HEALTH FOR LIFE PROJECT ANNUAL REPORT

JULY 1, 2015 TO JUNE 30, 2016

July 31, 2016 This publication was produced for review by the United States Agency for International Development. It was prepared by RTI International. Health for Life Project Annual Report

July 31, 2016

Contract AID-367-C-13-00001

Prepared for COR Office of Health and Education USAID/ P.O. Box No. 295 U.S. Embassy, Maharajgunj Kathmandu, Nepal

Prepared by RTI International 3040 Cornwallis Road Post Office Box 12194 Research Triangle Park, NC 27709-2194

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The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government. CONTENTS List Of Figures ...... iv List of Tables...... v Abbreviations ...... vi Background ...... 4 A. Accomplishments And Intended Outcomes For The Period ...... 5 Objective 1: Improve Health Systems Governance Of District Offices And Sub-District Level Facilities ...... 5 Objective 2: Develop and implement national evidence-based policy ...... 14 Objective 3: Strengthen National-Level Stewardship Of The Health Sector ...... 25 Objective 4: Institutionalize Nationwide System For Quality Improvement ...... 26 Objective 5: Improve Capacity Of District And Local Level Health Workers And Community Volunteers To Deliver High Quality FP/MNCH And Nutrition Services ...... 34 Objective 6: Improve Knowledge, Behavior, And Use Of Health Services Among Target Population ...... 47 Objective 7: Strengthen Lifeline's Capacity for Logistical Support ...... 54 Health for Life Staff composition ...... 54 B. Major challenges and constraints faced during the performance period that resulted in delays of achievement of outcomes, if applicable ...... 55 C. Highlights of the internship program as described in Section C.2.8.1D...... 57 D. Cumulative quantitative monitoring and evaluation data, including information on progress towards targets and explanations of any issues related to data quality ...... 58 Capacity Building Benchmarks ...... 58 PMP and PPR Indicators ...... 62 E. Information on the status of finances, including expenditure data based on the budget and accruals, as well as, when appropriate, analysis and explanation of cost overruns or high unit cost ..73 F. Information on management issues, including administrative problems, or problems with beneficiary groups, or implementing partners and what steps or actions were taken to manage these and lessons learned for future ...... 74 G. Anticipated future problems, delays, or conditions that may adversely impact implementation of the project and what measures are in place to deal with these ...... 75 H. Information on security issues, especially as these affect program integrity and safety of beneficiary groups and implementing partner ...... 75 I. Other information, such as new opportunities for program expansion, lessons-learned and success stories, and prospects for the following year’s performance ...... 76 Annexes ...... 77 Annex 1: Council Budget Allocations ...... 77 Annex 2: Joint Visits With GoN Staff From July 2015 And June 2016 ...... 78 Annex 3: Intern Testimonials ...... 82

Health for Life— Annual Report iii LIST OF FIGURES Figure 1.1 Three-Year Trend of Institutional Delivery in Selected High-Priority HFs of Health for Life Districts .. 6 Figure 1.2 Functionality Status of HFOMCs in EQ-Affected Districts ...... 8 Figure 1.3 Performance of HFOMCs in EQ-Affected Districts 2016 ...... 9 Figure 1.4 Status of HFOMC Revitalization, Health for Life EQ-Affected District Program as of June 2016 ...... 9 Figure 1.5 Major Activities Carried Out in the Demonstration Districts Using Flexible Health Grants ...... 14 Figure 2.1 Composition of Registered Pregnant Women by Caste/Ethnicity Against the Population Proportion in Health for Life Districts as of June 2016 ...... 16 Figure 2.2 Percentage of Registered Women who had Four ANC Visits Among All Live Births at 39 Sentinel Sites as of June 2016 (N=3,297) ...... 16 Figure 2.3 Percentage of Registered Women Who Delivered at Health Facilities and Percentage of Registered Women Who Had 1st PNC Within 24 Hours Among Live Births at 39 Sentinel Sites as of June 2016 (N=3,297) 18 Figure 2.4 Utilization of ANC, Institutional Delivery and PNC Services Among Registered Women, by Caste/Ethnicity at Sentinel Sites as of June 2016 ...... 18 Figure 2.5 Percentage of Registered Women Who Were Counselled and Chose To Use FP Among Closed Cases, by Caste and Ethnicity at 39 Sentinel Sites as of June 2016 ...... 19 Figure 2.6 Percentage of Registered Women Who Started Using a Modern Method of FP within 90 days of delivery, by Caste and Ethnicity at 39 Sentinel Sites as of June 2016 ...... 19 Figure 2.7 FP Methods Among Postpartum Women Currently Using FP Methods at Sentinel Sites as of June 2016 (N=976) ...... 19 Figure 2.8 General Readiness Index of HFs in EQ-Affected Districts 2016 ...... 22 Figure 4.1 Compliance with Physical Facility Standards at Selected HFs Of ...... 27 Figure 4.2 Compliance with IUCD Service Standards at Selected HFs of Dang ...... 28 Figure 4.3 District QAWCs Established Decision and Action Plans ...... 29 Figure 4.4 Readiness of HFs Regarding IP/HCWM (HF Midterm Survey) ...... 33 Figure 4.5 Compliance with Focused ANC Service Standards in Banke (High-Priority VDCs) ...... 33 Figure 4.6 Compliance with Standards for Care of Sick Child (2-59 Mo) in Selected HFs of Jajarkot ...... 33 Figure 5.1 Compliance with Standards at FP Training Sites ...... 37 Figure 5.2 Birthing Centers with LAFP ...... 40 Figure 5.3 LAFP in High-Priority and Other VDCs ...... 41 Figure 5.4 Status of Onsite Coaching and Joint Visits on CB-IMNCI ...... 43 Figure 5.5 IMNCI Service Utilization by 2-59 Month-Old Dalit Children in High-Priority VDCs, Rukum (HMIS Service Register) ...... 44 Figure 6.1: Percent of Adolescents Who Know the Legal Age of Marriage ...... 49 Figure 6.2 Percentage of Mother Group Meetings Held vs Those Planned ...... 52 Figure 6.3 Number of VDCs Conducting at Least 10 HMG Meetings per Year ...... 53 Figure 6.4 Examples of Good Practices by CAPs in Particular VDCs ...... 53 Figure 8.1 Health for Life Staff Categorization by Ethnicity ...... 54 Figure 8.2 Health for Life Staff Composition by Level and Gender ...... 54 Figure 8.3 Health for Life Staff Composition by Program and Ethnicity ...... 55

Health for Life— Annual Report iv LIST OF TABLES Table 1.1 Summary of HFOMC Functionality in High-Priority HFs as of June 2016 ...... 5 Table 1.2 Summary of HFOMC Performance in High-Priority HFs as of June 2016 ...... 6 Table 1.3 Categorization of HFOMCs Based on Functionality and Performance Measures in High-Priority HFs as of June 2016 ...... 7 Table 1.4 Status Of VHSARs, Local Health Plans And Approval From Municipal/Village Councils Of High- Priority HFs as of June 2016 ...... 10 Table 1.5 Municipal/Village Councils’ Allocation, Expenditure and Commitment in High-Priority HFs as of June 2016 ...... 11 Table 1.6 Status of VHSARs, Local Health Plans Developed and Approved from Municipal/Village Councils in Demonstration Districts as of June 2016 ...... 12 Table 1.7 Municipal/Village Councils Allocation, Expenditure and Commitment in Demonstration Districts as of June 2016 ...... 13 Table 2.1 Pregnant Women Tracked Using Mobile Technology in Health for Life Districts as of June 2016 ...... 15 Table 2.2 Summary of HF Readiness Visits by District ...... 20 Table 2.3 Summary of FCHV Readiness Visit by District and Semi-Annual Period ...... 21 Table 4.1 QAI TWG Meeting Summary ...... 26 Table 4.2 QAWC Meeting Status in Health for Life Core and Demonstration Districts ...... 29 Table 4.3 HF QI Implementation Status in Health for Life’s Core and Demonstration Districts ...... 32 Table 5.1 Readiness and Key Functions of Health Facilities and Hospitals Pertaining to CEONC Referrals ...... 36 Table 5.2 MSC Visits to HFs During Reporting Period ...... 39 Table 5.3 Percentage of Women Who Delivered at Home & Took Misoprostol, Against Expected Live Births, by District ...... 39 Table 5.4 Birthing Centers with Long-Acting FP (LAFP) in Health for Life Districts ...... 40 Table 5.5 CPR and LAFP Contribution in Health for Life Districts (HMIS) ...... 41 Table 5.6 Health for Life Support to Pre-VSC Meetings and VSC Service Utilization ...... 41 Table 5.7 IMNCI Visits to HFs During Reporting Period ...... 42 Table 5.8 Coaching at ANM schools ...... 46 Table 5.9 Knowledge and Skills assessment of ANM faculty members and students ...... 46 Table 6.1 BCC Materials Distributed in Various Districts ...... 51 Performance Management Plan (PMP) Report, July 2015-June 2016 ...... 62 Project Performance Report (PPR), July 2015 - June 2016 ...... 71

Health for Life— Annual Report v ABBREVIATIONS AFN Antenna Foundation Nepal DPC District Program Coordinator AHW Auxiliary Health Worker DPMAS District Poverty Monitoring and ANC antenatal care Analysis System ANM Auxiliary Nurse Midwife DQA data quality assessment ARI acute respiratory infection DRPM District Review and Planning Meeting ASRH adolescent sexual and reproductive DSA daily subsistence allowance health DWCO District Women & Children Office AWPB annual work plan and budget EBD evidence-based design AYFS adolescent and youth friendly services Eco-region Ecological Region BC birthing center EDCD Epidemiology and Disease Control BCC Behavior Change Communication Division BEOC basic emergency obstetric care/center EDP external development partner BEONC basic emergency obstetric and neonatal EHA essential hygiene actions care/center ENA essential nutrition actions BP blood pressure EPSEM Equal Probability of Selection Method BPP birth preparedness package ESG Evidence Support Group CAG Content Advisory Group FCHV Female Community Health Volunteer CAP Community Action Promoter FEP follow-up and enhancement program CAP/R Community Action FHD Family Health Division Promoter/Researcher FP family planning CB-IMCI community-based integrated FY fiscal year management of childhood illness G2G government-to-government CB-IMNCI community-based, integrated GBV gender-based violence management of newborn & childhood GESI gender equality and social inclusion illnesses GFA GFA Consulting Group CB-NCP community-based newborn care GIS geographic information system package GiZ German Federal Enterprise for CBO community-based organization International Cooperation CBS Central Bureau of Statistics GON Government of Nepal CEONC comprehensive emergency obstetric Health for Life Health for Life and neonatal care HA Health Assistant CF Collaborative Framework HC3 Health Community Capacity CH child health Collaborative CHD Child Health Division HCWM health care waste management CIP Costed Implementation Plan HET Health Education Technician CNCP Chlorhexidine Navi Care Program HF health facility COFP/C comprehensive family planning and HFOMC Health Facility Operation and counselling Management Committees COIA Commission on Information and HFRS health facility readiness survey Accountability HFQI Health Facility Quality Improvement COP Chief of Party HISPIX health information system CPR contraceptive prevalence rate performance index CTEVT Council for Technical Education and HLD high-level disinfection Vocational Training HMIS health management information CYP couple-years of protection system D(P)HO District (Public) Health Office HP Health Post DAG disadvantaged group HR human resources DDC District Development Committee HTSP healthy timing and spacing of DEO District Education Office pregnancy DHGSTF District Health Governance HW health worker Strengthening Task Force ICF ICF International DHIS District Health Information System ICP informed choice poster DHO District Health Office IEC information, education and DoHS Department of Health Services communications

