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Mid-term Evaluation of “Public-private partnership on Logistic

management of health commodities at Udyapur”

District Health Office

Udyapur, Nepal

December, 2015

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FINAL REPORT

Mid-term Evaluation of “Public-private partnership on Logistic

management of health commodities at Udyapur”

Suggested citation:

Liladhar Dhakal.2015. Mid-term Evaluation of Public-private partnership on Logistic

management of health commodities at Udyapur. Udyapur, Nepal : District Health Office

Udyapur, Nepal Development Society, and UNFPA, Nepal

Owned BY

District Health Office

Udyapur, Nepal

Supported BY

United Nations Population Fund, Nepal

Principal Investigator

Liladhar Dhakal

Nepal Development Society

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Acknowledgements

This mid-term evaluation report of the sub-district level health logistic management by

the third party in the Udyapur district was the result of efforts of many stakeholders. I

would like to thank Dr. Chuman Lal Das, Chief of District Health Office Udyapur and his

district health team for the guidance, support and information they provided during the

study. I am especially thankful to the UNFPA team; Mr. Deepak Adhikari, Public Health

Officer of Logistic Management Division, Mr. Ramdev Adhikari of Lifeline Nepal; Mr.

Keshab Prasad Timilsina and Mr. Krishna Bhattarai of DHO Udyapur for providing

access on the LMIS reports.

I would like to thank research assistant Mr. Rajesh Phuyal for his hard work during field

work. At last but not list, I would like to remember and thank all the respondents of the

DHO, Hospital, private sector logistic service provider, health facility staffs, HFOMC

members and FCHVs for their valuable time and information.

Liladhar Dhakal

Principal Investigator

Nepal Development Society

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Acronyms

3PL Third Party Logistic Provider

ASL Authorized Stock Level

DHO District Health Office

EOP Emergency Order Point

FCHV Female Community Health Volunteer

FEFO First Entry First Out

HF Health Facility

HFOMC Health Facility Operation and Management Committee

HP Health Post

IEC Information, Education and Communication

KII Key Informant Interview

LMD Logistic Management Division

LMIS Logistic Management Information System

PHCC Primary Health Care Center

PPP Public Private Partnership

UNFPA United Nation Population Fund

VDC Village Development Committee

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Contents

Acknowledgements .......................................................................................................................... 3

Acronyms ......................................................................................................................................... 4

List of Tables ................................................................................................................................... 7

List of Figures .................................................................................................................................. 7

Executive Summary ......................................................................................................................... 8

Background of the study ................................................................................................................ 11

Aim of the study ............................................................................................................................ 11

Objectives of the study................................................................................................................... 12

Methodology .................................................................................................................................. 13

Method of information collection .............................................................................................. 13

Process of Information collection .............................................................................................. 13

Selection of health facilities ....................................................................................................... 13

Selection of the respondents ...................................................................................................... 14

LMIS data review ...................................................................................................................... 15

Tools of information collection ................................................................................................. 16

Data Collection .......................................................................................................................... 16

Data Processing and analysis ..................................................................................................... 17

Limitations of the study ............................................................................................................. 17

Findings ......................................................................................................................................... 18

Reporting status ..................................................................................................................... 19

Expiry of Drugs...................................................................................................................... 19

Stock status of Drugs ............................................................................................................. 21

Quantification ........................................................................................................................ 23

Packaging ............................................................................................................................... 24

Supply and Distribution ......................................................................................................... 25

Use of local resource .............................................................................................................. 26

Stakeholders' perceptions about 3PL involvement ................................................................ 27

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Impact on work burden .......................................................................................................... 28

Sustainability of the program ................................................................................................. 29

Limitations of the 3PL involvement ...................................................................................... 30

Monitoring and Supervision .................................................................................................. 32

Role of the District Health Office .......................................................................................... 33

Role of the Third Party Logistic Provider .............................................................................. 33

Findings of observation .......................................................................................................... 34

Conclusions .................................................................................................................................... 36

Recommendations .......................................................................................................................... 38

Annexes .......................................................................................................................................... 40

Annex I: KII guidelines for the District health managers .......................................................... 40

Annex II: KII guidelines for the health workers ........................................................................ 41

Annex III: KII guidelines for the HFOMC members and FCHVs............................................. 44

Annex IV: KII guidelines for the third party logistic provider .................................................. 46

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List of Tables Table 1: List of health facilities selected for the study .................................................................. 14

Table 2 : List of Key Informants .................................................................................................... 15

List of Figures Figure 1: Time period of LMIS data review .................................................................................. 15

Figure 2: LMIS report reporting status by reporting months ......................................................... 19

Figure 3: Percent of reporting months reported expiry of drugs by reporting months .................. 20

Figure 4: Percent of reporting months of drugs reported for the expiry ........................................ 20

Figure 5: Percent of stock out of drugs before and after involvement of 3PL ............................... 21

Figure 6: Percent of stock out status of selected drugs .................................................................. 22

Figure 7: Reporting of over stock of drugs by reporting months ................................................... 22

Figure 8: Percent of over stock of drugs at health facilities by types of drugs .............................. 23

Figure 9: ASL/EOP reporting status in LMIS reports ................................................................... 31

Figure 10: Stock status of selected drugs in actual count .............................................................. 34

Figure 11: Stock status of commodities in actual count in six health facilities ............................. 35

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Executive Summary

Public-private partnership for the management of the health commodities at below

district was started in Magh 2070 BS in Udyapur district. This partnership program was

implemented in Udyapur with the support of the United Nations Population Fund, Nepal.

The objective of the program was to strengthen below district supply chain management

of the health commodities.

The aims of the mid-term evaluation were to explore and document effectiveness of the

partnership and suggest ways forwards for the future. Information was collected by the

key informant interview, observation and review of logistic management information

system data. District was divided into three clusters and the health posts of each cluster

were listed. Then, health posts for the information collection were randomly selected

from each cluster. Primary Health Care Center, Beltar and District Hospital were also

included in the study. In total, 13 health facilities for the logistic management

information system report review, 9 health facilities for the observation and the key

informant interview were selected. Total 38 key informant interviews with the district

health managers, health facility in-charge, store in-charge and the third party logistic

provider were carried out. Stores of the seven health facilities were observed. Logistic

management information system reports of 13 health facilities for 15 quarters were

reviewed. Quantitative data were managed in the Microsoft excel and qualitative data

were analyzed by themes. Triangulations of the quantitative and the qualitative

information were done where appropriate.

Review and analysis of the logistic management information system data revealed no

remarkable change in the reporting status. Over stock of the drugs was found decreased

after the involvement of the third party logistic provider. At the beginning of the

program, third party logistic provider had no expertise and was novice for the job. They

learned by doing. The quantification and the packaging of the drugs were facilitated by

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the involvement of the third party logistic provider. Actual counts of the drugs in the

stores were becoming possible after their involvement. The third party logistic provider

was supplying and distributing the health commodities as per the route and time fixed by

the district health office. They were found more efficient when they have large bulk of

health commodities to supply. For the small amount of drugs, health facilities staffs visit

the district health office. They followed necessary precautions while transporting and

handling of the health commodities. Furthermore, they had collected and submitted the

registration forms as well as the logistic management information system reports to the

concerned authority.

Involvement of the third party logistic provider has reduced the work burden of the

district health office and the health facilities providing more time to them for the other

aspects of health service management and the service delivery. For the sustainability of

the program, some cost sharing mechanism between the local government and the health

authority was suggested by the respondents. Many stakeholders took the involvement of

the third party logistic provider as the innovation having direct impact on the quality of

the health services. After the involvement of the third party logistic provider, supply of

the information, education and communication and the information system related forms

and formats was also improved and reached to the beneficiary on time.

Though logistic management of the health commodities was new and challenging as well

as less lucrative job from the economic perspective to the private firms, they took this job

as their social responsibility and were satisfied with the good-will they earned in the

society. However, they need to be more responsive to the comments and the expectations

of the peripheral health facilities. Moreover, they should give more attention on the store

management and strengthening of the information system in addition to supply of the

commodities. Major challenges for the private sector were lack of the technical expertise,

retention of the trained man power, lack of adequate stock of commodities in the district

store and low per unit cost of supply.

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To improve the effectiveness of the program, the district health office should provide the

orientation on the logistic system to its staffs and the third party logistic provider's staffs

provide regular follow up and monitoring. Furthermore, formal structure of the

coordination between the district health office and the third and the compensation

mechanism in case of damage of drugs due to unavoidable circumstance will facilitate the

program. Multi-year procurement system, technical personnel in district store and the

policy arrangement for the cost sharing of the program between local government and

health authority will ensure sustainability of the program.

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Background of the study

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

health services. Quality health service is almost impossible without efficient and effective

logistic systems that provide right health commodities, of the right quality, at the right

time, in the right quantity, to the right place and for the right cost. District health office

(DHO) Udyapur is committed to improve its logistic management system so that essential

drugs, vaccines, equipment, recording and reporting formats and Information, Education

and Communication (IEC) materials are available in all health facilities year round.

