containers for the collection of bio-degradable wastes and each is filled daily.

The lid is closed in the filled container and is soaked in an Em (effective micro-

organisms) fluid for 1 week. Then the container is opened and dumped in an especially

designed pit with compartments where underneath lie the earthworms. The manure

produced is used in agricultural purposes (viz. gardening) within the hospital premises.

3. Non combustible and Non bio-degradable waste

These kinds of wastes are filled in a big pit which is dug within the hospital premise. The

wastes are disposed off and as the pit fills up, it is closed with mud.

4. Placenta pit

There is a separate placenta pit for the disposal of the placenta. This pit is also used for

the disposal of other body tissues produced from surgery.

5.6.6 Management

To put any sets of tasks into proper perspective, there needs to be a co-ordinated

approach to the action. Though MWRH runs a waste collection and management committee,

which is a voluntary committee, waste management isn’t a prioritized issue here.

a) Staffing

Sweepers and Peons

All the staffs of the hospital work together voluntarily every Friday for hospital

cleanliness and awareness




b) Facilities

Colour coded buckets in each and every ward, Operation Theater, labour room,

OPDs, emergency, corridors, etc.

c) Budgeting

No budgeting on separate head on waste management

5.7 Strength Weakness Opportunity and Threat (SWOT) Analysis

Table 5.1: SWOT Analysis

Issues Strength Weakness Opportunities ThreatCollection ofwaste

Different colorcoded dustbinsavailable in alldepartments andaround thehospital premises

Patients andgeneral peopleare unaware ofthe color codingsystem

Information board should be placed at various places within thehospital

Haphazardcollection ofwaste; morehumanresourcesrequired toseparate thewaste again

Transportationof waste

Transported ondaily basis orwhen the bins arefilled

Safe handlingduringtransportationnot done

Gloves andmasks for safehandling should

be madeavailable

Increased riskof injuries andinfection tohandlers

Storage ofwaste

Stored inrespectivedustbins untiltransported;Dustbins are

placed inappropriatelocations and areaccessible

Not all dustbinsare closed;Some of themleak;Foul-smellaround the leakyand opendustbins

Replacement ofolder bins withnew ones and useof closeddustbins

Waste Disposal Disposal site Accessible

within thehospital premises

Disposal sites just behind theEmergency block

Disposal pits can be relocatedaway from thehospital blockwithin thehospital premises

Increased riskof spread ofinfection inEmergencyvisiting patients

Pits Separate pitsavailable fordifferent types ofwaste;

Pits are openexcept for

placenta pits; New pits are to

Pits have to besealed or closed;Large sized pitscan be made;

Becomes thesource ofinfection;Wastes could be




Separateearthworm housefor

biodegradablewaste

Separate placenta pit for placentaand human tissuewaste;Separate pit forcombustiblewasteSeparate pit fornon-combustibleand non-

biodegradable

waste

be dug once it isfilled;Pits are fenceless

Fence/Wallsaround the pitscan be made

washed away byrain;People/childrenmay fall down

Incinerator Broken/Notfunctional

Broken one can be repaired

Air pollution

Disposal process Biodegradablewaste

Waste goesthroughearthwormfarming system

Earthworm pitsare open;Time consuming;Size of drums aresmall

Compost manurecan be sold orused for

plantation andgardening

Combustiblewaste

Burned everyday Plastics are also burned in the

same pit

Hospital is planning to buy

plastic cutter inthe near future

Air pollution

Non-combustibleand non-

biodegradablewaste

Separatelydisposed in pit;Plastic bottlesand saline bottlesare sold

Pits are notclosed properlywhen filled;All the hazardouswaste aredisposed in thesame pit

Hospital is planning to buyneedle and glasscutter in the nearfuture;Pits can be

properly dumpedand sealed

Land is wasted;Increased riskofenvironmental

pollution

Manpower A waste

managementcommittee is present which isworkingvoluntarily;All the staffs ofthe hospital worktogether

Paid staffs are

not allocated bythe hospital;Lack of skillfulvolunteer forhandling ofwaste

Separate paid

staffs can beallocated by thehospital;Training to thestaffs forhandling ofwaste;Increased use of

Voluntary

committee istemporary;Increased riskof injuries andinfection tounskillfulhandlers




voluntarily everyFriday forhospitalcleanliness andawareness

gloves and maskduring handlingof waste

Budgeting Not allocated Should beallocated Wastemanagementcommittee willnot besustainable inthe absence of

budget

5.8 Conclusion

The hospital does not have adequate infrastructure required for waste management.