Health for Life— Annual Report vi IFPSC Institutionalized Family Planning NDHS Nepal Demographic and Health Service Centers Survey INGO international nongovernmental NFCC Nepal Fertility Care Center organization NFHP Nepal Family Health Program IP infection prevention NGO non-governmental organization IPCC interpersonal communication and NHEICC National Health Education, counseling Information and Communication IRHDTC Integrated Rural Health Development Center Training Center NHRC Nepal Health Research Council IUCD intrauterine contraceptive device NHRN Nepal Health Research Network JAR Joint Annual Review NHSP Nepal Health Sector Program KAP knowledge, attitudes and practices NHTC National Health Training Center KMC Kangaroo mother care NPC National Planning Commission L&D labor and delivery NPHL National Public Health Laboratory LAFPM long-acting family planning methods NSI Nick Simon Institute LC Learning Circle NSV non-scalpel vasectomy LDO Local Development Office OCP oral contraceptive pills LGCDP Local Governance and Community OPD out-patient department Development Program ORC outreach clinic LHGS local health governance system ORS oral rehydration salts LHGSP Local Health Governance PDT Project Development Team Strengthening Program PFM public financial management LLN LifeLine Nepal PHA public health analytics LMIS logistics management information PHAMED Public Health Administration, system Monitoring and Evaluation Division M&E monitoring and evaluation PHAT public health analytic techniques M/DAG marginalized/disadvantaged group PHC primary health care MCHW Maternal and Child Health Worker PHCC Primary Health Care Center MD Management Division PHCRD Primary Health Care Revitalization MDG millennium development goal Division MICS multiple indicator cluster survey PHD Population Health and Development Miso Misoprostol PHI public health informatics MNCH maternal, newborn, and child health PHO Public Health Office MNCHN maternal, newborn, and child health PMP Performance Management Plan and nutrition PMTCT prevention of mother-to-child MNH maternal and newborn health transmission MoFALD Ministry of Federal Affairs and Local PNC postnatal care Development PPFP post-partum family planning MoH Ministry of Health PPH post-partum hemorrhage MoHP Ministry of Health and Population PPICD Policy, Planning and International (now MoH) Cooperation Division MoLD Ministry of Local Development (now PPIUCD postpartum intra-uterine contraceptive MoFALD) device MRS medical recording software PPR Performance Progress Report MSC Matri Surakshya Chhaki, i.e., PSC Public Service Commission misoprostol QA quality assurance MTOT master training of trainers QACG Quality Assurance Coordination MWDR Mid-Western Development Region Group MWRA married women of reproductive age QAI-TWG Quality Assurance and Improvement MWRHD Mid-Western Regional Health Technical Working Group Directorate QAWC Quality Assurance Working NBC newborn care Committee NCASC National Centre for AIDS and STD QAWG Quality Assurance Working Group Control QI quality improvement NCell private national cell service provider QIT Quality Improvement Team NCP newborn care package

Health for Life— Annual Report iv QITAC Quality Improvement Technical TOCAT technical and organizational capacity Advisory Committee assessment tool RH reproductive health TOR terms of reference RHCC Reproductive Health Coordination ToT training of trainers Committee TT tetanus toxoid RHD Regional Health Directorate TWG Technical Working Group RHTC Regional Health Training Center TWG-HIM Thematic Working Group – Health RMNCH reproductive maternal, newborn and Information Management child health UNFPA United Nations Fund for Population RTI Research Triangle Institute Activities SAR semi-annual report USAID United States Agency for International SBA Skilled Birth Attendant Development SHP Sub Health Post USG United States Government SIR Strategic Information and Research VASP value-added service provider SLC School Leaving Certificate VDC Village Development Committee SMP Safe Motherhood Program VHSAP village health situation analysis profile SNL Saving Newborn Lives VHW Village Health Worker SPSS Statistical Package for Social Sciences VSC voluntary sterilization camp (data analysis software) WASH water, sanitation and hygiene SRH sexual and reproductive health WCDO Women and Children Development STS service tracking survey Office TA technical assistance WDR Western Development Region WHO World Health Organization

Health for Life— Annual Report v BACKGROUND Health for Life (Health for Life) is a $27.9 million, five-year project working in coordination with the Government of Nepal’s Ministry of Health (MoH) to support the testing and roll-out of national-level policies, guidelines, and programs. In addition to its national focus, the project works at the district level in 14 districts in the Mid- Western and Western regions, where it strengthens district and village health systems and helps identify and implement best practices. After the devastating earthquakes in April and May 2015, Health for Life began supporting the MoH in 10 of the 14 most-affected districts to improve health system governance, improve evidence-based planning, budgeting and policy making, and to institutionalize a national system for quality assurance and improvement. Additionally, in 2015, Health for Life started working in six ‘demonstration districts’ to assist in rolling out local health governance strengthening activities. The primary goal of Health for Life is to strengthen the Government of Nepal’s capacity to plan, manage, and deliver high-quality and equitable family planning, maternal, newborn, and child health services. Health for Life activities directly address key health system constraints in the following areas: local health systems governance; data for decision making and evidence-based policy development; human resources management; quality improvement systems; and knowledge and behavior change. Health for Life collaborates with a wide range of stakeholders, including academic and research institutions, training centers, media partners, and civil society. Health for Life’s objectives are to • Improve health system governance of district health offices and sub-district level facilities • Support development and implementation of national evidence-based policy • Strengthen national stewardship of the health sector • Institutionalize nationwide system for quality improvement • Improve the capacity of district and local health workers and community volunteers to deliver high- quality FP/MNCH and nutrition services • Improve knowledge, behavior, and use of health services among adolescents and marginalized groups • Strengthen capacity of USAID’s contractor, LifeLine Nepal, for an improved health logistics system.1 This annual report covers the period July 1, 2015, to June 30, 2016. It documents activities conducted during the project’s third year. Following Health for Life’s seven objectives, it describes key achievements, analyzes progress and challenges to date, budget and expenditures, and other information. In October 2015, the Health for Life project was expanded to ten of the districts most adversely affected by the April 2015 earthquake. Within the ten districts - Dhading, Dolakha, Gorkha, Kavrepalanchowk, Makawanpur, Nuwakot, Ramechhap, Rasuwa, Sindhuli, and Sindhupalchowk, Health for Life collaborates with a wide range of stakeholders, including USAID-funded projects and projects funded by other EDPs, academic and research institutions, pre-service training centers, media partners and civil society. The project in the 10 earthquake-affected districts has been strengthening the MoH's capacity to coordinate recovery and reconstruction, and plan, manage and restore high-quality family planning, maternal, newborn and child health (FP/MNCH) services. Health for Life activities directly address key health system constraints in the following areas: local health systems governance; evidence-based planning, budgeting and policy making; and quality assurance and improvement at district and sub-district levels. TA to the 10 earthquake-affected districts will also restore and improve the delivery of FP/MNCH services in selected areas. The Health for Life jumpstarted health system strengthening programs into ten earthquake affected districts beginning in October 2015. Three regional offices and seven district offices were established, and necessary staff as stipulated in the annual work plan were recruited, trained and deployed. A subcontract was awarded to Rolling Plans to recruit and manage local staff, and 208 local staff were recruited, trained and deployed to the VDC-level during this reporting period. Necessary equipment, including furniture, computers and vehicles was arranged

1 Health for Life’s contract was modified in July 2016 to delete this objective.

Health for Life—Annual Report 4 during this reporting period. Coordination meetings with GON officials including the PPICD, RHDs and D(P)HOs were organized to share project strategies and work plans. GESI strategies for earthquake affected district programs were developed and approved by USAID. Health for Life has provided TA to the PPICD through a Senior Technical Advisor deployed to MoH/PPICD. He is actively engaged in reviewing technical proposals and MoUs submitted to the PPICD by various agencies to support health recovery and reconstruction activities in earthquake affected districts. The MoH/PPICD signed MoUs with 41 organizations during this reporting period, and these partners have committed a total of NPR 3,764,969,687 to be invested for health recovery and reconstruction. Health for Life’s Senior Technical Advisor is also engaged in monitoring health recovery and reconstruction activities in the ten earthquake-affected districts along with PPICD and other development partners.

A. ACCOMPLISHMENTS AND INTENDED OUTCOMES FOR THE PERIOD

OBJECTIVE 1: IMPROVE HEALTH SYSTEMS GOVERNANCE OF DISTRICT OFFICES AND SUB-DISTRICT LEVEL FACILITIES 1.1 HFOMC HOLD HEALTH PROVIDERS ACCOUNTABLE FOR DELIVERY OF SERVICES BY BETTER MOBILIZING AND MANAGEMENT OF LOCAL RESOURCES HEALTH FACILITIES IN 14 HEALTH FOR LIFE DISTRICTS HAVE FUNCTIONING HFOMCS A total of 95.7 percent of Health Facility Operation and TABLE 1.1 SUMMARY OF HFOMC FUNCTIONALITY IN Management Committees HFs AS OF JUNE 2016 (HFOMCs) in high-priority HFOMC FUNCTIONALITY JUN 2015 (%)* JUN 2016 (%)** VDCs met all functionality MEASUREMENT CRITERIA criteria during this reporting HFOMCs Formed According To period. The HFOMCs in Guidelines/Directives 84.0 98.6 Arghakhanchi, Bardiya, HFOMCs Meet On a Regular Basis ( At Dailekh, Dang, Jajarkot, Jumla, Least Quarterly) 92.0 98.6 Kalikot, Kapilvastu, Rolpa and Meeting Scheduled, Agenda Distributed In Surkhet districts met all 95.0 100.0 functionality criteria while a Advance And Minutes Documented few HFOMCs in Banke, Participation Of Women And Dalit Pyuthan, Rukum and Salyan Members In Meeting 93.0 98.6 districts did not (Table 1.1). Health Facilities With The Provision Of The HFOMCs reformation Health Services During Regular Hours 99.0 98.6 criteria specified in the (10:00 -15:00) HFOMC guidelines/ directive *All VDCs in core districts **High-priority VDCs in core districts has not been met in Tharmare PHCC (Salyan) and Badikot HP (Pyuthan). Likewise, the participation of women and Dalit members did not meet criteria in Simli HP (Rukum) and Arkha HP (Pyuthan) at the time of assessment. Health facilities in both Holiya and of Banke failed to meet the “provision of health services during regular hours” criteria because health personnel were unable to show up regularly. Previously, HFOMC functionality and performance assessments were carried out in Health for Life core districts whereas this year Health for Life has focused HFOMC assessments on its high-priority VDCs, as per the new TA plan. As a result, functionality and performance scores as of June 2016 outlined in Tables 1.1 and 1.2 include the scores of all HFOMCs in core districts in 2015, and HFOMCs in high-priority VDCs in 2016. Nearly ninety-two percent of HFOMCs in high-priority VDCs have expanded their health services, 96.4 percent have upgraded the quality of services, 90.8 percent of HFOMCs mobilized additional resources and 99.3 percent prepared annual health plans (Table 1.2).