Strengthened supply chain management enables for quality health service delivery

through reducing problems like over stock, under stock, stock out and expiry of health

commodities.

Strengthening below district supply chain management through public private partnership

(PPP) approach is a collaborative effort of Logistic Management Division (LMD), DHO

Udyapur and United Nations Population Fund (UNFPA). It has envisioned sustaining the

collaboration among public, civil society, community or private organizations in order to

maximize access, quality, equity and effectiveness. PPP in below district level supply

chain management was started in Magh 2070 BS in Udyapur district. This is a pilot

program of Government of Nepal, Ministry of Health and Population to strengthen below

district level supply chain management of health commodities.

Aim of the study

Mid-term evaluation of the PPP aims to explore and document effectiveness of the

partnership to improve below district supply chain management of health commodities.

Furthermore, study will provides way forward for the future.

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Objectives of the study

1. To assess the status of the Logistic Management Information System (LMIS)

reporting and stock out situation of key commodities at health facilities

2. To identify the strength and weakness of the essential commodity supply chain

management

3. To find out the barriers for effective supply of logistics and maintaining stock at

health facilities

4. To devise the role of organizations working in the field of logistic management at

district and below to strengthen supply chain of health commodities

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Methodology

Method of information collection

Key informant interview (KII), observation and review of secondary data were carried

out. KIIs were carried out with District Health Officer, Public Health Officer, District

supervisors, District store in-charge and his assistant, Hospital store in-charge, managing

director of the third party, health facility in-charge, health facility store in-charge, health

facility operation and management committee (HFOMC) members and female

community health volunteers (FCHV). Hospital and health facilities stores were observed

and actual count of the drugs were done. Review and further analysis of LMIS data from

Magh 2068 BS to Kartik 2072 BS was carried out.

Process of Information collection

Principal investigator interviewed all district level stakeholders. Research assistant was

trained on KII technique by exposing him on the interview of district store in-charge,

hospital store in-charge, and some district supervisors. Then, he did KII of the health

facility in-charges, HFOMC members and FCHVs. Furthermore, research assistant

observed stores of the health facilities and did actual count of the selected drugs.

Selection of health facilities

For the selection of the health facilities (HF) to collect information, Udyapur district was

divided into three clusters based on its geography. The three clusters were remote HFs

consisting of 14 HFs, HFs in mid hill consisting of 23 HFs and HFs in Terai consisting of

10 HFs. After that, list of health posts (HP) of all three clusters were prepared separately.

Then, two HPs of each cluster were selected randomly for KII and observation. District

hospital and Beltar Primary Health Care Center (PHCC) were also included. Total health

facilities to be visited for KII were eight (One hospital, one PHCC and six HPs).

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Table 1: List of health facilities selected for the study

S no Name of Health Facilities LMIS data review KII Cluster

1 Sunerpur HP √ √ Terai

2 Triveni HP √ √ Terai

3 Murkuchi HP √ Terai

4 Vumersuwa HP √ Terai

5 Dumre HP √ √ Mid Hill

6 Siddhipur HP √ √ Mid Hill

7 Myankhu HP √ Mid Hill

8 Chaudhandi HP √ Mid Hill

9 Nametar HP √ √ Remote

10 Laphagaon HP √ √ Remote

11 Mainamaini HP √ Remote

12 Thanagaon HP √ Remote

13 Beltar PHCC √ √

14 District Hospital √

15 District Health Office √

Furthermore, other two HPs were selected randomly for LMIS data review. Hence, LMIS

report of 12 HPs and one PHCC was reviewed and analyzed. Table 1 presents name of

health facilities included in the study.

Selection of the respondents

Consultative meeting was organized in DHO with the participation of the district health

supervisors, members of district reproductive health coordination committee,

representative of UNFPA and representative of third party logistic provider (3PL).

Respondents as per table 2 were identified by the meeting. KIIs were carried out to them.

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Table 2 : List of Key Informants

S no Organization Number of KII Informants

1 DHO 9 District Health Officer, Public Health

Officer, District store in-charge and his

assistant, Family Planning Officer,

Immunization Supervisor, Public Health

Nursing Officer, Statistics Officer,

Account Officer,

2 Hospital 2 Hospital store in-charge and assistant

3 PHCC 4 PHCC in-charge, PHCC store in-charge,

HFOMC member and FCHV

4 HPs 22 HP in-charge, HP store in-charge,

HFOMC member and FCHV

5 Third party 2 Managing Director

Total 38

LMIS data review

Quantitative information was collected by the review of available LMIS reports. LMIS

reports of 13 health facilities of 15 reporting periods were reviewed. To explore change

after the intervention, LMIS reports of eight quarters (from Magh 2068 to Poush 2070

BS) before starting of the intervention and seven quarters (from Magh 2070 to Aswin

2072 BS) after the intervention were reviewed.

Figure 1: Time period of LMIS data review

Intervention started on Magh

2070 BS

Before Intervention

Magh 2068 Aswin 2072

After Intervention

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Consultative meeting identified items to be reviewed in the LMIS reports. They covered

essential reproductive health and child health commodities. All together 174 LMIS

reports were reviewed and analyzed for reporting status, under stock, over stock, stock

out and expiry of the drugs (Condom, Depoprovera Injectable, Oral Contraceptive Pills,

Oral Rehydration Salt, Zinc Suplhate, Co-trimoxazole 120 mg tablet, Iron tablet, Vitamin

A capsule, Magnesium Sulphate Injection, Oxytocin Injection, Amoxycillin 125 mg

suspension, Amoxycillin 500 mg capsule, Ciprofloxacin 500 mg tablet, Paracetamol 500

mg tablet, and Paracetamol 125 mg syrup).

Tools of information collection

Interview guidelines were used in KII (annex: I-III). They were semi-structured so that

both technical contents based on objectives of the study and the perspectives of the

respondents on the issues were captured. Instant probing was done based on issues during

KII. Structured format was used in desk review of LMIS reports (annex: IV). Both tools

(KII guidelines and format for desk review) were finalized through consultative meetings.

Data Collection

Trained research assistant collected information from health facilities. Principal

investigator collected information at district level and did review of LMIS reports. Hard

copies of the LMIS reports were retrieved from LMIS section Kathmandu and District

store Udyapur. Database for LMIS review was prepared in Microsoft excel sheet.

Principal investigator himself entered data and checked for the errors.

For the KII, respondents were visited individually so that they can express their views

independently and without any pressure. First, background and objective of the study was

clarified. Then, verbal consent was seen. They were assured for the confidentiality of the

information. Data were collected in the paper. Nepali language is used during KII.

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Data Processing and analysis

Status of logistic management in Udyapur district before and after involvement of 3PL

was compared with the help of information collected in KII and LMIS review.

Quantitative data derived from the review of LMIS were managed in the Microsoft excel.

Random check for the accuracy of the data entry was carried out. Data sheets were

protected to avoid any unknown (unintentional) changes in format during the data entry.

Findings for the key indicators were presented as absolute number and percentage as

appropriate.

A general analysis protocol for the qualitative data was developed, which consists of a

codebook with broad themes that responded to the questions asked. Then, qualitative data

were organized based on themes identified. Furthermore, new themes were also added in

the broad themes identified earlier. Then, data were interpreted. Quantitative and

qualitative results were triangulated where possible, and were presented throughout the

report under the relevant results sections.

Limitations of the study

Triangulations of quantitative and qualitative data were not possible for all topics,

because the data collection tools were designed to collect different but complementary

information. The study was not able to cover all the health facilities. Numbers of health

facilities included in the study were decided considering available resources and

objectives of the study. So the results may not be generalizable for the other health

facilities not included in the study.

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Findings

DHO stores receive drugs and necessary equipment from the center and regional medical

stores. They also procure some essential drugs at the district level. All supplies were

stored in the district store and supplied to HFs based on their demand. Supply of drugs

and equipment to the HFs is the responsibility of the DHO.

Health facility sends LMIS reports to the DHO on quarterly basis (each quarter consists

of three months). LMIS report has information about the expense of drugs in the last

three month, stock on hand, authorized stock level (ASL), emergency order point (EOP)

and quantity of the drugs to be supplied for next three months. This report should be

dispatched to the DHO by the end of first week of next quarter. After receiving LMIS

report of the facility, district store review reports and starts process of sending supplies

for the next quarter. This process involves analysis of LMIS report to identify item and

quantity to be supplied, preparing handover form, packaging of drugs considering its

nature and amount, fixing route of supply, loading in the vehicle, and delivery to the

health facility. When drugs and equipment reached to the health facility, health facility

in-charge or store keepers verify items as per hand over form and registered in the stock

book. Usually HFOMC members are also present in the verification of the items. Then,

drugs are stored properly in the health facility store.

The supply chain management of the health commodities (drugs, medicinal and surgical

equipment, IEC materials and forms and formats) at the below district is labor intensive

and demand more time of the DHO team. Because of increased number of items and

quantity as well as difficult geography, it is becoming more challenge for the DHO to

ensure year round availability of the health commodities in all health facilities. To

improve stock status of the drugs in the HF and facilitate below district supply chain

management related tasks of the DHO, DHO has established partnership with a 3PL.