There is inadequate number of skilled and trained human resources.

There is no authorized committee working for waste management of hospital and no

budget is allocated for the voluntarily working committee.

The openly disposing system within the hospital premises is posing a serious threat to the

health and environment around the hospital.

Lack of information about the color coding system inside the hospital is causing mess

during collection and disposal of waste.

The works done by the voluntary committee regarding waste management is exemplary

and is praised and appreciated by everyone.

The earthworm farming running in the hospital is very productive and environment

friendly.

5.9 Recommendations

As the hospital is being expanded and shifted in a new building, it is mandatory to have a

proper waste management system.

The infrastructure and trained human resources need to be increased.

Separate budget needs to be allocated for waste management.

The basic equipments and facilities for waste management should be fulfilled

accordingly.




The information regarding color coding system should be provided to everyone.

A sustainable waste management committee needs to be formed.

The hospital needs to help and motivate the voluntary committee working for waste

management.

Hospital can set an example to others by making earthworm farming more sustainable.




Chapter VI

FIVE YEAR PLAN ON DIARRHOEAL DISEASE CONTROL IN HDCS-CHAURJAHARI HOSPITAL, RUKUM

6.1 Introduction

World Health Organization (WHO) has defined diarrhea as having three or more loose or

liquid stools per day, or as having more stools than is normal for that person. Diarrhoea is caused

by a variety of micro-organisms including viruses, bacteria and protozoas. Diarrhoea causes a

person to lose both water and electrolytes, which leads to dehydration and, in some cases, to

death.

Table 6.1: Various types of diarrheal diseases

Type of Agent OrganismsToxin in food Bacillus cereus, Clostridium spp., Staph. Aureus

Bacterial Vibrio cholerae , Enterotoxigenic , E. coli, Shiga toxin-producing E. coli,

EIEC, Campylobacter jejuni, Clostridium difficile

Viral Rotavirus, Norovirus

Protozoal Giardiasis, Amoebic dysentery, Cryptosporidiosis

Diarrheal disease is still a leading cause of morbidity and mortality in country like Nepal.

Diarrheal diseases control program is functioning since 1983 with the aim to controlling the

morbidity and mortality due to diarrheal diseases within the country. Moreover, recognizing

diarrheal diseases as one of the major public health problems among children under five in

Nepal, the National Control of Diarrheal Diseases Programme (NCDDP) has been accorded high

priority status by GoN and is an integral part of Primary Health Care.

Standard diarrhoea case management with Oral Rehydration therapy, continued feedingand zinc tablet is provided in the health institutions by establishing Oral Rehydration Therapy

(ORT) corners in all Hospitals, Primary Health Care Centres, Health Posts and Sub Health Posts

throughout the country. All health facilities and community health volunteers serve as the

primary health providers in the treatment of Diarrhoea with low osmolar Oral Rehydration

Solutions (ORS) with Zinc supplementation.




6.2 Recent indicators of diarrheal diseases in Rukum district

6.2.1 Incidence of Diarrhea /1000 Population

Fig. 6.1: Incidence of Diarrhea/1000 Population

6.2.2 Percentage of severe dehydration among total cases

Fig. 6.2 Percentage of severe dehydration among total cases

522

-

518

2067/68 2068/69 2069/70

Incidence of Diarrhoea / 1000 Population

0.9% 1%0.68%

2067/68 2068/69 2069/70

Percentage of severe dehydration among totalcases




6.2.3 Proportion of CDD cases treated by FCHV

Fig. 6.3: Proportion of CDD cases treated by FCHV

6.2.4 Proportion of CDD cases treated by VHW/MCHW

Fig. 6.4: Proportion of CDD cases treated by VHW/MCHW

6.2.5 Proportion of CDD cases treated by HF

Fig. 6.5: Proportion of CDD cases treated by HF

33.67%

40%39%

2067/68 2068/69 2069/70

Proportion of CDD cases treated by FCHV

18.52%

25%21.37%

2067/68 2068/69 2069/70

Proportion of CDD cases treated by VHW/MCHW

47.79%

35%39.58%

2067/68 2068/69 2069/70

Proportion of CDD cases treated by HF




6.2.6 Diarrhea cases treated with Zinc and ORS

Fig 6.6: Diarrhea cases treated with Zinc and ORS

6.2.7 Number of <2 months children treated in HFs

Fig. 6.7: Number of <2 months children treated in HFs

6.3 Rationale

1. Diarrheal disease is one of the major public health problems of Rukum district.2. Diarrheal disease ranks first among diseases in terms of morbidity in HDCS-

CHAURJAHARI hospital and is among the top five diseases in Rukum district.