Health for Life—Annual Report 5 Health for Life provided TA to the TABLE 1.2 SUMMARY OF HFOMC D(P)HOs and other stakeholders to fill PERFORMANCE IN HFs AS OF JUNE 2016 vacant positions—mainly clinical staff— HFOMC PERFORMANCE JUN 2015 JUN 2016 in an effort to strengthen local health MEASUREMENT CRITERIA (%)* (%)** governance through the Public Service Provision Of Expanded Commission procedures. Lobbying for Health Services 83.0 91.5 this issue continued in all 141 high- Upgraded Quality Of Services 82.0 96.4 priority VDCs. Out of 734 sanctioned positions 76 percent of clinical positions Additional Resource Mobilization 96.0 90.8 were filled by the end of reporting Active Involvement Of Dalit And period (see section on Challenges). In Women Members 78.0 93.6 addition, 10.8 percent of positions were Social Audit Conducted 32.0 80.9 filled by DDCs, VDCs, or Municipalities and partly by development volunteers Prepared Annual Health Plan 97.0 99.3 sent by NPC. Clinical Staff Positions Filled 91.0 75.9 As requested by the D(P)HO, Health for *All VDCs in core districts **High-priority VDCs in core districts Life conducted basic training for 17 members of two HFOMCs (Khanadaha and Simalpani HFs) in Arghakhanchi. Health for Life organized a two-day Leadership and Management training for Chairpersons and Member Secretaries (i.e. In-charges of HFs) of HFOMCs in 141 high-priority HFs as part of enhancing HFOMC members’ general management capacity and clarifying their roles and responsibilities, including GESI and disaster preparedness planning. Likewise, a one-day orientation was carried out for members of 76 HFOMCs and local stakeholders at high-priority HFs on the Collaborative Framework and its implementation guidelines. At the request of the D(P)HOs, a one-day bookkeeping training was conducted for HF In-charges of all 141 high-priority HFs to enhance financial management capacity, increase compliance and reduce fiduciary risks. All of the above interventions contributed to improving functionality and performance of HFOMCs. To improve the coverage, quality, and utilization of health services in the most disadvantaged VDCs in a systematic manner, Health for Life focused support on evidence-based health planning in the 141 high-priority HFs and worked to improve collaboration with Municipalities, VDCs, community-based organizations and Social Mobilizers with the result that they are now better able to leverage resources for the expansion and improvement of health service utilization (see Annex 1). Figure 1.1, below, shows a few examples that we have tracked over the past three years of how the proportion of institutional delivery is in improving in Health for Life districts. FIGURE 1.1 THREE-YEAR TREND OF INSTITUTIONAL DELIVERY IN SELECTED HIGH-PRIORITY HFs OF HEALTH FOR LIFE DISTRICTS

100 80 60 40

PERCEN 20

Lekhgaon, Surkhet Matehiya, Banke Udharapur, Banke , Dang Kudu, Jajarkot 2012/13 2013/14 2014/15

Source: Health Facility Register BEST PRACTICES IN LOCAL HEALTH GOVERNANCE SCALED UP IN HEALTH FOR LIFE DISTRICTS As of June 30 2016, out of the 141 high-priority VDCs, 19 (13.5%) HFOMCs are “models” by meeting all functionality and performance criteria and being able to perform with little or no technical assistance, 58.2 percent

Health for Life—Annual Report 6 meet all 5 functionality criteria and at least 4 performance criteria, and 24.8 percent meet all 5 functionality criteria. In order to improve functionality and performance of the five HFOMCs that have yet to achieve full functionality (Betahani and Holiya in Banke, Arkha and Badikot in Pyuthan and Simli in Rukum), Health for Life is providing intensive TA. At the request of the respective D(P)HOs and in coordination with DDCs and other stakeholders, Health for Life supported a two-day HFOMC revitalization training which included GESI and Disaster Preparedness Planning to four HFOMCs (Channal in Kapilvastu, Pang in Rolpa, Rachuli in Kalikot and Garjhyangkot in Jumla) and also assisted in preparing Village Health Situation Analysis Reports (VHSARs) and local health plans. During this reporting period, Health for Life also collaborated with and provided TA to the following partners to expand local health governance activities.

TABLE 1.3 CATEGORIZATION OF HFOMCS BASED ON FUNCTIONALITY AND PERFORMANCE MEASURES IN HIGH-PRIORITY HFs AS OF JUNE 2016

Criteria for categorization of HFOMCs based CATEGORY OF JUN 2014 JUN 2016 on functionality and performance measures HFOMC (%) JUN 2015 (%) (%) Model HFOMCs: Meet all functionality and performance measures criteria and functioning without or Model 11.0 12.0 13.5 minimal support from outside. Progressive HFOMCs: Meet all 5 functionality and Progressive 45.0 52.0 58.2 at least 4 performance measures criteria Functional HFOMCs: Meet all 5 functionality Functional 22.0 20.0 24.8 criteria

Non-Functional HFOMCs: Meet only 4 or less Non-Functional 22.0 16.0 3.5 functionality criteria

TEAMING UP AND CLEANING UP: COLLABORATION Health for Life, having four overlapping AND TRANSFORMATION AT A RURAL HEALTH POST districts (Jajarkot, Kalikot, Rukum and Salyan) the health post in-charge in Ragda, remembers the held a series of meetings with USAID's day he arrived at his post just over a year ago. “Cows and other animals Health and Hygiene Project team where they were wandering about the health post compound,” he says. discussed and shared the following: Ragda, one of the most remote VDCs in Jajarkot, lies pressed up against the towering, snow-covered peaks of the Himalayas. It is home to • Participants were briefed on Health about 4,000 households, more than a third of which are dalit. Health for Life (Health for Life), a USAID-funded health system strengthening project for Life’s scope of work, overlapping districts is working with local communities to improve the quality of health care, and high-priority VDCs, and its especially among marginalized groups such as dalits. implementation strategies and approaches At request, members of the Health for Life team arrived to talk about the condition of the health post as well as availability, access • Discussed VHSAR preparation and and utilization of services. the evidence-based local planning process. “Health for Life helped to reform the HFOMC through a four-day Health for Life team proposed both project ‘revitalization’ training that included orientation on the Collaborative Framework Implementation Guidelines and how to cultivate effective activities using the local health plans as a collaboration with local organizations,” says. “That really motivated platform for collaboration the HFOMC members. By clarifying their roles and responsibilities, committee members realized the importance of their contribution to • Health for Life shared the VHSAR, improving conditions.” continues. “With the support of Health for local health plan template and QI tools. Life, the HFOMC prepared both a Periodic (5-year) and Annual Health Plan with the participation of the Ward Citizens Forum, Female Community Health for Life collaborated with USAID's Health Volunteers (FCHVs), healthy mothers groups and local leaders.” Sajhedari Bikas Project to provide equipment Over the next few months, the HFOMC identified the major gaps in health services, prioritized their needs, and set to mobilizing resources. and materials worth NPR 15,69,700 from NPR 50,000 was collected from local sources, and a number of Sajhedari’s small grants for sixteen birthing improvements were implemented, including digging a waste disposal pit, centers in five districts (Surkhet, 4; Bardiya, 3; installing toilets, connecting the water supply and forming a citizen charter. “The HFOMC has become much more engaged,” says. Dang, 4; Banke, 3; and Kailali, 2), which is “They’ve even supported the hiring of a Community Action Promoter who expected to improve institutional delivery at has had a marvelous effect on increasing utilization of MNCH services. those facilities. Based on the VHSARs and These achievements are possible due to the ideas and tremendous support of Health for Life to reform and revitalize HFOMC”. local health plans prepared by HFOMCs in high-priority VDCs, Health for Life supported Sajhedari Bikas by coordinating with

Health for Life—Annual Report 7 D(P)HOs, DDCs and HFOMCs to assess HFs’ needs for birthing centers, finalizing lists of required equipment and their specifications.

Health for Life coordinated with D(P)HOs, DDCs and other stakeholders to provide training materials to FAIRMED/INF in Kapilvastu for HFOMC revitalization and MNH with the following results: • Revitalized HFOMCs of VDCs • Ten district-level Supervisors were trained to be MNH trainers • Identified equipment and material specifications for three birthing centers • Trained 78 HWs jointly with UNFPA and FAIRMED on MNH Health for Life coordinated with D(P)HOs and HFOMCs and worked jointly with World Vision International, CARE and GiZ's Health Support Program. During the reporting period, in revitalizing HFOMCs, Health for Life supported World Vision in , Mohanyal, , and Pandon HFs in Kailali, worked with CARE in remote VDCs of Kailali (Nigali, , Khairala, Mohenyal, Pandon) and supported GiZ's Health Support program in Malakheti, Joshipur, Chaumala PHCCs to conduct HFOMC orientation on evidence-based local health. At the end of the orientation, VHSARs were prepared as a foundation for local health planning.

Based on VHSAR findings and local health plans, both of which were supported by Health for Life’s TA, and through discussions with HFOMCs, Save the Children provided equipment and instruments for the birthing center in Bankatti, power backup for the birthing in Betahani and constructed a placenta pit in Matehiya at the recommendation of the Health Facility Quality Improvement Team meeting.

FUNCTIONALITY AND PERFORMANCE OF HFOMC FUNCTIONALITY CRITERIA HFOMCS IN EQ-AFFECTED DISTRICTS 1. Formed according to GON guidelines Health for Life provided technical assistance to ten 2. Regular meetings (once a month) 3. Meetings called in advance and minutes documented D(P)HOs and 105 HFOMCs to assess functionality and 4. Presence of women and Dalit members performance of HFOMCs in 10 EQ-affected districts. The 5. Provision of services from 10 am to 3 pm assessment report showed that only 9 percent (n=10) of the existing HFOMCs had been formed according to GON guidelines. Despite this, there were HFOMCs at all health facilities functioning with some capacity: 44 percent were meeting regularly, 64 percent called meetings in advance and including an agenda, and decisions made during the meetings were found to be well-documented among 79 percent of HFOMCs. Similarly, female and Dalit HFOMC members were found to be vocal during meetings and 57 percent of health facilities were found to be providing services during regular hours. FIGURE 1.2 FUNCTIONALITY STATUS OF HFOMCs IN EQ-AFFECTED

DISTRICTS Health for Life provided technical assistance and support to ten D(P)HOs and DDCs in earthquake affected districts to conduct a two-day orientation for supervisors on HFOMC capacity building. This orientation aimed to prepare a pool of resource people to conduct HFOMC trainings at the VDC level. A total of 138 district-level supervisors (Males, 117; Females, 21) received orientation training.

Health for Life—Annual Report 8 Poor functionality of HFOMCs has led to poor performance. HFOMC PERFORMANCE CRITERIA Performance scores for all criteria were very poor in all 1. Expanded health services districts. While looking at performance criteria, only four out 2. Upgraded quality of services of 110 HFOMCs had expanded health services, four 3. Additional resource mobilized HFOMCs did some work relating to quality improvement, 4. Social audit conducted 5. Participation of women/Dalit members seven HFOMCs carried out social audits and 35 HFOMCs 6. Leadership and local health system strengthened mobilized additional resources at the local level. FIGURE 1.3 PERFORMANCE OF HFOMCs IN EQ-AFFECTED DISTRICTS 2016

With support from Health for Life, the D(P)HOs reformed 107 HFOMCs in the ten Health for Life earthquake- affected districts. Three HFOMCs (in Dhading, Ramechhap and Gorkha) could not be reformed due to community conflicts. A total of 105 HFOMCs received a two-day revitalization training as a part of their capacity building plan using NHTC training packages. A total of 965 HFOMC members (Male, 559; Female, 406) underwent orientation on their roles and responsibilities, functionality and performance measures of HFOMCs, disaster preparedness, GESI and work planning during the orientation. Furthermore, all HFOMCs assessed their performances using standard assessment tools and documented the score for future reference. FIGURE 1.4 STATUS OF HFOMC REVITALIZATION, HEALTH FOR LIFE EQ- AFFECTED DISTRICT PROGRAM AS OF JUNE 2016

18

12

6

Number of HFOMCs Kavre Sindhull Dhading Dolakha Gorhka Nuwakot Rasuwa Makawanpur Ramechhap Sindhupalchowk Total # of HFOMCs # of HFOMCs reformed # of HFOMCs revitalized

1.2 LOCAL HEALTH GOVERNANCE STRENGTHENED TO REDUCE INEQUALITIES OF ACCESS AND USE OF HEALTH SERVICES IN HEALTH FOR LIFE DISTRICTS Health for Life provided technical assistance to the D(P)HOs and HFOMCs to prepare Village Health Situation Analysis Reports (VHSARs) in all 108 high-priority VDCs using data from HMIS, Health Facility Readiness assessment and household surveys. The evidence was used to identify gaps in access and use of services, particularly by M/DAGs and subsequently shared with the HFOMCs to be used while preparing plans which address these gaps.