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According to the terms of reference (TOR), the 3PL should support DHO in fixing

amount to be supplied to the HFs, packaging, delivery and store management at the HFs.

Based on the TOR of partnership, this study collected information about experience of

stakeholders on different aspects of sub-district supply chain management.

Reporting status

LMIS reporting of 13 HFs for eight quarters before and seven quarters after involvement

of 3PL in the management of health commodities in sub-district level was carried out.

Before and after comparison of the reporting status revealed no any remarkable changes.

According to the respondents of the HFs, they were not receiving any support in the store

management and recording and reporting from the 3PLs. Findings of the LMIS report

review and KII matched for reporting status of the LMIS data.

Figure 2: LMIS report reporting status by reporting months

Expiry of Drugs

Reporting of expiry of fifteen drugs for thirteen reporting months (eight reporting months

before and seven reporting months after involvement of 3PL) were analyzed from the

LMIS reports. In total 2340 reporting months were analyzed for the reporting of expiry of

020406080

100120

Pe

rce

nt

Reporting months

LMIS reporting status

20

drugs. Highest numbers of drugs were found reported as expired on Magh 71 followed by

Kartik 72 and Kartik 70 reports (figure 3).

Figure 3: Percent of reporting months reported expiry of drugs by reporting months

Similarly, LMIS report revealed that Oxytocin was reported expired on 6.7 percent of

reporting months followed by MgSO4 and Zinc sulphate (figure 4). Highest expiry of

Oxytocin and MgSO4 may be due to on and off of delivery service where both drugs are

used and pushed supply in the irrelevant health facilities.

Figure 4: Percent of reporting months of drugs reported for the expiry

0.0

1.0

2.0

3.0

4.0

5.0

6.0

Pe

rce

nt

Percent of reporting months reported expiry of drugs by reporting months

Before involvement of 3PL After involvement of 3PL

1.20.6 0.0

0.7

4.0

0.71.3 0.7

4.4

6.7

0.6 0.0 0.0 0.0

2.0Pe

rce

nt

Percent of reporting months of drugs reported for expiry

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Stock status of Drugs

Analysis of LMIS report for the stock out of drugs revealed that there was almost no

change in stock out of drugs before and after involvement of 3PL. though lowest stock

out of drugs was reported in the report of Kartik 71, it steadily increased after that and

reached to highest point in the Kartik 72 (figure 5). It may be due to stock out of drugs in

the district store due to ongoing crisis and fuel shortage since last Shrawan 72. In the

KII, health facility in-charge expressed that there was no change in drug availability

before and after involvement of 3PL. This finding is in line with their views.

Figure 5: Percent of stock out of drugs before and after involvement of 3PL

Analysis of the stock out of the drugs before and after involvement of the 3PL was also

carried out by the drugs. It revealed that availability of all other drugs except MgSO4 and

Oxytocin was found improved after involvement of 3PL (figure 6). Percent of quarter

available three family planning methods was found improved after involvement of 3PL.

Similarly, remarkable change was noticed for Ciprofloxacin and Amoxicillin tablets.

MgSO4 and Oxytocin were used only in the facility with birthing facility. Higher

percentage of stock out of these two drugs may be due to no supply in the previously

supplied facilities because of discontinuity of the service.

05

10152025303540

Pe

rce

nt

of

sto

ck o

ut

qu

art

ers

Percent of stock out of drugs before and after involvement of 3PL

Before involvement of 3PL After involvement of 3PL

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Figure 6: Percent of stock out status of selected drugs

LMIS reports were also reviewed for the over stock of drugs. Over stock of drugs was

found highest in Baisakh 71, Kartik 71 and Magh 71. After Magh 71 it was slowly

decreased. In the latest LMIS report i.e. report of Kartik 72, more than 10 percent of

drugs were found over stocked at the health facilities (figure 7).

Figure 7: Reporting of over stock of drugs by reporting months

9

6

9

11

10

10

16

25

16

16

45

62

61

8

23

1

4

5

10

9

5

14

17

28

37

38

27

19

3

18

Condom

Depo

Pills

ORS

Zinc

Co-trim PD

Iron tab

Vitamin A

MgSO4

Oxytocin

Amoxycillin 125 mg, Dispersible

Amoxycillin 500 mg

Ciprofolxacin 500 mg

Paracetamol 500 mg

Paracetamol Syrup

Percentage of quarters with stock out of drugs

Stock out status of selected drugs

After 3PL Before 3PL

05

10152025303540

Pe

rce

nt

Reporting months

Reporting of over stock of drugs by reporting months

23

While exploring types of drugs reported over stocked in the health facility, Condom,

Pills, ORS, Zinc, Cotrim PD, MgSO4, Amoxycillin 500 mg and Paracetamol 500 mg

were reported over stocked after involvement of 3PL. Over stock of drugs were found

reduced for Depo, Vitamin A, Oxytocin, Cipro 500mg, and Paracetamol syrup. Similar

stock out status was reported for iron tablet (figure 8).

Figure 8: Percent of over stock of drugs at health facilities by types of drugs

Quantification

According to the in-charges and store keeper of the HFs, quantification of the drugs to be

demanded was done by themselves based on guidelines provided in the LMIS report

form. It is based on consumption pattern of the drugs. They have ASL and EOP of all

items. Drugs were demanded from the district store so that it is equal to the ASL.

Third party has assigned one employee in the district store. At the district store, store in-

charge and his assistant collects LMIS report of the HFs. According to the store in-

charge, though the employee of the third party assigned in the district store was technical,

they provided onsite coaching to him about LMIS report analysis and quantification of

0

10

20

30

40

50

60

70

Pe

rce

nt

Percent of over stock of durgs at health facilities by types of drugs

Before intervention After intervention

24

health commodities to send to HFs. After coaching, 3PL's employee checked ASL and

EOP of the HFs and helped store in-charge in quantification of health commodities.

District health managers said that quantification based on consumption patter should not

be the only basis to fix actual amount of drugs to send to HFs. It should take into account

of morbidity pattern, store space and remoteness of the HF. It is impossible to send drugs

on quarterly basis to remote health facilities. So, for some HFs, drugs more than stated in

ASL need to be supplied in the favorable season so that they have drugs available round

the year.

Some respondents from DHO revealed that, they found more drugs in actual count of the

drugs in the store of HF than the amount of drugs reported in the LMIS report. According

to them, 3PL also did actual count of the drugs in the HFs' store. Before involvement of

3PL, it was almost impossible because of lack of manpower.

Packaging

District store is getting support from 3PL in the packaging of the health commodities

according to the hand over forms made by the district store in-charge. Before

involvement of the 3PL, it was difficult because of lack of dedicated technical manpower

who can identify drugs and equipment. After 3PL had assigned a technical manpower

(Pharmacist or para-medical), packaging of the drugs had no more problems. The right

health commodities were packaged in the right way.

Now we have no problem in packaging. 3PLs employee is perfect for the job. He is

technical and identifies the drugs and the equipment mentioned in the handover form.

There is no mismatch between the health commodities mentioned in the handover

form and the commodities packaged. –District store in-charge

25

Supply and Distribution

According to the district level informants, the most important aspect of sub-district health

commodities logistics management system improved after the involvement of the 3PL

was the supply and distribution. 3PL

was found supplying and distributing

health commodities as per the route

and time fixed by the DHO.

Majority of the respondents reported

that 3PLsupplies health commodities

to the HFs when they had adequate load for the vehicle. HF staffs need to come to district

store for small amount of drugs or emergency supply.

When there was no road for the vehicle, 3PL hired labor and deliver the drugs to the HFs.

According to the 3PL it is very difficult to find labor to carry drugs to the health facility.

Furthermore, cost of labor is very high. Sometimes 3PL established temporary store in

place which is center for few health facilities.

All respondents were agreed that storage, supply and distribution of health commodities

demand more attention and

sensitivity. They are different than

other daily consumables. According

to 3PL, they have managed separate

vehicles and manpower to supply and

distribute drugs and equipment as per demand of DHO. It has avoided delay in supply.

Moreover, 3PL claimed that they are supplying and distributing drugs up to the health

facility store. Drugs and equipment should be protected from sunlight and water even

during transportation. 3PL said that they are taking proper care of drugs during

transportation also.

We got supplies from the 3PL when we

demand on large bulk. But we have to

send our staffs when we need supply in

small amount. –HF in-charge

3PL is supplying drugs anywhere at any

time. We don't have to be worried about

availability of vehicle.-DHO store in-

charge

26

According to the health facility in-charges, sometimes they are not getting drugs on time

and found drugs left somewhere on the way. Furthermore, majority of them claimed that

they have to visit DHO even after involvement of 3PL for supply of health commodities.

Health facility in-charge, HFOMC member and FCHVs shared that they had managed

supply of drugs to the health facility which was left on the way by the supplier.