3. The incidence of the disease seems to have a static trend in the previous three years and it

continues to be a significant problem.

100% 100% 100%

2067/68 2068/69 2069/70

Diarrhoea Cases Treated with Zinc and ORS

793794

783

2067/68 2068/69 2069/70

Number of <2 months children treated in HFs




4. Diarrheal disease incidence in the district continues to surpass the incidence of the nation

and the mid-west region.

5. Diarrheal diseases can be prevented by using available resources in the community.

6. Diarrheal diseases can be managed (diagnosis, treatment and referral) at the community

level by FCHVs, VHWs and MCHWs.

7. Diarrheal diseases have been given priority at national as well as regional levels and

decreasing the morbidity and mortality due to it can bring about special benefits in terms

of health status and economy.

8. Diarrheal disease is a significant cause of morbidity and mortality in children under five

years of age and controlling it can help in achieving the millennium development goal.

9. CB-IMCI addresses diarrhoea as one of the five major killer diseases in children.

6.4 Methodology

The selection of topic for developing five year plan was done by review of Annual report

of DoHS and interview with Chief Administrator, medical doctor and focal persons of HDCS-

Chaurjahari hospital.

Situational analysis on status of CDD in the district was done by taking secondary data

from record review of annual report of DPHO. With the goal of improving the health of all

children in Rukum district and ensuring that no child dies of diarrheal diseases, objectives,

targets, strategies and activities were set. Based on the information collected, Logical framework

matrix was designed.

6.5 Goal

Assuring no morbidity, mortality and no disability due to Diarrheal diseases in Rukum

district through promotive, preventive and curative services and help develop a healthy

population.

6.6 Objectives

6.7.1 General

To reduce morbidity and mortality due to diarrheal disease and dehydration in Rukum

district.




6.7.2 Specific

To reduce the Diarrheal disease related morbidity and mortality by increasing awareness

in the community.

To reduce the Diarrheal disease related morbidity and mortality through proper diagnosis

and treatment.

6.7 Target

To reduce incidence of diarrheal disease/1000 population from 518 to 259 i.e. by 50%.

To reduce the percentage of severe dehydration among total cases from 0.68% to zero.

To maintain the diarrhea cases treated with zinc and ORS at 100%.

To double the proportion of CDD cases treated in health facilities from 39.5% to 79%.

To double the proportion of CDD cases treated by FCHVs from 39% to 78%.




6.8 Problem Tree

Fig. 6.8: Problem tree of high morbidity due to diarrheal diseases

6.9 Strategies

6.9.1 Promotive

Spreading awareness through public health campaigns in the community.

Spread awareness through health awareness programs in schools and colleges.

Advocacy and lobbying for promotion of diarrhea related activities in Rukum district.

Promotion of environmental sanitation programs.

Training to the health care providers.

High Morbidity Due To Diarrhoeal Diseases

Consumption ofcontaminated water and

Lack of proper healthcare facilities

Pooraccess to

Poor sanitation andhygiene

Contaminated water and

- Lack of properwastemanagement

- Opendefecation

- Remotedrinking waterresources

- Lack of provision of tapwater fordrinking

purpose

- Poor hygiene practices

- Inadequatesanitationfacilities

- Lack of properdrainage

- Lack of trainedmanpower

- Inaccessible healthfacilities

- Lack of good referralsystem

- Inadequate drugs fortreatment of disease

Illiteracyand

unawarenes

Poor planning

Inadequatehealth

facilities

Loweconomy

Cultural beliefs




Orient community leaders including DDC and VDC members and faith healers.

Develop IEC materials as and when necessary.

Supervise/Monitor at all levels and provide feedback accordingly.

Development of the proper drinking water facility in the district.

Spreading awareness on the use toilet and hand washing.