Health for Life—Annual Report 9 VDC HEALTH RECOVERY PLANNING Health for Life provided technical assistance and support to D(P)HOs and DDCs to prepare VDC health recovery plans in high-priority VDCs. The D(P)HOs’ and DDCs' supervisors facilitated one-day, VDC-level health recovery planning sessions with the HFOMCs and other relevant people. During these meetings, Health for Life Program Coordinators and Development Associates presented the gaps in access and use of services that had been identified during assessments. Evidence from the VHSARs, HF-readiness assessments and household surveys was used to formulate actions to minimize problems related to access and use of services, particularly among M/DAGs. A total 47 VDC health evidence-based recovery plans were prepared during this reporting period. These VDC recovery plans will be presented to the VDC Executive Committees for endorsement and will be discussed at the Ward-level planning meeting in October 2016 as part of the 14-step local planning process. The final VDC health recovery plans will then be presented to VDC/Municipal councils for approval and resource allocation. District Health Governance Strengthening Task Forces (DHGSTFs) were formed and oriented in Nuwakot, Kavre, Sindhuli and Makawanpur districts and Health for Life is providing technical assistance to functionalize/regularize these task forces for better coordination to address social determinants of health. Health for Life district and regional staff provided support to the D(P)HOs to improve coordination among partners in all ten EQ districts through the Health and Nutrition cluster, RHCC and other relevant committees. Health for Life collaborated with One Heart Worldwide in Dhading and Sindhupalchowk, and with FairMed and World Vision in Sindhupalchowk for capacity building of HFOMCs. These organizations are providing technical assistance to the D(P)HOs to build the capacity of HFOMCs in VDCs other than Health for Life high-priority VDCs and are using the same capacity building packages. Health for Life has also collaborated with the Sajhedari Bikas project in EQ-affected districts in overlapping VDCs. Joint meetings with Sajhedari Bikas were held at the Central and District levels identify common areas of intervention between the two projects. Sajhedari Bikas, using their small grants mechanism, and TABLE 1.4 STATUS OF VHSARs, LOCAL HEALTH Health for Life are working PLANS AND APPROVAL FROM MUNICIPAL/VILLAGE together to provide power systems COUNCILS OF HIGH-PRIORITY HFs AS OF JUNE to health facilities in Health for 2016 Life high-priority VDCs in the EQ-affected districts. # OF LOCAL HEALTH # OF HIGH- # OF VHSARs PLANS DEVELOPED VILLAGE HEALTH PLANS DISTRICT PRIORITY DEVELOPED AND APPROVED BY ARE PREPARED USING HFS COUNCILS EVIDENCE AND Arghakhanchi 10 10 10 APPROVED BY VILLAGE Banke 10 10 10 COUNCILS AS AN INTEGRAL PART OF Bardiya 10 10 10 VILLAGE DEVELOPMENT Dailekh 11 11 11 PLANS Dang* 10 10 10 Out of 141 Health Facility Operation and Management Jajarkot 10 10 10 Committees (HFOMCs) in high- Jumla* 10 9 9 priority health facilities, a total of Kalikot 10 10 10 140 (99.3%) HFOMCs have updated their Village Health Kapilvastu 10 10 10 Situational Analysis Reports Pyuthan 10 10 10 (VHSARs), developed Local Rolpa 10 10 10 Rukum 10 10 10 Salyan 10 10 10 Surkhet 10 10 10 TOTAL 141 140 140 Source: Health for Life reports * Dang and Jumla districts are demonstration districts

Health for Life—Annual Report 10 Health Plans2 (LHPs) and secured approval from Municipal and TABLE 1.5 MUNICIPAL/VILLAGE COUNCILS’ Village Councils (Table 1.4). All ALLOCATION, EXPENDITURE AND COMMITMENT HFOMC members along with IN HIGH-PRIORITY HFs AS OF JUNE 2016 FCHVs, local leaders and Ward BUDGET ALLOCATION VS. Citizen Forum (WCF) members EXPENDITURE (FY 2015/016) participated in the local health BUDGET BUDGET COMMITMENT EXPENDITURE planning process in 140 high- ALLOCATION (FY 2016/17) IN IN NPR ('000)* priority HFs. The HFOMC in DISTRICT IN NPR ( '000) NPR ('000) in did not Arghakhanc 1,730 851 1,847 update their VHSAR nor did they develop the LHP on time because hi 2,217 244 2,678 the Member Secretary of the Banke HFOMC (i.e. health facility In- Bardiya 2,265 1,753 1,796 charge) was absent. The plan was Dailekh 2,939 1,470 4,616 prepared belatedly and the Village 2,713 825 3,251 Council committed a budget. Dang Jajarkot 6,676 6,089 2,583 The Councils of all 141 high- priority HFs have committed NPR Jumla 1,186 1,081 1,499 32,342,000 (USD 32,342) for FY Kalikot 2,151 2,046 1,938 2016-17. The HFOMCs are now in Kapilvastu 2,123 2,105 2,572 a strong position to leverage additional resources locally to Pyuthan 1,349 571 1,255 increase access to and quality of Rolpa 2,605 1,564 1,949 health services. Rukum 3,006 1,487 2,133 The Municipal and Village Councils Salyan 2,591 1,827 2,717 of the high-priority HFs allocated Surkhet 1,733 1,431 1,508 NPR 35,284,000 (USD 35,284) to TOTAL 35,284 23,344 (66.2%) 32,342 implement local health plans during Source: Health for Life reports FY 2015/016; NPR 23,344,000 * reported expenditure status does not covers full FY( 2015/016) (66.2% of the allocate amount) had been spent by the end of June 2016 (Table 1.5). Out of total expenditures, 27 percent was spent on local human resources (ANMs, AHWs, lab assistants, office assistants, stipends for CAP/Rs, etc.), 48 percent for quality improvement activities (QI fund, furniture, equipment, fencing, construction/maintenance, medicine, etc.) and 22 percent for service expansion and strengthening activities (child health, immunization, safe motherhood promotion, FCHVs, etc.) (Annex 1). In summary, the high-priority HFs in Bardiya, Jumla, Kalikot and Kapilvastu, have a healthier burn rate than others, particularly HFs in Arghakhanchi, Banke, Dang, Pyuthan and Rukum (see Table 1.5). Health for Life provided TA to HFOMCs to develop local health plans and submit them to the Councils for approval through the local planning process. Engaging with community-level groups and authorities and integrating local health plans into the overall local development plan at the village and municipal levels has helped local health issues gain recognition and has made health issues a part of the local development agenda, as envisioned by the Collaborative Framework. With Health for Life’s support, the D(P)HOs of all 14 core districts developed Calendars of Operations for FY 2015/016 that reflect all health-related activities planned by the GoN, NGOs/INGOs, including available resources. The primary purpose of the Calendar of Operations was to consolidate and create synergy among D(P)HOs’ and partners’ activities over the year so that available time and resources could be utilized efficiently. This effort was in response to a request made by Regional Directorate and D(P)HOs. Health for Life organized a two-day workshop in each project district, coordinated with all stakeholders, facilitated the sessions and came up with District Calendars of Operations in all 14 core districts which were used as a tool for implementing D(P)HOs’ and partners’ activities.

2 Previously known as village health plan

Health for Life—Annual Report 11 The D(P)HOs conducted Social Audits (SAs) in 255 VDCs (87 new, 168 follow-up) in 11 of Health for Life’s core districts during FY 2015/016, where Health for Life coordinated with the DDC, D(P)HO, District Health Governance Strengthening Task Force (DHGSTF) and helped the D(P)HOs to integrate Social Audit Action Plans in accordance with the PHCRD plan and implement them accordingly. The Social Audits highlighted many issues, including: • no lab facilities in HFs • delayed birthing center construction • absence of extended PHCs/ORCs in needy • drug stockout and equipment not funtioning wards • no water and solar lighting in birthing centers • demand for stretcher in every ward not met • no waiting rooms for clients • ANM vacancies and other vacant positions in • poor maintenance of citizen charters and HFs; and many other issues related to staff suggestion boxes absenteeism • FCHV incentives and support for mothers’ group meetings not given Findings from the SA were used to update the VHSARs in high-priority HFs, focusing mainly on issues of quality and access raised by the community. Review of progress against the SA has indicated that many of the raised issues have been addressed or are in the process of being addressed. Examples include: • The DDC of Banke contributed NPR 1,000,000 for the construction of a birthing center in Holiya HP • The Dhanabang Village Council in Salyan committed NPR 275,000 to Dhanabang HP and NPR 300,000 to Valchour for the construction of a PHC/ORC building • The Kabhra Village Council gave NPR 359,726 in Salyan to construct additional rooms at the HP • The DDC in Kapilvastu contributed NPR 800,000 to HP to construct a BC.

DISTRICT HEALTH GOVERNANCE STRENGTHENING TASK FORCES (DHGSTFs) ARE FUNCTIONAL AND EFFECTIVE TABLE 1.6 STATUS OF VHSARs, LOCAL The Collaborative Framework (CF) meant to HEALTH PLANS DEVELOPED AND strengthen local health governance has not been fully embraced, which has made the local APPROVED FROM MUNICIPAL/VILLAGE planning process difficult. The MoH has yet to COUNCILS IN DEMONSTRATION send a budget envelope to the districts for DISTRICTS AS OF JUNE 2016 planning. Thus the use of the TABUCS # OF LOCAL eAWPB features in selected Health for Life HEALTH districts has not materialized. # OF HFS PLANS INCLUDING # OF VHSARs DEVELOPED A District Health Governance Strengthening URBAN DISTRICT DEVELOPED & HEALTH Task Force (DHGSTF), as provisioned in the APPROVED CLINICS Collaborative Framework, has been formed in BY all 14 core districts and in four additional COUNCILS demonstration districts (Dang and Jumla are Chitwan 45 39 39 included in core districts). In the 14 core Dang 39 39 39 districts, 30 DHGSTF meetings, ranging from one to three meetings per district, were Jhapa 56 33 24 organized during the reporting period. Likewise, Jumla 30 30 30 DHGSTF meetings were held four times in Kailali 52 42 42 Kaski, three times in Kailali and Dang, and twice in Chitwan and Jhapa demonstration Kaski 55 54 53 districts. These meetings encouraged the TOTAL 277 237 227 HFOMCs to prepare VHSARs and evidence- Source: Health for Life reports based local health plans, and to secure approval from the Councils through the 14-step planning process. Based on district-specific criteria, the Task Force allocated and monitored flexible health grants to HFs in Kailali, Chitwan and Kaski and instructed the HFOMCs to make efficient use of the allocated budget to improve access to services and service quality.

Health for Life—Annual Report 12 Health for Life district teams assisted regular meetings of these task forces in all 18 districts where they were held. Support was provided to the DHGSTFs to regularize their functions and responsibilities. The DHGSTFs played a lead role at the district level to support the VDCs and Municipalities in implementing the CF guidelines and HFOMCs encouraged and developed evidence based local health plans. A Technical Coordination Team meeting was held to review progress and discuss matters raised by the DHGSTFs. The following issues related to implementation were discussed: • Practical problems at PHCCs in chairing the HFOMCs • Review basic HFOMC guidelines to update as per the changed context • Request to hold a Policy Advisory Committee (PAC) meeting A total of 237 (85.6%) HFOMCs (including Urban Health Clinics) in the demonstration districts developed VHSARs and 227 (81.9%) HFOMCs developed evidence-based local health plans and secured approval from Municipal/Village Councils in the six demonstration districts (Table 1.6). In FY 2015/16, 150

TABLE 1.7 MUNICIPAL/VILLAGE COUNCILS ALLOCATION, EXPENDITURE AND COMMITMENT IN DEMONSTRATION DISTRICTS AS OF JUNE 2016

FLEXIBLE HEALTH GRANT ALLOCATION vs NUMBER OF FLEXIBLE EXPENDITURE FOR FY 2015/016 COUNCIL HEALTH GRANTS BUDGET ALLOCATED BY EXPENDITURE BY COMMITMENT HFs/UHCs FOR FY ALLOCATION IN END JUNE 2016 BURN FOR FY DISTRICT 2015/016 NPR ('000) IN NPR ('000) RATE (%) 2016/017 IN NPR ('000) Chitwan 19 1,798 656 36.5 3,449 Dang 39 1,632 866 53.1 10,229 Jhapa 20 1,897 756 39.9 6,716 Jumla 30 1,250 1,043 83.4 3,785 Kailali 26 1,889 1,413 74.8 16,156 Kaski 16 1,534 1,136 74.1 10,423