Another responsibility of the 3PL is to collect registration form (Dhakhila report) from

the health facility and submit it to the DHO store. According to the DHO store in-charge,

3PL has sent its staff to the health facility with the drugs. 3PL staff has brought Dhakhila

report with them. It has facilitated proper inventory management of the DHO store and

health facility.

Use of local resource

Many respondents of DHO and HFs experienced that involvement of 3PL has brought

positive change in the health commodity supply system. Now they don't have to be

worried about supply of health commodities. They are using their effort and time in other

aspects of health service. According to the respondents of the DHO and some health

facility in-charges, previously they had limited fund for the supply of drugs. So they were

not able to send drugs on time and their capacity to address needs of the health facilities

were limited. They used to seek help

from the local government to supply

health commodities. Furthermore,

they also expensed money of the

HFOMC in drug supply. But after

the involvement of the 3PL with the

funding of the UNFPA, DHO is

becoming more responsive to the

demand of the health facilities and

I welcomed 3PL's involvement in health

commodities supply because we don't have to

allocate support of VDC for this task. Before

3PL, we used money of VDC and HFOMC in

the health commodity supply. Nowadays we

are using their money in other aspects of

health service delivery. – HF in-charge

27

supplying health commodities as per the demand. Many health facilities are diverting

support of local government i.e. Village Development Committee (VDC) and money of

the HFOMC in other aspects of service delivery. They claimed that it has helped in the

improvement of quality of service.

Stakeholders' perceptions about 3PL involvement

Involvement of 3PL in the supply chain management of health commodities below the

district in the Udyapur was new for all stakeholders of the district health system including

the 3PL itself. The study collected views of the different stakeholders about the

involvement of the 3PL. Majority of the HFOMC members and FCHVs took it as

innovation. Most of them reported that after the involvement of the 3PL, HFs are

receiving health commodities on time.

The district manager and other district supervisors took it as good practice as it has

helped them to ensure the availability drugs in the service site round the year.

Furthermore, the 3PL had supplied drugs whenever it was available in the district store

which prevented dumping of health commodities in district store and scarcity in the HFs.

IEC materials including Health Management Information System (HMIS) forms and

formats were also delivered to the health

facility on time. Before involvement of the

3PL, supply of HMIS forms and formats as

well as IEC materials to the HFs took long

time, sometimes a year also. Timely supply

of HMIS forms and formats has improved

recording and reporting system as well as

quality of information of the service

delivery. IEC materials were available for the target population.

I felt that involvement of 3PL has

improved supply of drugs in the health

facility. It should be continued. 3PL is

doing well till date and hope they will

do better in the future.-HFOMC

member

28

However, views of the HFs in-charge were contrasting to other stakeholders. Majority of

them thought that government is moving back from its responsibility by involving 3PL in

the sub-district level supply chain management of health commodities. They said that the

3PL supplies health commodities on time only to the health facility which has road

access. Remote health facilities were not receiving supplies on time. Before involvement

of the 3PL, HF staffs visited DHO and brought necessary drugs and materials to the

facility with them. This was practiced by all HFs irrespective of road access. But now,

health workers did not know when the 3PL supplies drugs to them.

Involvement of 3PL in the sub-district supply chain management of the health

commodities was quite new and challenging for the 3PL itself. This is technical area and

no private party had any previous experience of such work. According to the 3PL, they

are learning from the DHO, store and HFs. The 3PL expressed its satisfaction with the

support received from the DHO, HF staffs and community peoples. The 3PL doing the

job currently expressed that the work is challenging and very sensitive. The 3PL said that

they are taking it as their social responsibility. The 3PL further added that they are

earning social capital rather than economic benefit from the work and are willing to

continue this work if they got the opportunity in the future.

Impact on work burden

District level respondents experience no additional work burden because of the 3PL's

involvement. They did not have to make any change in the district health system's

We don't know when the 3PL supplies drugs to us. When asking to them about supply of

drugs, they usually say tomorrow. But I don't know when their tomorrow will come. So

I think it is good to go myself to DHO and have drugs rather than waiting for the supply

by 3PL. – HF store in-charge

29

structure and working procedure. According to them it was just addition of additional

human, financial and material resources in their regular job. In fact, it has reduced their

work burden and helped them to do their regular logistic job with more efficacy and

effectiveness.

Majority of the respondents said that the involvement of the 3PL had reduced problem of

absents of the health workers in the HF. Before the involvement of the 3PL, health

workers themselves need to visit DHO for the supply of drugs. It took many days for the

remote HFs which are suffering from lack of adequate number of the health workers.

Now 3PL is supplying necessary drugs and the health workers don't have to leave health

facility. So, it has helped in improving the health service by the uninterrupted supply of

health commodities and reducing the health workers absent in the facility.

According to the district level respondents, the 3PL has supported the district store

management. Furthermore, they have just started supporting peripheral HFs to manage

their store properly, keeping it clean and maintain drugs according to first expiry first out.

First the DHO personnel provided onsite training to the 3PL's employee on store

management. Then, he visited various peripheral HFs to support them in store

management.

Sustainability of the program

Before funding from the UNFPA, DHO had limited fund i.e. approximately Nrs.

300,000.00 per year. This was grossly inadequate for the year round supply of all health

commodities to the all HFs. DHO distributed this fund to the all HFs considering amount

of supplies and distance of the HF as well as means of transportation available. HFs

themselves also sought support from the VDCs and utilized the HFOMC fund too.

Currently, UNFPA is supporting more than five times of the government budget for the

sub-district level supply chain management of health commodities and the 3PL was

30

involved in the process. All stakeholders raised issues of the sustainability of the program

after the phase out of UNFPA support. Respondents suggested following mechanisms for

its sustainability.

• Establishment of the some kind of cost sharing mechanism between the local

government (DDC, VDC and municipality) and the HF

• Delegating authority of buying drugs to the VDC/municipality in coordination

with the local HF. Ministry of health and population or any responsible

government authority should facilitate them by fixing the rate of drugs or

establish large suppliers in the districts.

Limitations of the 3PL involvement

The study tried to explore the limitations of the 3PL involvement in the process of sub-

district level supply chain management of health logistics. According to the 3PL

currently working with the DHO, the task was completely new for all private sectors. All

private service providers had fear of unknown at the start of the program. None of them

have expertise required to manage the task. Though some private party had individuals

with some experience of the health sector, no private party had any institutional expertise

related with supply chain management of health commodities. The DHO manager shared

that at the start of the program they found no private firm interested for the job. They did

consultation with the private firms and requested to participate in the process.

The main responsibility of the 3PL is the management of supply chain of health

commodities below the district. So efficiency and effectiveness of the 3PL is heavily

depends on the availability of the health commodities in the district store. According to

the district level respondents, in the last two fiscal years, the DHO store had inadequate

stock of the health commodities. Because of this inadequacy, the DHO store could not

handover the adequate amount of health commodities to the 3PL for the supply to the

HFs. That’s why many HFs are complaining of not getting drugs on time and suffering

31

from problem of stock out of some key commodities. Another major implication of the

inadequate health commodities in the district store was the increased frequency of trips to

be made by the 3PL to the HFs. So many respondents suggested that one prerequisite for

the involvement of 3PL is the adequate stock of the health commodities in the district

store.

Existing information system of the health logistics has some inadequacies. Some

respondents revealed that sometimes the LMIS report did not provide the actual condition

of the drugs in the HF. Many times number of drugs reported in the LMIS did not match

with the actual count of the drugs in the store. Many HFs did not report ASL and EOP.

About half of the HFs did not report ASL/EOP. EOP is the projected expense of a month

and ASL is the projected expense of five months. ASL is always five times of EOP. But,

still some HFs are not aware about it. It has implication on the quantification of the drugs

to supply to the HFs.

Figure 9: ASL/EOP reporting status in LMIS reports

According to the 3PL, there is no formal mechanism of the compensation for the damage

of the health commodities or other risk possessed by unavoidable circumstances. Till date

it was practiced based on coordination between the DHO and the 3PL. But they

recommended it should be a part of the contract. They also pointed out that there is no

58

7

3544

7

49

Matched Not matched No ASL/EOP

ASL/EOP reporting in LMIS report

Before 3PL After 3PL

32

any formal mechanism or body at the district to monitor, collaborate and oversight the

involvement of the 3PL.

According to the district level respondents another major limitation of the involvement of

the 3PL in the management of the sub-district level health logistics is the current per unit

supply rate of the commodities. They

revealed that the current district per unit

supply rate treat drugs like as other daily

consumables or construction materials.

They added that the health commodities

can't be supplied as other materials

because they are fragile and chemically

unstable. So their supply requires more

attention, security and space.

Another problem faced by the DHO and the 3PL is the mismatch between starting times

of fiscal year. Government fiscal year starts on July and UNFPAs fiscal year starts on

January. Because of this, there was gap in contract which impacted availability of drugs

in the HF.