6.9.2 Preventive

Encourage public for safe drinking water.

Use of healthy food consumption.

Self Protection Strategies (Personal Hygiene)

6.9.3 Curative

Management of Diarrheal diseases cases according to WHO guidelines

Supply adequate drugs for treatment of Diarrheal diseases in all health institutions

and FCHVs.

Provision of ORT and Zinc supplementation in the management of the diarrheal

disease.

Provision of grading of dehydration and appropriate treatment.

Provision of good referral system.

Capacity building of the HDCS-Chaurjahari Hospital to manage large number of

cases.

6.10 Activities

6.10.1 Phase divisionTable 6.2: Phase division

Phase I Committee formation and Planning One yearPhase II Implementation Three yearsPhase III Re-assessment and Evaluation One year




6.10.2 Formation of Diarrheal control program central committee

a. Members District Health Officer - Chairperson

Medical Superintendant (District Hospital)

Hospital Director (HDCS-CHR Hospital)

Local Development Officer

District Development Officer

District Education Officer

Representatives from NGOs, INGOs

Representatives from HPs, SHPs, PHCCs

Representatives from FCHVs

Rep resentatives from Mothers’ Groups

Advisory Board

o Medical Officers

o Public Health Officials

b. Functions of the committee

1. Formation of policies

2. Formation of different units and coordinating their activities

3. Identification of target groups

a. Children

b. Mothers’ group

c. Health workers at all levels

d. Faith healers

e. Community leaders

f. Schools4. Assessment of resources

a. Human Resources

i. Human Development and Community Service (HDCS) Chaurjahari

hospital, Rukum and its staff

ii. Rukum DPHO and its staff




iii. Rukum district hospital and its staff

iv. 2 PHCCs and its staff

v. 25 HPs and its staff

vi. 27 SHPs and its staff

vii. 387 FCHVs

viii. Mothers group, faith healers, members of youth clubs

ix. VDC chairmen, members of VDC and VDC staff, staff of locally operating

NGOs/INGOs/international aid agencies

b. Financial resources

i. DPHO

ii. HDCS Chaurjahari hospital

iii. NGOs/INGOsiv. Municipalities and VDCs

c. Logistics

i. IEC materials

ii. Stationeries and transportation

iii. Training venues

iv. Drugs

5. Monitoring

6. Establishment of diarrheal disease ward in the district hospital

6.10.3 Formation of Units

A. Information Education Communication and Training unit

This unit will be responsible for developing manuals and curriculum related to various

aspects of Diarrheal diseases for health education and training. Training of health workers

will be conducted at all levels. In the first one and half years of second phase, training of all

the target groups will be conducted and during the next two years guidelines will be

implemented. During this period regular supervision and monitoring of the activities will be

done and additional training sessions will be conducted as required.

Risk Awareness Program (RAP) will be conducted to spread awareness about the

importance of nutrition, hand washing, healthy food habits, oral rehydration solution, zinc




supplementation, safe drinking water, Vitamin A supplementation, breast feeding,

Immunization,

The unit will specify a date to be celebrated as Diarrheal Disease Control Day annually

in the district. On this day, health education programs will be conducted regarding risk

factors, prevention and management of Diarrheal diseases. Also, free drug distribution and

rally including scho ol children, mothers’ group, community leaders and health workers will

be held. Essay and quiz competition, street drama and role play among school children will

also be held on the same day.

The unit will also organize door to door awareness program regarding Diarrhealdiseases with the help of FCHVs, VHWs, MCHWs, youth clubs and school children.

Interaction programs between the unit and different groups of people will be held.

Table 6.3: Training activities

Training for Training objectives Trainer Setting

Frequency

ctors from districthospital, HDCS-CHR hospital andPHCC

nagement of diarrhealdiseases and severedehydration

erts HO arly

dical staff of

PHCC(excludingdoctors), HPs andSHPs

nagement of Diarrheal

diseases cases based onWHO guidelines

ctors from district hospital,

HDCS CHR hospital andPHCC

CC f yearly

Ws and MCHWs gnosis, treatment andreferral of diarrhea cases

dical staffs ofPHCC(excluding doctors),health posts and sub health

posts

CC f yearly

FCHVs gnosis, treatment andreferral of diarrhea cases


posts

CC f yearly

thers’ group cation regarding risk

factors, signs, symptoms,danger signs and propermanagement of Diarrheacases

HVs al set up f yearly

th healers cation regarding diagnosisand timely referral ofdiarrhea cases


posts

CC, HP,SHP

arly

ool teachers cation regarding risk dical staffs of CC, arly




B. Administrative and Logistics Unit

This unit will be responsible for conducting the following activities:

a. Keeping records of financial transactions.