TOTAL 150 10,000 5,871 58.7 50,758 Source: Health for Life reports HFs received flexible health grants and used them mainly for service expansion, child health and maternal health/FP issues, based on HFOMC and Ward Citizen Forum responsiveness; use of data for decision-making; plans approved by Village Council; last year’s grant utilized in accordance with the plan; and, transparent accounting of unspent funds from the previous year. Concerned local Councils have also committed NPR 50,758,000 (USD 50,758) for FY 2016/017. HFOMCs are now in a position to leverage these additional resources to increase access to and improve quality of health services in the six demonstration districts (Table 1.7 & Figure 1.2). All VDCs and municipalities in the demonstration districts are covered following the principle of ' the district as a working unit'. In coordination with the DDC and D(P)HO, Health for Life organized a two-day TOT at the district level for D(P)HO supervisors and DDC representatives on the provisions of the Collaborative Framework, VHSAR and the evidence-based local health planning process in all six demonstration districts. Similarly, a one-day orientation was organized by Health for Life at the sub-district level for HF In-charges and Chairpersons of VDCs/Municipalities on the CF provisions, VHSAR and inclusion of health in the local planning process in all six demonstration districts. These capacity building efforts and collaborations with district and local level stakeholders contributed to achieving the above-mentioned results. Health for Life promoted joint field visits (Health for Life, MoH/DoHS and MoFALD) to contribute to institutionalizing learning, thus strengthening collaboration both at the national and local level. Senior Officials from the MD/DoHS and MoFALD conducted field visits to observe the implementation of the CF provisions, provide on-the-spot guidance and make significant contributions to Health for Life's core and demonstration

Health for Life—Annual Report 13 FIGURE 1.5 MAJOR ACTIVITIES CARRIED OUT IN THE DEMONSTRATION DISTRICTS USING FLEXIBLE HEALTH GRANTS

HEALTH SERVICE EXPANSION AND SYSTEMS CHILD HEALTH STRENGTHENING • Revitalized PHC-ORC Committee • Collected baseline data of under-two children • Expanded and strengthened PHC-ORCs for immunization and nutrition status • Organized health camps • Conducted refresher training for FCHVs on • Oriented HFOMCs, Nagarik Manch, political leaders and social diarrhea and pneumonia workers on health programs • Ran a healthy child competition to motivate • Oriented school teachers on ASRH regular growth monitoring • Presented oral hygiene classes to primary level students • Oriented FCHVs and mothers on immunization • Motivated leaders, FCHVs, teachers for utilization of services and nutrition • Planned, monitored and reviewed with HFOMCs • Ran training on Sarbottam Pitho preparation, • Reviewed CF activities by HFOMC, HF staff and FCHVs nutrition education and exhibition program

MATERNAL HEALTH AND FAMILY PLANNING DISEASE CONTROL AND PROCUREMENT • Collected baseline data on pregnant women • Ram orientation on tuberculosis for CB-DOTS • Monitored/tracked pregnant women who don’t come for providers and FCHVs regular ANC visits • Oriented HFOMCs and FCHVs on • Raised awareness of ANC visits and institutional delivery to communicable diseases materials for service pregnant women in clusters provisions/office use like laptops in Kailali. • Oriented pregnant mothers and women of reproductive age on ANC visits, FP and EPI • Provided incentives to FCHVs for referring pregnant women to 4 ANC visits • Ran orientation program for health mothers’ groups in every ward • Collected baseline data on FP-eligible couples • Ran a camp to provide LAFP methods • Oriented FCHVs and eligible women on FP services districts. They also facilitated important sessions during the district-level ToT on CF provisions for district supervisors of D(P)HOs, DHGSTF members and Executive Officers of newly-formed Municipalities in Chitwan, Jhapa, Jumla, Kailali and Kaski districts (Annex 2).

OBJECTIVE 2: DEVELOP AND IMPLEMENT NATIONAL EVIDENCE-BASED POLICY 2.1 GUIDELINES DEVELOPED AND IMPLEMENTED FOR NATIONAL AND REGIONAL PERFORMANCE REVIEW MEETINGS OF MOH PROGRAMS (A FRAMEWORK FOR ANALYSIS) DATA ROUTINELY USED AT ALL LEVELS TO REVIEW PROGRAM PERFORMANCE, IDENTIFY PRIORITIZED ACTIONS, AND DEVELOP PLANS TO IMPROVE PERFORMANCE Health for Life worked with 14 D(P)HOs to conduct annual review meetings using public health analytic techniques (PHAT), providing technical support to the District Review Working Group from the preparatory phase to report writing. Data were analyzed and presented as per the review guidelines developed by the Management Division. Health for Life staff, along with district health office, conducted a PHAT assessment using a standardized checklist. The assessment findings show that the performance of three districts - Dang, Jumla and Kalikot - were acceptable; nine districts’ performance was ‘progressive,’ and two districts, Arghakhanchi and Kapilvastu, were ‘model’ districts. DHIS-2 ROLLED OUT IN HEALTH FOR LIFE DISTRICTS Due to various reasons, including technical problems, the GoN has not been able to roll out the DHIS-2 system during this reporting period. Consultants from other supporting partner organizations are working on the remaining work of customization, and the Management Division plans to roll out DHIS-2 in the coming fiscal year.

Health for Life—Annual Report 14 MOBILE-BASED HMIS RECORDING/REPORTING SYSTEM FOR SELECTED INDICATORS PILOTED IN SELECTED HFs IN COLLABORATION WITH HMIS SECTION The mobile-based HMIS recording and reporting system for 11 indicators was not piloted as planned due to indecisiveness on collaborative modalities with the HMIS section. H4L will respond to implementing this activity in next quarter. SERVICE UTILIZATION IN ALL CORE DISTRICTS MONITORED THROUGH HEALTH SERVICE DATA DISPLAY FLEX Health for Life initially provided data display flexes to all HFs in the core districts in FY 2013-2014 to monitor service utilization at the HFs. Although the service data display flex was intended to be used for several years, overwriting was not properly maintained. At the request of the districts, flexes were redistributed to four districts and a few backups were kept at the regional office. SERVICE UTILIZATION BY PREGNANT WOMEN AT 39 SENTINEL SITES MONITORED USING MOBILE TECHNOLOGY (A SERVICE DELIVERY AND ICT INNOVATION REPORTED UNDER OBJECTIVE 2) To increase equitable service utilization of ANC, institutional delivery, PNC and family planning by women, CAP/ Rs have been mobilized at the VDC level in collaboration with the HFOMCs at 39 sentinel sites. Service utilization by pregnant women is monitored through mobile phones, from the moment a pregnancy is confirmed to 90 days postpartum. As of June 30, 2016, 7,367 pregnant women have been registered and tracked (Table 2.2); 3,426 of them delivered (live births) and 2,041 of them continued to receive postnatal care and family planning counselling. Eighty-one percent of the expected pregnant women at these 39 sentinel sites were registered and tracked (ranging from 61.5 percent in Dang to all pregnant women3 in Kapilvastu) in the approximately fifteen months since the program was started.

TABLE 2.1 PREGNANT WOMEN TRACKED USING MOBILE TECHNOLOGY IN HEALTH FOR LIFE DISTRICTS AS OF JUNE 2016 # OF % OF # OF # OF WOMEN WHO EXPECTED # OF # OF PREGNANT WOMEN CONTINUED TO PREGNANT PREGNANT DISTRICT SENTINE WOMEN THAT RECEIVE WOMEN IN WOMEN L SITES REGISTERED DELIVERED* POSTPARTUM FP SENTINEL REGISTERED ** ** COUNSELLING SITES* Arghakhanc 2 323 268 83.1 186 149 hi Banke 3 766 707 92.3 280 95 Bardiya 3 1268 802 63.2 136 112 Dailekh 3 630 671 106.5 344 213 Dang 3 1211 744 61.5 172 26 Jajarkot 2 405 310 76.5 40 17 Jumla 3 370 390 105.5 213 131 Kalikot 2 452 320 70.8 152 123 Kapilvastu 3 513 643 125.4 454 273 Pyuthan 3 526 543 103.2 354 212 Rolpa 3 549 400 72.9 219 147 Rukum 3 704 449 63.8 291 166 Salyan 3 668 412 61.7 142 44 Surkhet 3 724 708 97.9 443 333

TOTAL 39 9,107 7,367 80.9 3,426 2,041

3 More than 100 percent was recorded, revealing an incorrect estimated number of expected pregnancies.

Health for Life—Annual Report 15 Note: *Approximately fifteen months. ** against # of expected pregnant women in sentinel site. *** Live births to correspond with population‐based survey (DHS and MICS). Of the total registered pregnant women, 33.5 percent are Brahmin/Chhetri followed by Janajatis (22.4%) and Dalits (22.1%) (Figure 2.1), corresponding to the caste/ethnic composition recorded in the 2011 Census, with a slightly higher instance of Dalit, Madhesi and Muslim women registered. FIGURE 2.1 COMPOSITION OF REGISTERED PREGNANT WOMEN BY CASTE/ETHNICITY AGAINST THE POPULATION PROPORTION IN HEALTH FOR LIFE DISTRICTS AS OF JUNE 2016 36.1 33.5 28.1 22.1 22.4 18.9

7.2 7.8 6.9 6.6 5.6 4.8

Dalit Janajati Madhesi Muslim Brahmin/Chhetri Other

Pregnant women register (%) Pop. Proportion % ( Census 2011)

Among total registered women who delivered (live births), 77 percent completed all four ANC visits, 65.2 of them according to protocol (Figure 2.2). FIGURE 2.2 PERCENTAGE OF REGISTERED WOMEN WHO HAD FOUR ANC VISITS AMONG ALL LIVE BIRTHS AT 39 SENTINEL SITES AS OF JUNE 2016 (N=3,297)

Total 65.2 Surkhet 80.2 Bardiya 75.6 Pyuthan 74.0 Dang 72.2 Banke 70.1 Dailekh 69.5 Kapilvastu 69.4 Salyan 65.7 Rolpa 58.7 Arghakhachi 57.1 Jumla 51.0 Jajarkot 47.5 Rukum 43.2 Kalikot 40.3

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0

Health for Life—Annual Report 16 78 percent of the 3,297 registered women who gave live birth delivered their last baby at a health institution, ranging from 50 percent in Jajarkot to 94 percent in Bardiya (Figure 2.3). First PNC check-ups within 24 hours averaged 79 percent, ranging from 55 percent in Jajarkot to 93.5 percent in Dang.

Health for Life—Annual Report 17 FIGURE 2.3 PERCENTAGE OF REGISTERED WOMEN WHO DELIVERED AT HEALTH FACILITIES AND PERCENTAGE OF REGISTERED WOMEN WHO HAD 1ST PNC WITHIN 24 HOURS AMONG LIVE BIRTHS AT 39 SENTINEL SITES AS OF JUNE 2016 (N=3,297) 100.0 80.0 60.0 40.0 20.0 0.0

Banke Dang Jumla Rolpa Salyan Total Bardiya Dailekh Jajarkot Kalikot Rukum Surkhet KapilvastuPyuthan Arghakhachi

% of women that delivered at health facility among live births % of women that had first PNC within 24 hours among live births

Although similar proportions of Dalit and Janajatis women are registered through the mobile-based tracking system, disparity in ANC visits, institutional delivery and PNC service utilization remains a challenge. Janajati women were found utilizing more services than Dalits, whereas, Madhesi women had less service utilization than other castes in all three major services, particularly in completing four ANC visits, as per protocol (Figure 2.4).

FIGURE 2.4 UTILIZATION OF ANC, INSTITUTIONAL DELIVERY AND PNC SERVICES AMONG REGISTERED WOMEN, BY CASTE/ETHNICITY AT SENTINEL SITES AS OF JUNE 2016 100 87 85 90 83 82 78 78 78 80 76 76 76 71 70 68 69 68 70 60 58 60 51

% 50 40 30 20 10 0 Dalit (n=787) Janajati (n=736) Madhesi (n=187) Muslim (n=199) Brahmin/Chhetri Other (n=199) (n=1189)

4 ANC as per protocol Institutional delivery 1st PNC visit

Of the 2,041 women whose cases were closed upon completing the 90-day post-partum period, nearly 48 percent decided to use a family planning method after being counselled on different methods of family planning available. The intention to use FP was highest among Janajati women and lowest among Madhesi women (Figure 2.5).