Monitoring and Supervision

At the beginning phase, every program demands intensive support, monitoring and

supervision. All stakeholders should be oriented about the program including its

objective, process and expected outcomes. Many health facilities in-charge and district

stakeholders reported that there was more space in information dissemination among the

stakeholders. According to the HF in-charge, though it is not necessary to know how the

facilities will receive drugs and who is supplying, but it is necessary to know when and at

what condition will it arrive. Furthermore, if the HFs know the jobs and responsibility of

the supplier, they can make proper use of the 3PL's expertise and also provide necessary

In a truck, we can supply 2.5 tons of rice

or cement but we can supply only 0.5

tons of drugs. There is similar per unit

cost of supply for drugs and other

materials. Then, how it is possible to

supply drugs with per unit cost prevalent

in the district now? - 3PL

33

support. Respondents suggested periodic review meeting as well as monitoring from the

DHO about the work of 3PL.

Role of the District Health Office

All respondents agreed that the task of managing the health commodities at the sub-

district level was new for the private party and they have limited expertise on it. So

facilitation and intensive support from the DHO is crucial for its effectiveness and

continuity. According to the district health managers, they are providing onsite coaching

on the quantification, packaging, store management, and review of LMIS reports to the

employee of the 3PL. Overall logistic management was led by the DHO personnel. They

are helping the 3PL to learn by showing examples of task to be performed. The DHO was

also provided orientation to the 3PL about the sensitivity of the task and precautions to be

taken while handling, loading and unloading of the drugs, storing and transporting.

Respondents from the DHO said that the facilitation of the DHO will be crucial to orient

members of the district per unit rate fix committee so that they understand special

characteristics of the health commodities and recommend for the different per unit supply

cost for the health commodities. They also expressed need of multi-year contract with the

3PL so that private sector develops expertise. Furthermore, some district level

respondents expressed that the DHO should establish some mechanism of compensation

for the damage or risk at the time of disaster.

Role of the Third Party Logistic Provider

According to the majority of the respondents, 3PL should show more pro-activeness in

the process of health commodities supply. According to the district level respondents,

3PL should hire technically competent personnel and retain him/her for longer period.

Only the staff trained can provide support in management of the district and health

facility stores. They also added that the 3PL should mange varieties of vehicles suitable

for the geography and the road of the district. Many respondents from the HFs expected

34

3PL's support in the HF's store management and adequate communication between them

about schedule of drug supply.

Findings of observation

Study team observed stores of the DHO, the district hospital and the seven HFs. During

the observation, it was found that all stores maintained drugs as first expiry first out

system. Less than half stores had proper ventilation and had adequate racks and other

arrangements for the proper storage of the drugs. Among seven health facilities' where

actual counts of the selected drugs (Condom, Contraceptive Oral Pills, Depoporvera

Injectable, Vitamin A, Iron tablet, Oxytocin Injection, Cotrimoxazole PD, Amocycillin

500 mg, Magnesium Sulphate Injection, Ciprofloxacin 500 mg and Oral Rehydration

Salt) were carried out, one did not have mentioned EOP after the involvement of the 3PL

(Laphagaon HP). Among other six health facilities, 17 percent commodities were stock

out, 35 percent were under stock (stock on hand for less than one month expense) and 14

percent were over stock (stock on hand for more than five months)(Figure: 10).

Figure 10: Stock status of selected drugs in actual count

Among actual count drugs Condom was overstocked in 83 percent of facilities followed

by Pills and Deop. Similarly iron tablet was under stock in 83 percent of facilities

followed by Oxytocin, Cotrimoxazole PD and Ciprofloxacin tablet. Amoxycillin 500 mg

1827 27

09

18 17

45

27

9

64

45

18

3527

0

27

9 9 914

Siddhipur HP Dumre HP Nametar HP Triveni HP Beltar PHCC Sunderpur Total

Stock status of selected drugs in actual count

Stock out under stock Over stock

35

capsule was found stock out in 67% facilities followed by Magnisium Sulphate (figure

11).

Figure 11: Stock status of commodities in actual count in six health facilities

0 0 0 0 0

17 17 17

67

50

17

0

17

33

17

33

83

50 50

33

17

50

83

33

17

0

17

0 0 0 0 0 0

Stock status of commodities in actual count in six health facilities

stock out under stock Over stock

36

Conclusions

DHO Udyapur is one of the first four districts which contracted 3PL for the sub-district

level management of health commodities. Contracting private party for the management

of the health commodities was new for both the DHO and the private sectors also. No

private sectors have expertise required for the logistic management of health

commodities at the beginning. Very few private parties showed their interest at the

beginning. Formally, 3PL started sub-district level logistic management of health

commodities since Magh 2070 BS in Udyapur district. Around two years' experience of

different stakeholders revealed that involvement of the 3PL for the sub-district level

logistic management of health commodities contribute in the delivery of quality health

service through increased availability of the drugs in the HFs, reducing work burden of

the health workers and management of additional resources for the health service.

Provision of technical support to the HFs in recording and reporting of health

commodities, collection of reports and follow-up were major responsibility of the 3PL.

Analysis of LMIS reports revealed no remarkable change in reporting status. Reporting

of the expiry of the drugs found highest after the involvement of the 3PL. However, it

may be due to drugs over stocked in the health facility before the 3PL. Stock status of

drugs were found increased in the beginning of the 3PL. But it became worse in the last

two quarter and it may be due to lack of adequate drugs in the district store. Until and

unless there is adequate health commodities in the district store, role of the 3PL will be

limited in improving stock status of health commodities at the HFs.

The 3PL involved in the health logistic management did not have adequate expertise in

various aspects of health logistic management. The DHO provided orientation as well as

onsite coaching to them and utilized their support. Health commodities to send to HFs

were quantified by the DHO store and the 3PL support on it by review and analysis of

ASL/EOP of the HFs. Actual counts of the drugs in the stores were becoming possible

37

after the involvement of the 3PL. Furthermore, the 3PL has provided support in

packaging of the right health commodities in right way.

The 3PL was supplying and distributing health commodities as per the route and time

fixed by the DHO. Direction provided by the DHO was followed by the 3PL. The 3PL

was supplying health commodities to the HFs when there were adequate load for the

vehicle. For small amount of health commodities, many health workers reported visit to

the DHO store themselves. The 3PL was reported difficulty in finding labor to supply

health commodities in the remote VDCs without road access for the vehicles. It was

found that health commodities were transported and handled with necessary precautions.

Furthermore, the 3PL had collected and submitted registration form as well as LMIS

reports to the concerned authorities.

Involvement of the 3PL in the health commodities management has reduced work burden

of the DHO and the HFs staffs. Moreover, resources saved in the DHO and the HFs due

to handing of health logistics by the 3PL was diverted in other aspects of health service.

It has contributed in the improvement of the health service quality. Many respondents

suggested some type of cost sharing mechanisms between local government bodies and

the DHO for the sustainability of the involvement of 3PL in the health commodities

supply and management.

Many stakeholders took the involvement of the 3PL as the innovation having direct

impact on the quality of the health services. It has not only improved availability of the

drugs in the HFs but also make IEC materials available to the targeted population. In

contrast, there is ample space to improve in the availability of the health commodities in

remote HFs. Adequate attention should be paid to make health commodities available in

remote HFs on time.

Though logistic management of the health commodities was new and challenging as well

as less lucrative from the economic perspective, the 3PL was found satisfied with the job

38

and expressed their willingness to continue the work. It was found that the 3PL should be

pro-active in improving its organizational expertise and be more responsive to the need of

the peripheral health facilities. Furthermore, they should give attention on the store

management and strengthening of information system in addition of supply part.

Existing per unit cost of supply does not differentiate health commodities from other

daily consumables and construction materials. The stakeholders should take action to

make members of the concerned authority understand the sensitivity of the health

commodities so that they recommend different per unit cost for supply of health

commodities. It will make this job more lucrative for the private party and they will

invest in their capacity enhancement.

Mismatch in the starting of the fiscal year of the DHO and the funding agency was also

reported as hindrance for the continuity of the contract of the 3PL leading to stop of the

supply of commodities for the certain period. Review of the implementation status of the

program should be given priority. Adequate monitoring and supervision of the work of

the 3PL at the DHO and the peripheral HFs will help them to work effectively and

efficiently.