b. Record keeping of logistics.

c. Provision of human resources (trainers and trainees)

d. Provision of logistics

i. Drugs

ii. ORS and zinc supplementation

iii. Stationeries and transport facilities

C. Monitoring and Supervision unit

This unit will monitor and supervise activities. It will observe and record the

activities, identify deviations and take corrective actions.

Monitoring of the following activities will be done:

I. Attendance percentage

II. Total numbers of trainings conducted

III. Total number of drugs distributed

IV. Total number of ORS distributed

V. Assessment of the knowledge of trainees after the training by using

questionnaires

6.10.4 Evaluation of the program

Evaluation of the program will be done based on following indicators:

Table 6.4: Indicators of CDD

ain Indicators Numerator and Denominator

factors, prevention andtimely management ofdiarrhea cases

PHCC(excluding doctors),health posts and sub health

posts

HP,SHP

uth groups(clubs),dents of secondaryand highersecondary levels

cation regarding riskfactors, prevention andtimely management ofDiarrhea cases


posts

ools f yearly




Incidence ofdiarrhea/1000

population

Total diarrheal cases in one yearTotal population in the same year

X 1000

Percentage ofseveredehydrationamong totalcases

Total number of severe dehydrationTotal diarrheal cases in the same period

X 100

Proportion of CDDtreated byFCHVs

Total number of diarrhea cases treated by FCHVsTotal diarrheal cases in the same period

X 100

Proportion of CDDtreated byVHWs/MCHWs

Total number of diarrhea cases treated by VHWs/MCHWs Total diarrheal cases in the same period

X 100

Proportion of CDDcases treated by

HF

Total number of diarrhea cases treated in HF Total diarrheal cases in the same period

X 100

Diarrhea CasesTreated withZinc and ORS

Total number of diarrhea cases treated with Zinc and ORS Total diarrheal cases in the same period

X 100

6.11 Budgeting of five year plan of Control of Diarrheal Disease Program(Based on interviews with the concerned authorities and the annual budget allocated

for the district by the Government of Nepal.)

Table 6.5: Budgeting of five year plan 1. Committee Formation and Planning Rs. 50,000

2. Administrative and Logistic Unit

Purchasing furniture Rs. 50,000Stationeries and Transport Rs. 1,80,000Drugs Rs. 25,00,000

3. Training

Activities Targetmanpower

Numberofmanpower

Dailyallowances

Numberof days

Number ofactivities (inPhase II)

Total (in NRs.)

Training program

a. Trainer(expert)

b. Doctors

1

8

3000

500

1

1

1 x 3 = 3

3

9,000

12,000Training

program a. Trainer(Doctors)

1 700 2 2 x 3 = 6 8,400




b. H.A. c. AHW d. Nursingstaff

154719

500500500

222

333

45,0001,41,00057,000

Training

program

a. Trainer

(Medicalstaff ofPHCC, HP,SHPexcludingdoctors)

b. VHWs c. MCHWs d. FCHVs e. Mothers’group

5

4334387

500

200200200

3

333

2 x 3 = 6

333

45,000

77,40061,2006,96,60020,000

Training program a. Trainer(Medicalstaff ofPHCC, HP,SHPexcludingdoctors)

b. Schoolteachers c. Studentsand youth

groups

5 500 1 1 x 3 = 3 7,500

Refreshment for orientation and training program

4,20,000 (4086 x 100; + misc.)

Travel Allowance 75,0004. IEC Unit

Publication of IEC materials (Posters,Pamphlets, Leaflets, Flip charts, Hoarding

boards, etc.)

70,000

Distribution of IEC materials (allowances andrefreshment for volunteers)

45,000

Media advertisement (TV, Radio, Newspaper) 1,50,000School Health Program (Quiz competition,Essay competition, etc.)