Health for Life—Annual Report 18 FIGURE 2.5 PERCENTAGE OF REGISTERED WOMEN WHO WERE COUNSELLED AND CHOSE TO USE FP AMONG CLOSED CASES, BY CASTE AND ETHNICITY AT 39 SENTINEL SITES AS OF JUNE 2016

Total (n=2041) 47.8 Other (n=133) 52.6 Brahmin/Chhetri (n=737) 49.7 Muslim (n=123) 39.0 Madhesi (n=112) 32.1 Janajati (n=420) 47.1 Dalit (n=737) 35.0

0.0 10.0 20.0 30.0 40.0 50.0 60.0

Among the 976 registered women surveyed 90 days after delivery, 95 percent had started using a modern method of family planning (Figure 2.6). FIGURE 2.6 PERCENTAGE OF REGISTERED WOMEN WHO STARTED USING A MODERN METHOD OF FP WITHIN 90 DAYS OF DELIVERY, BY CASTE AND ETHNICITY AT 39 SENTINEL SITES AS OF JUNE 2016 120.0 100.0 80.0 60.0 40.0 20.0 0.0 Dalit (n=366) Janajati (n=198) Madhesi (n=36) Muslim (n=48) Brahmin/Chhetri Other (n=70) Total (n=976) (n=366)

While observing the type of FP method used, injectables (Depo) is the preferred method of (50%), followed by male condoms and sterilization. Long-acting methods was being used by 12 percent of women. Only one percent of the women use lactational amenorrhea to prevent pregnancy (Figure 2.7). FIGURE 2.7 FP METHODS AMONG POSTPARTUM WOMEN CURRENTLY USING FP METHODS AT SENTINEL SITES AS OF JUNE 2016 (N=976) Other method Pills Male condom lactational 4% 5% 18% amenorrhea method 1% IUCD 3%

Sterilization 10%

implants 9%

Injectable 50%

Health for Life—Annual Report 19 SEMI-ANNUAL REVIEW MEETING CONDUCTED WITH CAPS AND CAP/RS The first semi-annual meeting with CAPs to review service utilization was conducted in all 14 districts at district headquarter where the HMIS data on service utilization was reviewed and shared. For CAP/Rs, the review meeting was held at and in two groups. Mobile tracking data at the time of meeting was reviewed and discussed. Issues regarding regular monitoring, proper mobile handling, and timely review meetings and improving service utilization status was particularly emphasized. The mobile tracking process, troubleshooting problems with the app and recordkeeping were also reviewed. Finally, the meeting addressed which areas CAPs and CAP/Rs need to focus on to improve equitable service utilization. ANNUAL HEALTH SERVICE DATA QUALITY AUDIT (DQA) INITIATED IN COLLABORATION WITH HMIS, LMIS AND PHAMED Due to the earthquake and political instability including the blockade, the RDQA (Routine Data Quality Assessment) training was conducted in March 2016, although initially planned for August 2015. The M&E technical working group decided to customize the RDQA tool as per local need and started working on it. The M&E specialist from Health for Life was also involved in customizing the RDQA tool. The tool was approved by the PHAMED in June 2016. Before full implementation, the group decided to pilot the audit in two districts of each development region, which were selected based on their annual performance (one low performing, one high performing). HMIS RECORDING AND REPORTING FORMS UPDATED, PRINTED AND DISTRIBUTED IN COLLABORATION WITH OTHER PARTNERS Health for Life provided technical support to the HMIS section to revise and update the HMIS recording and reporting forms. Health for Life also supported the HMIS section financially to print and transport HMIS recording and reporting forms to all health facilities in all 14 Health for Life core districts. MIDTERM HF READINESS SURVEY CONDUCTED (SUBCONTRACTOR WILL ALSO CONDUCT HISPIX (NATIONAL LEVEL) ASSESSMENT AND PHAT REVIEW) The HF Readiness Midterm Survey was conducted through a sub-contractor, HERD. Due to the blockade and fuel crisis, the survey was delayed by four months. The final report from HERD was submitted to Health for Life in June 2016. A PHAT review was not conducted during this reporting period. READINESS ASSESSMENT (HF, FCHV, AND CLIENT EXIT) CONTINUED DURING FIELD VISITS BY HEALTH FOR LIFE DISTRICT STAFF(S) During the reporting period, 587 health facilities readiness assessments were conducted by Health for Life staff in all 14 core districts. During the same period, 975 FCHVs were assessed for their readiness and 310 client exit interviews were conducted (Tables 2.2 and 2.3). Based on the readiness assessment findings, Health for Life staff coached HF staff on how to improve.

TABLE 2.2 SUMMARY OF HF READINESS VISITS BY DISTRICT JUL-DEC 2015 JAN-JUNE 2016

DISTRICT PRIORITY GENERAL PRIORITY GENERAL TOTAL TOTAL VDC VDC VDC VDC Kapilvastu 13 2 15 21 4 25 Arghakhanchi 16 9 25 17 1 18 Pyuthan 17 6 23 13 2 15 Rolpa 22 8 30 18 4 22 Rukum 13 1 14 11 2 13 Salyan 17 1 18 21 0 21 Dang 15 17 32 24 17 41 Banke 19 8 27 17 6 23 Bardiya 18 4 22 17 9 26 Surkhet 6 10 16 20 1 21 Dailekh 11 3 14 15 1 16 Jajarkot 13 3 16 14 0 14 Jumla 10 6 16 16 8 24 Kalikot 14 2 16 19 5 24 TOTAL 204 80 284 243 60 303

Health for Life—Annual Report 20 TABLE 2.3 SUMMARY OF FCHV READINESS VISIT BY DISTRICT AND SEMI-ANNUAL PERIOD JUL-DEC 2015 JAN-JUNE 2016 DISTRICT PRIORITY GENERAL PRIORITY GENERAL TOTAL TOTAL VDC VDC VDC VDC Kapilvastu 21 2 23 41 0 41 Arghakhanchi 18 19 37 25 2 27 Pyuthan 28 6 34 24 1 25 Rolpa 39 11 50 40 0 40 Rukum 26 0 26 24 0 24 Salyan 30 2 32 33 0 33 Dang 27 28 55 50 10 60 Banke 34 18 52 38 6 44 Bardiya 64 4 68 53 11 64 Surkhet 4 10 14 23 0 23 Dailekh 24 6 30 22 0 22 Jajarkot 16 4 20 18 0 18 Jumla 22 8 30 38 0 38 Kalikot 21 0 21 21 3 24 TOTAL 374 118 492 450 33 483

Some key results from the Readiness Assessment (HF and FCHV) and Client Exit Interviews: HF READINESS • Out of the 587 visits, 238 were new visits and 349 HFs were re-visits; 488 were high-priority VDCs; 33 were conducted at PHCCs and 554 at HPs; 490 have a birthing center • The calculated average readiness score is 60 percent; by category, the average scores are: basic amenities, 54 percent; basic equipment, 89 percent; standard precautions for IP, 40 percent; and medicine and commodities 57 percent • 699 SBA-trained staff were available in those 490 birthing centers (ranging from 0 to 5 SBAs per center) • Nearly 58 percent of institutional deliveries reported in the last month’s visit are by women from marginalized communities • 78 percent of birthing centers reported that partographs were being used for clinical decision-making during labor and delivery • 67 percent of health workers trained on IPCC were found to be using all six steps of counselling during FP services (96 observed cases among IPCC-trained health workers) • Nearly 83 percent of observed cases of family planning service provision maintained both audio and visual privacy during counselling (167 observed cases) • Also among observed cases, seven out of ten service providers used family planning kits or materials during counselling, while only 73 percent confirmed pregnancy before giving FP methods • 93 percent of HFs reported sending last month’s HMIS reports on time, and the same percent of HF (93%) sent LMIS reports on time • Only 48 percent of HFs had updated monthly monitoring worksheets for the previous month • 68 percent of HFs were displaying up-to-date monthly service coverage information in a public place • 98 percent of HFs had organized FCHV meetings in the last month FCHV READINESS • Among 975 FCHVs visited, 81 percent were from high-priority VDCs, 23 percent were members of HFOMCs, 20 percent were members of the HF-QI team • 83 percent of FCHVs had received IPCC training and 93 percent of FCHVs could recite the three or more steps of counselling • 87 percent of FCHVs were able to recite three home rules for the treatment of diarrhea

Health for Life—Annual Report 21 • 98 percent of FCHV were able to mention three or more essential newborn care practices after delivery • 92 percent of FCHV had condoms with them while 88 percent had pills • 69 percent of FCHV were able to recite danger signs of pneumonia of under-2-month old children, while 70 percent of them were able to recite danger signs of pneumonia among 2-month to five-year old children • Only 31 percent FCHV reported that some kind of health promotional activities had been conducted in their VDC. CLIENT EXIT INTERVIEWS • A total of 310 exit client interviews were conducted this fiscal year, with a majority of clients visiting health facilities for general checkups (41%), family planning (30%), immunization (18%) and delivery services (5%) • 73 percent of post-partum women who received counseling on comprehensive information reported that service providers followed all five steps of counselling while providing services • 39 percent of clients interviewed were using some method of FP. Almost all clients reported that they received counseling on FP while visiting for immunization service, while 73 percent received counseling on family planning services during general treatment visits. In contrast, only 53 percent of client who were visiting health facility for delivery and PNC-related services received counseling on family planning. HF READINESS ASSESSMENT IN EQ-AFFECTED DISTRICTS Health for Life conducted HF Readiness Assessment in all 110 health facilities in the EQ-affected districts between March and April 2016. The major findings of assessment are presented here. • The general readiness index of health facilities in EQ-affected districts was 16.3 percent. Makawanpur (34.4 %) had highest readiness score while Nuwakot (4.2 %) has the lowest general readiness score • While looking at different categories of HF readiness, basic amenities was at 6.8 percent, basic equipment at 37.6 percent, standard precaution for infection prevention was at 0.8 percent and medicines and commodities was at 20.1 percent • There are 54 birthing centers in Health for Life high-priority VDCs and 38 birthing centers have been providing at least one long Acting Family Planning services. 12 birthing centers have been providing two LAFP (IUCD and Implant). Ramechhap and Sindhupalchowk districts have more birthing centers providing LAFP, whereas Rasuwa and Makawanpur districts have no LAFP services in Health for Life priority VDCs. • Out of 54 birthing centers 32 (59.3 %) have Skilled Birth Attendants and 85 percent use oxytocin and 66.7 percent use partograph during delivery. • There was a chronic shortages of clinical staff in all facilities in EQ-affected districts. Only 57.5 percent of sanctioned clinical positions were found filled in health posts, whereas only 36.6 percent of sanctioned clinical positions were found filled in PHCC. Rasuwa (80%) and Dolakha (74 %) districts have highest number of clinical staff position filled, whereas Sindhupalchowk (31.4 %), Sindhuli and Gorkha (50 %) districts have lowest number of clinical positions filled against sanctioned positions. While looking at results of HF Readiness Assessments of 110 health facilities in EQ-affected districts, delivery of services is mainly affected by lack of human resources, basic medicines and commodities and service quality was deteriorating due to lack of standard precautions for infection prevention. FIGURE 2.8 GENERAL READINESS INDEX OF HFs IN EQ-AFFECTED DISTRICTS 2016