Recommendations

Recommendations for the DHO and the 3PL

• Provide regular follow up to the HFs for the timely reporting of LMIS

• Provide orientation and regular technical support to the HFs to make LMIS report

complete and accurate, especially about ASL/EOP calculation and store

management

• Establish formal body or mechanism for monitoring and coordination

• Establish compensation mechanism in case of damage of drugs due to

unavoidable circumstances

39

• Advocate for the different per unit cost of supply of health commodities

Recommendations for the DHO

• Help 3PL to enhance their technical capacity through, orientation and onsite

coaching

• Ensure adequate stock of health commodities in the district store. Coordinate and

collaborate with the concerned higher authority of the government for the purpose

• Allocate health commodities adequate for at least a year for remote health

facilities

• Minimize need of emergency supply by providing drugs as per ASL

• Increase monitoring and supervision of the health commodities management at

the HFs

• Advocate for the multi-year contract of the 3PL with the higher authority

• Assign technical person (pharmacy graduate) in the district store

• Advocate at the policy for the arrangement of cost sharing between local

governance and health office which arrange necessary fund for the sub-district

level health commodities

Recommendations for the 3PL

• Increase role in store management of the peripheral HFs

• Improve retention capacity of the trained human resource

• Arrange varieties of means of transportation

• Improve communication with peripheral health facilities

40

Annexes

Annex I: KII guidelines for the District health managers

!= cGtjf{tf lng] JolQmsf] kl/ro M gd:sf/ . d]/f] gfd ============================= xf] . d lhNnf :jf:Yo sfof{no, pbok'/, / UNFPA s]f nflu g]kfn ljsf; ;dfhsf] tkm{af6 ;fj{hlgs lghL ;fem]bf/L cawf/0ff cg'?k lhNnf :6f]/af6 :jf:Yo ;+:yfx?;Dd cTofaZos cf}iflw, ;fwg tyf ;fdu|Lx? 9'jfgL ug]{ sfo{j|md ;DaGwL oxfFsf] cg'ej, ck]Iff / wf/0ffx¿ ;fy} o; sfo{j|mdnfO{ ;'wf/ ug{sf nflu oxfFsf ;'emfjx? a'em\g rfxG5' . xh'/sf] af/]df / xh'/sf] kbsf] af/]df ;fdfGo hfgsf/L af6 s'/fsfgL ;'? ug{ rfxG5' .

!=! cGt{jftf{ lnPsf] ldltM

!=@ cGt{jftf{ lbg] JolQmsf] gfd / kbM

!=# sfof{nosf] gfdM

!=$ sfof{no /x]sf] :yfgM

!=% sfdsf] cg'ej -k"/f u/]sf] jif{_M

!=^ tkfO{n] o; :jf:Yo ;+:yfdf sfd ug'{ ePsf] slt jif{ eof] <

@= ;fj{hlgs lghL ;fem]bf/L cawf/0ff cg'?k lhNnf :6f]/af6 :jf:Yo ;+:yfx?;Dd cTofaZos cf}iflw, ;fwg

tyf ;fdu|Lx? 9'jfgL ug]{ af/]df :jf:Yo ;]jf Joj:yfks x?sf] cg'ejx?, ck]Iffx? / wf/0ffx?

d'Vo k|Zgx¿ k|f]a k|Zgx¿

@=! o; sfo{qmddf oxfFsf] ;+Ungtfsf af/]df s[kof elglbg'xG5sL <

• tkfO{Fsf] ;xeflutf o; sfo{j|md df s:tf] / s'g 9ª\usf] /x]sf] 5 <

• tkfO{Fsf] ;+:yfn] o; sfo{j|mdnfO{ s;/L ;xof]u ul//x]sf] 5 <

@=@ o; lhNnfdf xfn lhNnf :6f]/af6 :jf:Yo ;+:yfx?;Dd cTofaZos cf}iflw, ;fwg tyf ;fdu|Lx? 9'jfgL ug]{ sfo{ s;l/ ;+rfng eO/x]sf] 5 < s:n] g]t[Tj lnO/fv]sf] 5 < s:n] ;xof]u ul//x]sf] 5<

• kl/df0f lgwf{/0fdf • Kofs]lhªdf • 9'jfgL tyf ljt/0fdf • k|ltj]bg tofl/ tyf k|]if0fdf

@=#= o; sfo{df lghL If]qsf] ;+nUgtf nfO{ s;l/ lnO/fVg' ePsf] 5 <

• Joj:yfklso af]em s:tf] ePsf] 5 < • gofFkg s]lx cfPsf] 5 < • :jf:Yo ;+:yfdf cf}iflw, ;fwg tyf ;fdu|Lx?sf]

41

pknAwtf sf] l:ylt • l56f] 5l/tf] ePsf] 5 ls 5}g .

@=$= o; sfo{df lghL If]qsf] ;+nUgtf x'g' eGbf cl3 / ;+nUgtf eO;s] kl5sf] cj:yfnfO{ s;l/ lnO/fVg' ePsf] 5

• s] lghL If]qsf] ;+nUgtfn] o; sfo{df lhNnf :jf:Yo Joj:yfkg jf :jf:Yo ;]jf Joj:yfkgdf ;xof]u ldn]sf] 5<

• lghL If]qsf] ;+nUgtf kl5 ePsf vf; pknlJwx? s] s] x'g\ <

• lgHfL If]qsf] ;+nUgtf kl5 tkfO{n] s] s:tf ;d:ofx? ef]Ug' jf b]Vg' ePsf] 5< pxfFx¿n] 5'66} lsl;dsf ;]jf ;'ljwfx¿ lbg'k5{ h:tf] nfU5 <

@=% o; sfo{df lghL If]qsf] ;+nUgtfsf] eljZosf] af/]df oxfFsf] s] wf/0ff 5 <

• pxfFx¿sf] e"ldsfx¿df s:tf] kl/jt{g cfjZos b]Vg'x'G5 < To;}u/L pxfFx¿n] ug]{ sfo{j|mddf, sfo{j|mdsf] Joj:yfkgdf < ;]jf ;'ljwfx? <

• lghL If]qsf] ;+nUgtf kl5 lhNnf :jf:Yo Joj:yfkg jf :jf:Yo ;+:yf Joj:yfkgdf s] s] r'g}ftL b]Vg' ePsf] 5 <

@=^ o; sfo{df lghL If]qsf] ;+nUgtfsf] nflu cfkm\gf] ;+:yf tyf ;+/rgfdf s'g} kl/jt{g jf ;'wf/ Nofpg] kxn ug'{ k/\of] jf ug'{x'G5 <

• s] kl/jt{g ug'{ eof] jf ug'{x'G5 < • s'g—s'g kIfx? kl/jt{g x'g'x'Fb}g h:tf] nfU5 <

#= xfldn] 5nkmn u/] jfx]s ;fj{hlgs lghL ;fem]bf/L cawf/0ff cg'?k lhNnf :6f]/af6 :jf:Yo ;+:yfx?;Dd cTofaZos cf}iflw, ;fwg tyf ;fdu|Lx? 9'jfgL ug]{ af/]df cGo s'g} s'/f eGg afFsL 5 h:tf] nfUb5 eg] s[kof eGg' xf]nf .

$= xfdLn] oxfFx? ;+u w]/} k|Zg u¥of} . ca oxfFx¿nfO{ s'g} s'/f ;f]Wg cyjf xfdLnfO{ s]xL eGg dg 5 eg] ;Sg'x'G5 .

Annex II: KII guidelines for the health workers

!= cGtjf{tf lng] JolQmsf] kl/ro M gd:sf/ . d]/f] gfd ======================== xf] . d lhNnf :jf:Yo sfof{no, pbok'/, / UNFPA s]f nflu g]kfn ljsf; ;dfhsf] tkm{af6 ;fj{hlgs lghL ;fem]bf/L cawf/0ff cg'?k lhNnf :6f]/af6 :jf:Yo ;+:yfx?;Dd cTofaZos cf}iflw, ;fwg tyf ;fdu|Lx? 9'jfgL ug]{ sfo{j|md ;DaGwL oxfFsf] cg'ej, ck]Iff / wf/0ffx¿ ;fy} o; sfo{j|mdnfO{ ;'wf/ ug{sf nflu oxfFsf ;'emfjx? a'em\g rfxG5' . xh'/sf] af/]df / xh'/sf] kbsf] af/]df ;fdfGo hfgsf/L af6 s'/fsfgL ;'? ug{ rfxG5' .

42



!=# sfof{nosf] gfdM

!=$ sfof{no /x]sf] :yfgM


!=^ tkfO{n] o; :jf:Yo ;+:yfdf sfd ug'{ ePsf] slt jif{ eof] <


tyf ;fdu|Lx? 9'jfgL ug]{ af/]df ;]jf k|bfosx?sf] cg'ejx?, ck]Iffx? / wf/0ffx?

d'Vo k|Zgx¿ k|f]a k|Zgx¿ :ki6 kfg]{ k|Zgx¿ -cfjZos k/]df dfq_

@=! ;fj{hlgs lghL ;fem]bf/L cawf/0ff cg'?k lhNnf :6f]/af6 :jf:Yo ;+:yfx?;Dd cTofaZos cf}iflw, ;fwg tyf ;fdu|Lx? 9'jfgL ug]{ sfo{qmddf oxfFsf] ;+Ungtfsf af/]df s[kof elglbg'xG5sL <

• tkfO{Fsf] ;xeflutf o; sfo{j|md -lhNnf af6 c}iflw kfpg] tyf :jf:Yo ;+:yfdf cf}iflw Joj:yfkg ug]{ ;DaGwdf _ df s:tf] / s'g 9ª\usf] /x]sf] 5 <

• tkfO{Fsf] ;+:yfn] o; sfo{j|mdnfO{

s;/L ;xof]u ul//x]sf] 5 <

• o;sf] af/]df lj:tf/df atfO{lbg'x'G5 < • o; afx]s cGo s]xL 5 < • sg} pbfx/0fx¿ 5g\ <