15,000

Training Manuals 40,000Seminars and workshops 50,000CDD Day 25,000Door to door awareness program 25,000Rally 10,000




5. Supervision, monitoring and evaluation

Field visits 35,000Review meetings 30,000Provision of record forms andreports

25,000

Provision of feedbackquestionnaires

15,000

Evaluation meeting at districtlevel

10,000

6. Preparation of Field Report Rs. 1,00,000

7. Establishment of Diarrheal Diseases ward Rs. 2,00,000

8. Miscellaneous expenses Rs. 1,00,000

Total budget of five year for control of diarrheal diseases 2014 -2018 is Rs. 54,00,100

6.12 Logical Framework Analysis

The Logical Framework Approach (LFA) is a tool – or rather an open set of tools – for

project design and management. Its purpose is to provide a clear, rational framework for

planning the envisioned activities and determining how to measure a project’s success, while

taking external factors into account.

Table 6.6: Log frame matrix

Narrative Summary Objectively VerifiableIndicators

( OVIs)

Means OfVerification (MoV)

Assumptions

GoalTo decrease themorbidity of diarrhealdiseases and assuring nomortality.

▪ Incidence▪ Prevalence▪ Percentage of severedehydration

▪ KAP Assessment

▪ Annual DistrictHealth Report

▪ Final Report of 5year plan

▪ Political Stability▪ Financial

Adequacy

Purpose

1. To reduce number ofnew diarrheal cases

▪ Annual Incidence▪ Percentage of diarrhoea

among IMCI cases▪ Number of Public

Awareness Campaigns

▪ Annual Report of

DPHO▪ Annual Health

Report▪ Reporting from

Awareness ProgramConductors

▪ Surveillance

▪ Concerned

authorities support/involvement

▪ Proper Reportingand Recording

▪ Support of donoragencies fortraining programs




Authorities Records▪ Reporting from

laboratory

▪ Financial adequacyto provideincentives andfacilities to staffs

2. To reduce diarrhoearelated dehydration

Proportion/percentageof diarrhoea withdehydration

▪ Annual Report ofDPHO

▪ Hospital Records

▪ Prompt treatmentfacilities.

▪ Adequate trainedmanpower,infrastructure/resources

3. To prevent diarrhoearelated mortality

▪ No. of deaths due todiarrhea and severe

dehydration▪ CFR

▪ Annual HealthReport of DPHO

▪ Hospital Records

▪ Good recordingand timely

reporting system▪ Adequate facility,

infrastructure,manpower to

provide prompttreatment to

prevent deaths▪ Preparedness to

manage epidemics4. To establish properdiagnosis andmanagement protocol

▪ Number of trained healthworkers

▪ Number of trainingsessions to healthworkers

▪ Number of treated cases▪ Number of referrals▪ Mortality Rate▪ CFR

▪ Annual Reports ofDPHO

▪ Hospital records▪ Minute Books ofTraining sessions

▪ Competency of themedical personnelat all levels

▪ Availability ofgood qualityservices at healthfacilities

▪ Adequatemanpower andfinancial strength

to train healthworkers

▪ support fromhospitaladministration andgovernment

Output ▪ Annual Incidence Rate ▪ Annual Health ▪ Trained manpower




1. Reduction in numberof new diarrheal cases

by 50%.

▪ Percentage ofDIARRHOEA amongIMCI cases

Report of DPHO ▪ Finance▪ Safe drinking

water▪ Environmental

sanitation2. Reduction in

percentage of severedehydration among newcases from 0.68% tozero.