Health for Life—Annual Report 22 STRENGTHEN HMIS AND USE OF DATA Health for Life provided technical assistance to the D(P)HOs in the ten EQ-affected districts for analyzing data and preparing presentations for regional review meetings. Health for Life teams, including the Development Associates, are continuously working with health facility staff to improve data quality in all 108 high-priority VDCs. As a result of Health for Life technical assistance health facilities are now using all tools for recording at health facilities and monthly HMIS reports are adhering to service registers. Health for Life also provided support to the D(P)HOs for designing and printing HMIS flex charts to be used at district and health facility-level. These HMIS flex charts will be distributed to all health facilities in the EQ- affected districts in July-August 2016. Health for Life also provided GIS maps to all ten EQ-districts which show HF location and reconstruction status as well as which health-related organizations are working in each VDC. These maps are now being used to improve coordination among partners at the district level. Health for Life, in consultation with the D(P)HOs, selected 30 sentinel sites in the ten EQ-affected Health for Life districts to implement mobile tracking technology for the registration and tracking of pregnant women. Mobile devices have been purchased and implantation will start in July 2016. 2.2 NHRC PRIORITIZES, OVERSEES AND REGULATES RESEARCH BASED ON ESTABLISHED PRACTICE OF HEALTH SECTOR PLANNING AND BUDGETING NHRC RESEARCH NETWORK AND KNOWLEDGE MANAGEMENT CAPACITY STRENGTHENED Health for Life is providing support to the NHRC to build capacity in research networking and knowledge management. A health research consultant has been provided by Health for Life and is based at the NHRC to synchronize published research reports from health journals in Nepal. The consultant also conducted an assessment of current NHRC websites. More than 300 abstracts have been prepared according to priority areas and are ready for upload. An important aspect of the support is development of the NHRC’s web portal which combines efficient knowledge management with an online proposal review and approval process. For this, a scope of work has been finalized and the activity has been planned for the coming fiscal year. WORKSHOP ORGANIZED ON ETHICAL CLEARANCE FOR USAID PARTNERS AND RESEARCH ORGANIZATIONS A two-day orientation workshop on “Research Ethics and Responsible Conduct of Health Research” for all USAID partners and major research agencies in Nepal was held on August 6-7, 2015, organized by Nepal Health Research Council and supported by Health for Life. The purpose of this workshop was to orient all USAID implementing partners and research organizations on the ethical clearance approval process to conduct research in Nepal. A total of 29 participants from 22 different organizations (including USAID) attended the workshop. Of these organizations, 17 were USAID development partners implementing various programs and four were research organizations. The participants were mainly COPs, DCOPs, and M&E Specialists/Advisors.

Health for Life—Annual Report 23 The workshop ended with the following suggestions: • Revise the ethical clearance guidelines and clarify the demarcation between regular monitoring and research; this will help in understanding the research and/or surveys requiring ethical approval • Revisit the application fee for ethical approval making it facilitative rather than impeding health research in Nepal. Students should be freed from any levies or fees as they hinder health research. Similarly, the percentage-based fee should be converted to a flat rate • The ethical clearance guidelines should also include the proposal submission format, information about fees and a template of informed consent.

Health for Life—Annual Report 24 OBJECTIVE 3: STRENGTHEN NATIONAL-LEVEL STEWARDSHIP OF THE HEALTH SECTOR 3.1 MOH'S NEXT HEALTH SECTOR STRATEGY (NHSP-III), THIRD LONG-TERM HEALTH SECTOR PLAN (2018-2038) AND COMPREHENSIVE HEALTH SECTOR PLAN (2016-2021) DEVELOPED IN COLLABORATION WITH EDPS AND TA PROGRAMS CONTRIBUTED TO DEVELOP NHSS (2015-2020) AND NHSS-IP Health for Life supported the MoH in developing the NHSS (2015-2020) by providing national and international expertise through the Program Development Team (PDT). Senior Management Team members, Advisors and Specialists of Health for Life participated and contributed among a series of thematic areas. Health for Life consolidated evidence and lessons related to service delivery, quality, BCC, decentralization of local health governance from the field and shared these with the thematic groups and the PDT. Health for Life team members engaged in drafting different chapters and speaking with stakeholders at different levels. The strategy document has been finalized, approved by the Cabinet and published by the MoH in both English and Nepali. The Health for Life team has been heavily engaged with MoH, Divisions, Centers and other stakeholders in preparing the NHSS-IP in different reform areas and sub-sectors. The MoH decided not to develop a Third Long Term Health Sector Plan. URBAN HEALTH POLICY 2072 The MoH recently received Cabinet approval of Nepal’s first urban health policy. The policy includes provisions that were guided in part by representatives from MoFALD that emphasized aligning the policy provisions with the Collaborative Framework. The Primary Health Care Revitalization Division of the DoHS, which is also a member of the Technical Coordination Team (TCT), an institution created by the Collaborative Framework, led the policy’s development. The Collaborative Framework appears to have had a significant influence on the urban health policy; the rationale for the policy is explained thus: “…..this policy is imperative to managing an urban health program, in line with the integrated and coordinated implementation of the Collaborative Framework on Strengthening Local Health Governance signed between MoH and MoFALD in December 2013, and its implementation guidelines.” PROVIDE TA TO DOHS TO STRENGTHEN PFM SYSTEMS AND IMPLEMENT USAID’S GOVERNMENT-TO-GOVERNMENT-SUPPORTED REDBOOK ACTIVITIES AND BUDGETING Health for Life provided TA for the finalization of amendments to the Implementation Letter for FY 2015/16 in close consultation and coordination with the respective Divisions/Centers of DoHS and USAID. Moreover, TA is ongoing for the preparation and finalization of the Implementation Letter for next fiscal year as well. This includes, among other activities, reviewing the proposed TABUCS and LMBIS and settling mismatches between LMBIS and the USAID reimbursements. The Implementation Letter will address changes, it is expected, during implementation of USAID-funded Redbook activities. The Health for Life team supported and facilitated finalization of the audit report for USAID’s G2G-supported Redbook activities in FY 2014/15 in close coordination with the Financial Administration Section, DoHS. Joint field visits with a DoHS official and auditors were conducted to coordinate and facilitate the audit in the districts. Furthermore, TA was provided to the DoHS to settle some questions raised by the Audit Report for fiscal year 2013/14. Supporting documents were obtained during joint field monitoring visits with DoHS officials and were submitted to USAID, which helped to settle the issue. Health for Life gave technical assistance during the designing, planning, organizing and reporting of four regional workshops, at which 164 participants attended from D(P)HOs, hospitals and regional offices located in all districts and regions.

Health for Life—Annual Report 25 The project team supported the preparation of Trimester Reimbursement Claims for the disbursements from USAID and the Trimester Progress Report of Implementation Letter activities. Finally, Health for Life supported and facilitated orientations to D(P)HO officials in Solukhumbu and Morang, as required by USAID, to implement activities reimbursed by USAID during a joint on-site coaching with the DoHS and USAID officials, as per the DoHS Risk Mitigation Action Plan (RMAP). Solukhumbu and Morang are the districts selected for on-site capacity building a higher level of USAID Redbook budget allocations in the current fiscal year, in line with RMAP.

OBJECTIVE 4: INSTITUTIONALIZE NATIONWIDE SYSTEM FOR QUALITY IMPROVEMENT 4.1 NATIONAL QI SYSTEM Health for Life continued contributing to National Quality Assurance coordination mechanisms (QI TAC, QAI TWG) with MD, and continued district QAWC meetings in all Health for Life districts to improve quality of care in HFs with D(P)HOs. QI TECHNICAL ADVISORY AND QAI TECHNICAL WORKING GROUP MEETINGS Health for Life, together with other stakeholders, worked with the QA Section of the Management Division to functionalize QAI TWG. The QAI TWG met twelve times since its formation, including twice this year. The key decisions and results from the two meetings held during this reporting period are summarized below. The QI TAC meeting was not organized despite our efforts. This was specifically due to the unavailability of the DG and Directors and because there was no QA Section Chief. TABLE 4.1 QAI TWG MEETING SUMMARY

DATE QAI TWG KEY DISCUSSIONS AND DECISIONS Dec 29, 2015 Tenth Meeting (Previous Oriented newly appointed QA focal persons from Divisions and Centers on national QI system. members from different Health for Life presented on progress and preliminary findings from field testing the HF QI system. Divisions were transferred and new members have joined) April 19, 2016 Eleventh Meeting This meeting was conducted in the presence of Directors from MD and FHD. Health for Life shared the process of implementation of HF QI system, WHO presented MPDSR and NSI updated implementation of MSS at hospitals. Partners shared the need for development of national level QA monitoring mechanism.

QAI PARTNERS MEETING With support from Health for Life, the Management Division organized a partners’ meeting on June 28, 2016, working on quality assurance and improvement. This meeting was attended by the Director and QA Section Chief of the Management Division, USAID, UNFPA, GIZ, WHO, Swachhata (Health and Hygiene)/SNV, NHSSP, NSI as well as Health for Life. Though invited, UNICEF could not participate. The primary objective of this workshop was to update the QA Section, Management Division, regarding their work on the Quality Assurance and Improvement process. All agencies made presentations of their progress. Considering the promising results from the funds allocated to hospitals, the MD Director informed participants that MD had expanded allocations of funds to the PHCs (NPR 250,000 to each PHC) for quality-related issues and he requested partners to support functionalization of HFOMCs across the country. Since NHSS IP has been developed and QI is a crosscutting issue, it was decided to develop 'minimum service readiness quality improvement tools. Health for Life will be coordinating development and compilation of these tools. The need for managing quality-related data and resources including a 'secretariat' and technical human resources was also discussed. A visual display of quality of care at health facilities was also discussed. SUPPORT FOR NHSS IP DEVELOPMENT

Health for Life—Annual Report 26 Health for Life supported the Management Division to develop its NHSS Implementation Plan (IP). A series of meetings were conducted to develop implementation plans pertaining to quality assurance and improvement interventions under the Management Division. In the process of developing the IP, Health for Life helped to prepare indicators related to the quality assurance system, quality of care of services at the point of care, IP/HCWM and health infrastructure. Participants also outlined the role of the Management Division pertaining to the quality improvement system, improvement of readiness at health facilities and monitoring the quality of care done by the respective program divisions and centers. WHO SEARO QI MEETING Health for Life, together with the WHO, supported the Management Division to prepare a national QA/QI presentation in Regional Workshop on quality for May10-13, 2016. Health for Life also made a poster presentation. FIELD TESTING HF QI SYSTEM IN DANG, JUMLA AND SURKHET Health for Life provided support to the D(P)HOs in Dang, Jumla and Surkhet to implement HF-level QI activities. After orientation to the district QAWCs, with support from Health for Life, the D(P)HOs led the process of implementation in their respective districts. Health for Life supported orientation of all 19 health facilities in these districts (Dang, 39; Jumla, 30; and Surkhet, 50) on the HF QI system, carrying out self-assessments on quality of services using the QI tools and preparing action plans for the HF Service provider using QI tools in Surkhet QI teams. In this process, Health for Life (district teams and consultants), supported the HF QI teams in orienting the respective HFOMCs on the HF QI system and worked together with the HFOMCs to finalize action plans for resource mobilization. Implementation of the HF QI system has provided a broad range of information pertaining to quality of services which will be useful for the periodic monitoring of quality of services as well as in preparing action plans to address gaps. The follow-up to the HF QI System shows that the HFs have improved their readiness as well as quality of services (Figures 4.1 and 4.2). FIGURE 4.1 COMPLIANCE WITH PHYSICAL FACILITY STANDARDS AT SELECTED HFs OF JUMLA

Health for Life—Annual Report 27 100 90 80 70 60 50 40 Percentage 30 20 10

Badki Mahat Dhapa Hanku Kudari LamraRaralihi Kartik Swamit

1st Quarter (Jul‐Oct. 2015) 2nd Quarter (Nov. 2015‐Feb. 2016) 3rd Quarter (Mar‐Jun. 2016)

FIGURE 4.2 COMPLIANCE WITH IUCD SERVICE STANDARDS AT SELECTED HFs OF DANG 100

80

60

40 Percentage

20

Rajpur Duruwa Sisahaniya

Mar‐Jun, 2015 Jul‐Oct. 2015 Nov 2015‐Feb. 2016 Mar‐Jun. 2016

ADDRESSING GAPS Health for Life is working with HFOMCs to improve quality of services. Findings from the QI Assessment have been incorporated into the Village Health Situation Analysis Report (VHSAR) and also helped in incorporating Village Health Plans into the Annual Village Development Plans. In the pilot districts, in FY 2015/16, the total health budget allocated was NPR 4,564,000 out of which NPR 3,639,000 was spent. Surkhet alone allocated NPR 1,733,000. In Dang and Jumla, all the VDCs prepared VHSARs for FY 2016/17, which include gaps identified during the HF QI assessment. In Surkhet, this included all priority VDCs. The total budget allocated for health in these three districts was NPR 6,258,000, with Surkhet, which is not a CF district, allocating NPR 1,508,000. ASSESSMENT OF FIELD TESTING The assessment of the HF Quality Improvement System field testing started in Dang in June 2016. The overall objective of the field test was to look into the feasibility of implementing a simplified HF Quality Improvement System so that quality of services provided by HWs/HFs are assessed periodically, and to support HFs in improving quality of care as necessary. There were delays recruiting consultants, and, because of bad weather; it is expected that it will be completed by the end of July 2016 in Jumla and Surkhet. Preliminary findings from the field test in Dang show that health facilities have started using a systematic approach to assessing quality of care and addressing gaps identified by mobilizing local resources, including the VDC planning process. The health facilities visited had functioning QI teams that were reporting quarterly as per the guidelines, and health facility workers clearly understood that the quality improvement system was the most important part of delivering health care services.