• s]xL sf/0fx¿ 5g\ <

@=@ o; lhNnfdf xfn lhNnf :6f]/af6 :jf:Yo ;+:yfx?;Dd cTofaZos cf}iflw, ;fwg tyf ;fdu|Lx? 9'jfgL ug]{ sfo{ s;l/ ;+rfng eO/x]sf] 5 < s:n] g]t[Tj lnO/fv]sf] 5 < s:n] ;xof]u ul//x]sf] 5<

• kl/df0f lgwf{/0fdf • Kofs]lhªdf • 9'jfgL tyf ljt/0fdf • k|ltj]bg tofl/ tyf k|]if0fdf

• o;sf] af/]df lj:tf/df atfO{lbg'x'G5 < • o; afx]s cGo s]xL 5 < • sg} pbfx/0fx¿ 5g\ < • s]xL sf/0fx¿ 5g\ <

@=#= o; lhNnfdf xfn lhNnf :6f]/af6 :jf:Yo ;+:yfx?;Dd cTofaZos cf}iflw, ;fwg tyf ;fdu|Lx? 9'jfgL ug]{ sfo{df lghL If]qsf] ;+nUgtf nfO{ s;l/

• :jf:Yo ;+:yfdf cf}iflw, ;fwg tyf ;fdu|Lx?sf] pknAwtf sf] l:ylt

• l56f] 5l/tf] ePsf] 5 ls 5}g . • Joj:yfklso af]em s:tf] ePsf] 5

< • gofFkg s]lx cfPsf] 5 <


43

lnO/fVg' ePsf] 5 <

@=$= o; lhNnfdf lhNnf :6f]/af6 :jf:Yo ;+:yfx?;Dd cTofaZos cf}iflw, ;fwg tyf ;fdu|Lx? 9'jfgL ug]{ sfo{df lghL If]qsf] ;+nUgtf x'g' eGbf cl3 / ;+nUgtf eO;s] kl5sf] cj:yfnfO{ s;l/ lnO/fVg' ePsf] 5

• s] lghL If]qsf] ;+nUgtfn] o; sfo{df lhNnf :jf:Yo Joj:yfkg jf :jf:Yo ;]jf Joj:yfkgdf ;xof]u ldn]sf] 5<


• lgHfL If]qsf] ;+nUgtf kl5 tkfO{n] s] s:tf ;d:ofx? ef]Ug' jf b]Vg' ePsf] 5<

• pxfFx¿n] 5'66} lsl;dsf ;]jf ;'ljwfx¿ lbg'k5{ h:tf] nfU5 <


@=% lhNnfdf lhNnf :6f]/af6 :jf:Yo ;+:yfx?;Dd cTofaZos cf}iflw, ;fwg tyf ;fdu|Lx? 9'jfgL ug]{ sfo{df lghL If]qsf] ;+nUgtfsf] eljZosf] af/]df oxfFsf] s] wf/0ff 5 <

• pxfFx¿sf] e"ldsfx¿df s:tf] kl/jt{g cfjZos b]Vg'x'G5 < To;}u/L pxfFx¿n] ug]{ sfo{j|mddf, sfo{j|mdsf] Joj:yfkgdf < ;]jf ;'ljwfx? <

• lghL If]qsf] ;+nUgtf kl5 lhNnf :jf:Yo Joj:yfkg jf :jf:Yo ;+:yf Joj:yfkgdf s] s] r'g}ftL b]Vg' ePsf] 5 <


@=^ lhNnfdf lhNnf :6f]/af6 :jf:Yo ;+:yfx?;Dd cTofaZos cf}iflw, ;fwg tyf ;fdu|Lx? 9'jfgL ug]{ sfo{df lghL If]qsf] ;+nUgtfsf] nflu cfkm\gf] ;+:yf tyf ;+/rgfdf s'g} kl/jt{g jf ;'wf/ Nofpg] kxn ug'{ k/\of] jf ug'{x'G5 <

• s] kl/jt{g ug'{ eof] jf ug'{x'G5 <

• s'g—s'g kIfx? kl/jt{g x'g'x'Fb}g h:tf] nfU5 <




44

Annex III: KII guidelines for the HFOMC members and FCHVs

!= cGtjf{tf lng] JolQmsf] kl/ro M gd:sf/ . d]/f] gfd /fh]z km'ofFn xf] . d lhNnf :jf:Yo sfof{no, pbok'/, / UNFPA s]f nflu g]kfn ljsf; ;dfhsf] tkm{af6 ;fj{hlgs lghL ;fem]bf/L cawf/0ff cg'?k lhNnf :6f]/af6 :jf:Yo ;+:yfx?;Dd cTofaZos cf}iflw, ;fwg tyf ;fdu|Lx? 9'jfgL ug]{ sfo{j|md ;DaGwL oxfFsf] cg'ej, ck]Iff / wf/0ffx¿ ;fy} o; sfo{j|mdnfO{ ;'wf/ ug{sf nflu oxfFsf ;'emfjx? a'em\g rfxG5' . xh'/sf] af/]df / xh'/sf] kbsf] af/]df ;fdfGo hfgsf/L af6 s'/fsfgL ;'? ug{ rfxG5' .



!=# :jf:Yo ;+:yfsf] gfdM

!=$ uf lj ; sf] gfdM


@= ;fj{hlgs lghL ;fem]bf/L cawf/0ff cg'?k lhNnf :6f]/af6 :jf:Yo ;+:yfx?;Dd cTofaZos cf}iflw, ;fwg tyf ;fdu|Lx? 9'jfgL ug]{ af/]df dlxnf :jf:Yo :jo+ ;]ljsf jf :jf:Yo ;+:yf Joj:yfkg ;ldltsf ;b:osfdlxnf :jf:Yo :jo+ ;]ljsf jf :jf:Yo ;+:yf Joj:yfkg ;ldltsf ;b:osfdlxnf :jf:Yo :jo+ ;]ljsf jf :jf:Yo ;+:yf Joj:yfkg ;ldltsf ;b:osfdlxnf :jf:Yo :jo+ ;]ljsf jf :jf:Yo ;+:yf Joj:yfkg ;ldltsf ;b:osf cg'ejx?, ck]Iffx? / wf/0ffx?

d'Vo k|Zgx¿ k|f]a k|Zgx¿ :ki6 kfg]{ k|Zgx¿ -cfjZos k/]df dfq_

@=! ;fj{hlgs lghL ;fem]bf/L cawf/0ff cg'?k lhNnf :6f]/af6 :jf:Yo ;+:yfx?;Dd cTofaZos cf}iflw, ;fwg tyf ;fdu|Lx? 9'jfgL ug]{ sfo{qmddf tkfO{sf] tkfO{sf] tkfO{sf] tkfO{sf] e"ldsfe"ldsfe"ldsfe"ldsf s] 5<

• tkfO{Fsf] ;xeflutf o; sfo{j|md df s:tf] / s'g 9ª\usf] /x]sf] 5 <

• tkfO{Fsf] ;+:yfn] o; sfo{j|mdnfO{ s;/L ;xof]u ul//x]sf] 5 <

o kl/df0f lgwf{/0f o Kofs]lhª o 9'jfgL tyf ljt/0f o k|ltj]bg tofl/ tyf k|]if0f

• lhNnfaf6 pknAw cf}iflw sf] bflvnf ubf{ jf Kofs]h v]fln cf}iflw k|of]udf Nofpg eGbfcl3 tkfO{x?sf] e'ldsf s] x'G5 <

• o;sf] af/]df lj:tf/df atfO{lbg'x'G5 <

• o; afx]s cGo s]xL 5 <

• sg} pbfx/0fx¿ 5g\ < • s]xL sf/0fx¿ 5g\ <

@=@= o; lhNnfdf xfn lhNnf :6f]/af6 :jf:Yo ;+:yfx?;Dd cTofaZos cf}iflw, ;fwg tyf

• :jf:Yo ;+:yfdf cf}iflw, ;fwg tyf ;fdu|Lx?sf] pknAwtf


45

;fdu|Lx? 9'jfgL ug]{ sfo{df lghL If]qsf] ;+nUgtf nfO{ s;l/ lnO/fVg' ePsf] 5 <

• l56f] 5l/tf] • Joj:yfklso af]em • gofFkg

• o; afx]s cGo s]xL 5 < • sg} pbfx/0fx¿ 5g\ < • s]xL sf/0fx¿ 5g\ <

@=#= o; lhNnfdf lhNnf :6f]/af6 :jf:Yo ;+:yfx?;Dd cTofaZos cf}iflw, ;fwg tyf ;fdu|Lx? 9'jfgL ug]{ sfo{df lghL If]qsf] ;+nUgtf x'g' eGbf cl3 / ;+nUgtf eO;s] kl5sf] cj:yfsf] af/]df ljleGg ;/f]sf/x?sf] s:tf] k|ltlqmof, cg'ej tyf wf/0ff kfpg' ePsf] 5<

• lhNnf :jf:Yo sfof{no, c:ktfn, cGo :jf:Yo ;+:yf tyf :jf:Yo ;]jf k|bfosx?af6 o; sfo{df slQsf] ;xof]u ldn]sf] 5<


• lgHfL If]qsf] ;+nUgtfdf tkfO{n] s] s:tf ;d:ofx? ef]Ug' jf b]Vg' ePsf] 5<



@=$ lhNnfdf lhNnf :6f]/af6 :jf:Yo ;+:yfx?;Dd cTofaZos cf}iflw, ;fwg tyf ;fdu|Lx? 9'jfgL ug]{ sfo{df lghL If]qsf] ;+nUgtfsf] eljZosf] af/]df oxfFsf] s] wf/0ff 5 <

• o; sfo{nfO{ lg/Gt/tf lbg lghL If]qsf s] s] r'gf}lt x'g;S5g\ .