▪ Case detection Rate▪ Percentage of

DIARRHOEA amongIMCI cases

▪ Annual HealthReport of DPHO

▪ SurveillanceReports

▪ Lab reports

▪ Proper Reportingand RecordingSystem

▪ Lab technician▪ Reliable

SurveillanceStrategy

3. Maintain the percentage of casestreated with ORS at100%

▪ Written protocol ofdiagnosis

▪ Written protocol ofmanagement

▪ Protocol for referral

▪ Annual HealthReport

▪ Record Books

▪ Coordination withHealth facilities

▪ Motivated andtrained health care

providers

4. ▪ Immunizationcoverage rate

▪ Drop-out rate


▪ DPHO report

Activities15 day training program

for peripheral levelhealth workers

▪ Number of trainees ▪ Minute book oftraining period

▪ Assessment ofknowledge oftrainees at end oftraining period

▪ Qualified trainers▪ Motivated trainees

IEC materialDistribution

▪ % of IEC materialsutilized

▪ Number of occasionsand places ofdistribution

▪ Population receivingIEC materials

▪ Annual RecordBook

▪ Enough IECmaterials

▪ Standardized IECmaterials

Public awareness on ▪ Number of awareness ▪ Minute books ▪ Adequate resources




environmental sanitation programs▪ Number of VDCs where programme wasconducted

▪ Number of participants▪ Number of healtheducation programs

▪ Annual record books ▪ Finance

Safe drinkingwater/Chlorination

▪ Number of householdssupplied of chlorine

▪ Chlorine distributionregister

▪ Amountconsumed/record

▪ Adequate finance▪ Aware people

Lab test of water ▪ Number of samples sentfor test

▪ Number of positivesamples

▪ Lab reports ▪ Adequate finance▪ Trained manpower

Healthy foodconsumption/preparationtraining

▪ Number of participants▪ Number of trainingsessions

▪ Minute books ▪ Trained manpower

School/ College HealthProgram

▪ Number of sessions▪ Number of participants

▪ Minutes▪ Reports from

school/collegewhere the sessionwas organized

▪ Adequatemotivation toschool or college

▪ Adequatelymotivated students

Public Awareness ▪ Number of awareness program

▪ Numbers of VDCswhere program wasconducted

▪ Number of participant▪ Number of educators

▪ Minute books▪ Annual Record

Book

▪ Adequateresources

Refresher trainings tocare providers

Number of trainees▪ Number of sessions

▪ Minute book oftraining

▪ Adequate resources

Capacity building ofHDCS-CHR Hospital

▪ Number of beds fordiarrhea andsevere/dehydration

patients▪ Number of doctors for

diarrhea and

▪ Hospital records▪ Annual Health

Report

▪ Support fromgovernment

▪ Donor's support




dehydration cases▪ Number of cases

treated each yearStrengthening of EPI

(measles vaccine)

program

▪ % of increase incoverage

▪ % of decrease indrop-out rate


▪ DPHO report

• Smooth supplyof vaccines and

logistics• Proper recording

and reportingsystem

6.13 Conclusion

• Reducing the burden of Diarrheal diseases in the district requires combined efforts from

higher level officials to health workers at community level (FCHVs, VHWs, MCHWs).

• Awareness regarding Diarrheal diseases in the community (especially among mothersand child caretakers) plays a key role in prevention and prompt treatment of the disease.

• Early diagnosis and appropriate treatment can help reduce diarrhea and dehydration-

related mortality in the community.

• Adequate supply of drugs and other materials should be maintained to treat the cases in

time and avoid complications.

• Adequate supply and proper use of ORS and Zinc supplementation should be maintained

to treat diarrhea and dehydration.• The development of hospital and strengthening its facilities, which is chiefly concerned

from the financial point of view for staffing and providing logistics, has to be supported

by lobbying at various levels.

• Regular supervision and monitoring is mandatory for fulfillment of objectives in

accordance with the five year plan.

6.14

Problems / Constraints

The following problems / constraints can be faced during the implementation of the program:

1. Difficulty in acquiring sufficient budget.

2. Timely conduction of activities.

3. Mobilization of human resources and logistics.




4. Timely supervision and monitoring.




Chapter VII

RECOMMENDATIONS

To the Department:

• To increase monitoring and direct supervision of students’ activities in field to at leastonce in each district.

• To focus more on practical aspects of the work to be done in the field.• To manage inter-district transport facilities for students.

To DHO and Bardiya District Hospital, Bardiya:

• To work in collaboration with the DDC to empower and uplift the education and healthstatus of Bardiya district.

• To continue the health programs being run by DHO and emphasize on LLIN distribution.• To add pathological services in laboratory so as to diagnose and treat more diseases in the

hospital without having to refer elsewhere.

To Mid-Western Regional Hospital, Surkhet:

• To form a sustainable waste management committee and allocate separate budget for it.• To sustain and expand earthworm farming which is biological and environment friendly

method of waste management.• To repair the broken incinerator so that hazardous waste can be well managed.

To HDCS-Charujahari Hospital, Rukum:

• To work in collaboration with all the health-care providers in the district for successfullyreducing the burden of Diarrhoeal diseases in the district with the feasible long term plan.




Chapter VIII

LEARNING REFLECTIONS

The District Health System Management field was a great experience for us ‘to -be

doctors’ to learn about the health care delivery system in different districts of Nepal in terms of

accessibility, service delivery, effectiveness and limitations. We had the opportunity to know

about the different health programs run by the DPHO/DHOs as well as about their organograms,

manpower and administration of different health institutions under them. We also learned about

the reporting and logistics management systems of health facilities in the district and the

importance of the efficiency of such systems. This exercise also provided us with the opportunity

to observe the coordination among different health related organizations working in the districts

and also differences in infrastructure, manpower and service delivery of different hospitals

(zonal, district and private/community hospitals).

Apart from these observations, we also gained experience in communicating with

different people in and out of health related organizations and collecting primary as well as

secondary data. We have acquired skills in performing epidemiological analyses so as to assess

the burden of the disease; critically analyzing a part of a health institution and recommending

ways to improve them; and also formulating a five year plan on a pertinent health issue of a

district so that it ceases to exist as a health problem in the days to come.This field experience was a chance for us to know the differences between working in

health facilities in the center and periphery of this country. It provided us with the opportunity to

discover the geography, language, tradition and culture of the Mid-Western Development

Region, a region mostly neglected by the rest of the country. This undertaking at this stage of our

medical career will definitely prove to be a milestone in the path of making us adept in the roles

that are to be played by a doctor in a health setup; care provider, decision maker, communicator,

community leader and manager - “The Five Star Doctor”.




ANNEX

List of Activities for District Health System Management Field (MBBS, MaharajgunjMedical Campus, Institute of Medicine, Kathmandu)

2070/071 (Bardiya, Surkhet and Rukum)Month Falgun

25-Chaitra15

Chaitra16 -Baishak 5

Baishak 6 – Baishak25

S.N. Activities Weeks/Days

1 2 3 1 2 3 1 2 3

First Placement (Bardiya)

1 Reach the destination 1

2 Accommodation, logistic management,Rapport building with senior public healthofficer and other staffs at DHO- Bardiya

1

3 Formulation of tools with group discussion 1

4 Prepare district health profile of BardiyaDistrict

4

5 Visit to District Development Committee(DDC) and meeting with Medical Officer ofDistrict hospital Bardiya.

1

6 Visit to peripheral health institutes andother NGOs/INGOs

1

7 Prepare hospital profile of Bardiya DistrictHospital and supervision by Mr. Prem Baseland Mr. Shiva Prasad Sapkota.

3

8 Group discussion for topic ofepidemiological study

1

9 Preparation of tools for epidemiologicalstudy

1

10 Meeting with the Malaria Inspector andcollection of data for epidemiological study

1

11 Conduct epidemiological study 3

12 Preparation for presentation 1

13 Presentation of our findings and feedback 1




14 Departure from Bardiya to Surkhet 1

Second Placement (Surkhet)

1 Arrival at Surkhet 1

2 Arrangement of accommodation andlogistics and rapport building with hotelowner.

1

3 Meeting and rapport building with MedicalSuperintendent of Mid-Western RegionalHospital, Surkhet.

1

4 Visit to the different departments of thehospital and observation of hospital.

1

5 Group discussion and selection of topic forcritical analysis

1

6 Preparation of tools for critical analysis 2

7 Data collection, interview with focal persons and observation of waste collectionmechanism in OPDs, In-patient, Emergency,OT and laboratory

5

8 Critical analysis of different aspects of wastemanagement

3

9 Visit to Earthworm farming site and wastedisposal site

1

10 Preparation for presentation and reportwriting

3

11 Presentation of our findings and feedbackfrom Medical Superintendent and focal

persons

1

12 Departure from Surkhet to Rukum 1

Third Placement (Rukum)

1 Arrival at Rukum 1

2 Accommodation, lodging management 1




3 rapport building 1

4 Group discussion, selection for topic forcritical analysis, formulation of tools

1

5 Collection of data 1

6 Interview with MS, DPHO/DHO,stakeholders

2

7 Survey with patients and health workers 4

8 Review of national plan and policies 3

10 Data analysis 3

11 Preparation for presentation 1

12 Presentation and feedback 1

13 Finalization of report 1

14 Preparation for returning/ analysis of DHSMfield program

1

dhsm report

Documents