• r'gf}ltx? ;fdgf ug{ lghL If]qsf] e"ldsf s;/L kl/:s[t xF'b} hfg'k5{ -olb cfjZos k/]df_ <

• lhNnf :jf:Yo sfof{no, c:ktfn, :jf:Yo ;+:yf tyf :jf:YosdL{x?sf] e"ldsfx¿df s:tf] kl/jt{g cfjZos b]Vg'x'G5 < To;}u/L pxfFx¿n] ug]{ sfo{j|mddf, sfo{j|mdsf] Joj:yfkgdf < ;]jf ;'ljwfx? <



@=% lhNnfdf lhNnf :6f]/af6 :jf:Yo ;+:yfx?;Dd cTofaZos cf}iflw, ;fwg tyf ;fdu|Lx? 9'jfgL ug]{ sfo{df lghL If]qsf] ;+nUgtfsf] nflu of] ;+:yf tyf ;+/rgfdf s'g} kl/jt{g jf ;'wf/ Nofpg] kxn ug'{ k/\of] jf ug'{x'G5 <

• s] kl/jt{g ug'{ eof] jf ug'{x'G5 <

• s'g—s'g kIfx? kl/jt{g x'g'x'Fb}g h:tf] nfU5 <



46

@=^ of :jf:Yo ;+:yfdf pknAw ePsf cf}iflw tyf pks/0f sf] af/]df ;]jfu|lxsf] k|ltlqmof s:tf] kfpg' ePsf] 5<

• cf}iflwsf] pknAwtfsf] af/]df • ;]jfsf] u'0f:t/sf] af/]df



@=& of] :jf:Yo ;+:yfsf] cf]ifwL /fVg] tl/sf, 7fpF tyf ;/;kmfOsf] af/]df tkfO{sf] k|ltlqmof s] 5 <

cf}iflw pko'Qm ?kdf -3fd, kfgL, cf]; cflb_ af6 ;'/lIft hf]ufP/ /flvPsf] 5 ls 5}g< cf}iflw /fVbf klxnf ldlt ;lsg]nfO{ klxnf k|of]u ug{ ldNg] ul/ /flvPsf] jf k|of]u ul/Psf] 5 ls 5}g< klxnf -lghL If]q cfpg' eGbf_ / clxn] s] km/s 5<



$= xfldn] 5nkmn u/] jfx]s ;fj{hlgs lghL ;fem]bf/L cawf/0ff cg'?k lhNnf :6f]/af6 :jf:Yo ;+:yfx?;Dd cTofaZos cf}iflw, ;fwg tyf ;fdu|Lx? 9'jfgL ug]{ af/]df cGo s'g} s'/f eGg afFsL 5 h:tf] nfUb5 eg] s[kof eGg' xf]nf .

%= xfdLn] oxfFx? ;+u w]/} k|Zg u¥of} . ca oxfFx¿nfO{ s'g} s'/f ;f]Wg cyjf xfdLnfO{ s]xL eGg dg 5 eg] ;Sg'x'G5 .

Annex IV: KII guidelines for the third party logistic provider

!= cGtjf{tf lng] JolQmsf] kl/ro M gd:sf/ . d]/f] gfd lnnfw/ 9sfn xf] . d lhNnf :jf:Yo sfof{no, pbok'/, / UNFPA s]f nflu g]kfn ljsf; ;dfhsf] tkm{af6 ;fj{hlgs lghL ;fem]bf/L cawf/0ff cg'?k lhNnf :6f]/af6 :jf:Yo ;+:yfx?;Dd cTofaZos cf}iflw, ;fwg tyf ;fdu|Lx? 9'jfgL ug]{ sfo{j|md ;DaGwL oxfFsf] cg'ej, ck]Iff / wf/0ffx¿ ;fy} o; sfo{j|mdnfO{ ;'wf/ ug{sf nflu oxfFsf ;'emfjx? a'em\g rfxG5' . xh'/sf] af/]df / xh'/sf] kbsf] af/]df ;fdfGo hfgsf/L af6 s'/fsfgL ;'? ug{ rfxG5' .


!=@ cGt{jftf{ lng] JolQmsf] gfdM

!=# cGt{jftf{ lbg] JolQmsf] gfd / kbM

!=$ sfof{nosf] gfdM

47

!=% sfof{no /x]sf] :yfgM

!=^ sfdsf] cg'ej -k"/f u/]sf] jif{_M

!=& d'Vo e'ldsf tyf lhDd]jf/Lx¿M


tyf ;fdu|Lx? 9'jfgL ug]{ af/]df lghL ;]jf k|bfossf] cg'ejx?, ck]Iffx? / wf/0ffx?

d'Vo k|Zgx¿ k|f]a k|Zgx¿ :ki6 kfg]{ k|Zgx¿

@=! o; sfo{qmddf oxfFsf] ;+Ungtfsf af/]df s[kof elglbg'xG5sL <

• s:tf] / s'g 9ª\usf] /x]sf] 5 < • tkfO{Fsf] ;+:yfn] o; sfo{j|mdnfO{

s;/L ;xof]u ul//x]sf] 5 < o kl/df0f lgwf{/0f o Kofs]lhª o 9'jfgL tyf ljt/0f o k|ltj]bg tofl/ tyf

k|]if0f



@=@= o; lhNnfdf xfn lhNnf :6f]/af6 :jf:Yo ;+:yfx?;Dd cTofaZos cf}iflw, ;fwg tyf ;fdu|Lx? 9'jfgL ug]{ sfo{df lghL If]qsf] ;+nUgtf nfO{ s;l/ lnO/fVg' ePsf] 5 <

• :jf:Yo ;+:yfdf cf}iflw, ;fwg tyf ;fdu|Lx?sf] pknAwtf

• l56f] 5l/tf] • Joj:yfklso af]em • gofFkg



@=#= cf}iflw, ;fwg tyf ;fdu|Lx? 9'jfgL ug]{ sfo{df lghL If]qsf] ;+nUgtf x'g' eGbf cl3 / ;+nUgtf eO;s] kl5sf] cj:yfsf] af/]df ljleGg ;/f]sf/x?sf] s:tf] k|ltlqmof, cg'ej tyf wf/0ff kfpg' ePsf] 5<

• lhNnf :jf:Yo sfof{no, c:ktfn, cGo :jf:Yo ;+:yf tyf :jf:Yo ;]jf k|bfosx?af6 o; sfo{df slQsf] ;xof]u ldn]sf] 5<


• lgHfL If]qsf] ;+nUgtfdf tkfO{n] s] s:tf ;d:ofx? ef]Ug' jf b]Vg' ePsf] 5<



@=$ o; sfo{df lghL If]qsf] ;+nUgtfsf] eljZosf] af/]df oxfFsf] s]

• o; sfo{nfO{ lg/Gt/tf lbg lghL If]qn] s] s] r'gf}lt ;fdgf ug'{knf{ < • r'gf}ltx? ;fdgf ug{ lghL If]qsf] e"ldsf s;/L kl/:s[t xF'b} hfg'k5{

48

wf/0ff 5 < -olb cfjZos k/]df_ < • lhNnf :jf:Yo sfof{no, c:ktfn, :jf:Yo ;+:yf tyf :jf:YosdL{x?sf] e"ldsfx¿df s:tf] kl/jt{g cfjZos b]Vg'x'G5 < To;}u/L pxfFx¿n] ug]{ sfo{j|mddf, sfo{j|mdsf] Joj:yfkgdf < ;]jf ;'ljwfx? <

@=% o; sfo{df lghL If]qsf] ;+nUgtfsf] nflu cfkm\gf] ;+:yf tyf ;+/rgfdf s'g} kl/jt{g jf ;'wf/ Nofpg] kxn ug'{ k/\of] jf ug'{x'G5 <

@=^ lhNnfdf lhNnf :6f]/af6 :jf:Yo ;+:yfx?;Dd cTofaZos cf}iflw, ;fwg tyf ;fdu|Lx? 9'jfgL ug]{ sfo{df lghL If]qsf] ;+nUgtfsf] nflu yk s:tf >f]tx? cfjZos k5{g\ </ tL ;|f]t ;fwgsf] Joj:yf s;l/ ug{ ;lsG5 <



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