Health for Life—Annual Report 28 TA TO D(P)HOS TO ORGANIZE PERIODIC QAWC MEETINGS IN ALL HEALTH FOR LIFE DISTRICTS FIGURE 4.3 DISTRICT QAWCS ESTABLISHED DECISION AND ACTION PLANS

5

Number of QAWCs

Banke Jumla Rolpa Dang Jhapa Kaski BardiyaDailekhJajarkot Kalikot Pyuthan RukumSurkhet Salyan Kailali Kapilvastu Arghakha... Chitawan

Health for Life continued its TA to D(P)HOs to conduct QAWC meetings as per the guidelines and implement its action plan in all 18 districts (core plus demonstration districts). A total of 51 QAWC meetings (Figure 4.3) were conducted during this reporting period, where they developed action plans focused on quality of FP/MNCH service delivery based on HF QI assessment findings, and supervision and monitoring visits. During this reporting period, a total of 159 activities were planned and more than 100 were accomplished (Table 4.2). TABLE 4.2 QAWC MEETING STATUS IN HEALTH FOR LIFE CORE AND DEMONSTRATION DISTRICTS

DISTRICT DATE DECISION IMPLEMENTATIO N STATUS Arghakhanchi Oct 30, 2015 • Renovation of damaged hospital drain pipeline and maintenance of Completed incinerator • Decided to provide material/supplies to birthing centers using QI Completed budget (NPR 298,000 out of NPR 335,000) • Provide plastic apron for IP, plastic basin/bucket, gas stove Completed (Simalpani and Dhakawang HP), autoclave (Maidan, Chhatragunj, Mar 1, 2016 and Dhanchaur), bedsheets and rubber sheet (hospital) for the quality improvement of services. • Implement HF QI in 10 new general HFs and district MCH clinic • Coordinate with Health for Life for HF QI orientation in 11 Jun 30, 2016 general HFs including HFOMCs Ongoing

Banke Aug 12, 2015 • Decided to implement HFQI team orientation in 11 HFs Completed in 9 HFs • Decided to support Bankatuwa PHC for solar panel and inverter Completed from Save the Children during QAWC meeting • Manage regular and adequate supply of essential drugs and key Completed Jan 26, 2016 commodities including iron tablets and MSC to the HFs/ FCHVs. Managed to establish HF QI budget in 13 HFs for quality improvement of services Completed • Prepared annual health plan and sent to DDC May 22, 016

Bardiya Sep 23, 2015 • Made effective annual review of 2071/72 (all program focal Completed person would prepare and present their program status, provide feedback to HFs) Feb 17, 2016 • Provided HF QI orientations to HFs (Sanoshre, , Implementing (10 were Mainapokhar, Motipur, , Khairichandanpur. Padnaha, completed out of 11) May 26, 2016 , , Nayagaun & District MCH clinic) • Installed hand pump to solve the problems of drinking water in Completed IP set will be MCH clinic distributed in all HFs from QI fund

Sep 15, 2015 • Decided to strengthen HMIS system and provide raw data to Completed Dailekh supervisors for data verification and to minimize errors • Decided to provide logistic support by using QI budget allocated Completed from MD for such materials as (Water Tank – Rawotkot and Jan 8, 2016 Sigaudi; Footstep – Kharigaira, Malika, Karnali, Gamaudi

Health for Life—Annual Report 29 DISTRICT DATE DECISION IMPLEMENTATIO N STATUS and Sattala; Autoclave – Raniban, Sigaudi, Kusapani, Bissala and Gamaudi HF) • Agreed to mobilize QI Budget to fill gaps as per action plan Ongoing

Jun 10, 016 Dang Aug 5, 2015 • Implemented HF QI in all 40 HFs including IFPSC Completed (Field testing district) • Shared HF readiness findings in QAWG meeting and reviewed Completed Dec 15, 2016 HMIS data and provided feedback • Discussed and decided to conduct CEONC assessment in 10 HF Completed Feb 22, 2016 &2 hospitals and distributed referral slips from May 11, 2016 Management division and supply to all HFs Completed • Distributed color-coded buckets in 15 HFs Jajarkot Sep 28, 2015 • Supplied IP materials to birthing centers (soap, phenyl, bed sheets, Completed gas stoves with cylinders, etc. Jan 24, 2016 • Reviewed/followed up on 10 HFs and HFs were selected for Not completed expansion in FY 2072/73 • Started IUCD and implant services on a regular basis at district Completed MCH clinics. Completed • Implemented HF QI system in 10 general VDCs ( Punma, , Dashera, Salma,Lah, Dadagaun, Rokaya gaun, , Nayakbada, Khalanga and district MCH clinics Jun 17, 2016 Completed • Started to analyze monthly reports of HFs by QAWC focal person • Decided to supply IP materials to 38 HFs and gas stoves to Sakala, Dashera, Karkigaon and Bhoor HFs Jumla Aug 6, 2015 • Followed up on 12 HFs HF QI including 2 general Completed (Field testing district) VDCs; Implemented HF QI system in18 general VDCs Jan 10, 2016 • Coordinated and collaborated with NGO/INGO/KAHS to Completed improve health service quality, Jun 24, 2016 • Prepared list of BCs and provide equipment needed Completed Kailali Apr 5, 2016 • Purchased 5 autoclaves from district QI Budget and provided to Completed HFs based on assessment • Decided to send 2000 packets of Virex powder to 10 HFs Ongoing • Distributed 43 pairs of utility gloves and materials related to health Completed care waste management Completed • Followed up on 8 HFs’ QI orientations Kalikot Sep 29, 2015 • Conducted QI follow-ups on HFs in Bharta, Lalu, Kumalgaun, Completed Malkot, Rupsa, Nanikot, Ramnakot and Phoimahadev and Jan 8, 2016 decided to implement HF QI system in 10 more HFs Completed • Circulated letter to BCs to utilize Aama Surakshya budget for May 6, 2016 addressing gaps Ongoing Kapilvastu Oct 6, 2015 • Accomplished 1-day HF QI review/follow up in 10 priority HFs Not Completed • Supplied 40 types of medicine to HFs after gaps identified • Installed solar systems in Dubiya, Rajpur, Siswa , and Completed Maharajgun and provided equipment as per gaps identified in Completed in in Dubiya, newly-established birthing center (, Chanai, Rajpur, Siswa , Pakadi and Feb 14, 2016 and Bhagwanpur) Maharajgunj and equipment provided as per need and purchased equipment's for BCs • Provided autoclaves to Hardauna HP and in labani, Chanai, Gugauli

Jun 17, 2016 Completed Pyuthan Sep 23, 2015 • Completed HF QI orientation at three HFs including MCH Completed in MCH clinic, Feb 18, 2016 clinic (out of 10 HFs planned) and followed up on 10 HFs Dhuwang and Liwang HPs only Jun 10, 2016 • Conducted FU HF QI assessment Completed • Conducted client exit interviews and discussions in QI Team Ongoing meeting Rolpa Aug 31, 2015 • Reviewed QI status at 10 priority HFs of previous year Completed Dec 28, 2016 • Formed and reviewed committee for Annual Review meeting for Completed May 17, 2016 using PHAT • Reformed DQAWC as per revised guidelines Completed

Rukum Oct 14, 2015 • Organized joint monitoring visit of QAWC and DHGTF members Completed • Decided to use supervision and monitoring budget to address gaps at high priority VDCs (identified during QI team orientation) Implemented in 1st • Provided TA to prepare District Annual Health Plan and estimated quarter DHGTF visit Feb 25, 2016 annual budget to send to DDC council May 30, 2016 Not completed; lobbying for fund utilization Salyan Aug 31, 2015 • Developed integrated monitoring plan/schedule of DHO Completed

Health for Life—Annual Report 30 DISTRICT DATE DECISION IMPLEMENTATIO N STATUS • Completed procurement process of medicine and distributed to Completed HFs (Amoxicillin 500mg:-32,000 Tab , Cotrim- 480mg- 32,000 Feb 15, 2016 Tab, Gloves-5,000 pairs, ORS:-9,000 sachet, Amoxicillin 250 mg- 9,000 tab, Dicyclomine 10 mg) Jun 28, 2016 • Completed QI follow up assessment in 10 priority VDCs Completed • 10 more VDCs selected for QI orientation D(P)HO for QI Ongoing of service in the BCs as per the guidelines Ongoing

Surkhet Oct 30, 2015 • Prepared list of ANMs working in HFs Completed Jan 7, 2016 • Sent request to DDC and Health for Life to construct placenta pit Completed (Field testing district) in birthing center. Apr 23, 2016 • Conducted monitoring and supervision visits to Gutu, and Completed

Health for Life—Annual Report 31 IMPLEMENT HEALTH FACILITY QI SYSTEM IN 14 HEALTH FOR LIFE DISTRICTS INCLUDING FOUR DEMONSTRATION DISTRICTS WITH QAWCs, D(P)HO AND HFOMCs, AND PRINT AND DISSEMINATE QI GUIDELINES AND QI TOOLS HEALTH FACILITY QI IMPLEMENTATION (CF AND CORE) Health for Life has provided TA to the D(P)HOs to form a total 540 HF QI teams, out of which 168 were formed this reporting period, including the demonstration districts. Health facilities in all high-priority VDCs have formed QI teams. A total of 195 QI teams were oriented on the QI system and its processes during this reporting period. QI teams are now meeting on a monthly basis and have started to use the QI tools to self-assess and identify gaps/issues which are being brought to the HFOMC meetings.

HF Readiness Midterm Survey has shown that 83 percent of all HFs have formed QI Teams as opposed to 100 percent of high-priority VDCs. They also found that 47 percent of QIT teams have developed at least one action plan in last three months: 67 percent of high-priority VDCs and 25 percent of other VDCs. TABLE 4.3 HF QI IMPLEMENTATION STATUS IN HEALTH FOR LIFE’S CORE AND DEMONSTRATION DISTRICTS TOTAL QI TEAMS FORMED QI ORIENTATION DISTRICT TOTAL TOTAL FY 2014/15 FY 2015/16 FY 2014/15 FY 2015/16 Arghakhanchi 17 2 19 9 1 10 Banke 36 4 40 10 9 19 Bardiya 31 0 31 10 11 21 Dailekh 23 0 23 0 12 12 Dang 35 4 39 14 26 40 Jajarkot 33 1 34 11 2 13 Jumla 12 18 30 12 18 30 Kalikot 29 0 29 0 17 17 Kapilvastu 12 1 13 10 1 11 Pyuthan 35 1 36 10 2 12 Rolpa 41 2 43 10 6 16 Rukum 21 4 25 10 3 13 Salyan 31 1 32 10 0 10 Surkhet 16 34 50 10 40 50 Subtotal 372 72 444 126 158 284 Chitwan n/a 19 19 0 10 10 Jhapa n/a 20 20 0 8 8 Kailali n/a 41 41 0 10 10 Kaski n/a 16 16 0 9 9 Subtotal 96 96 0 27 27 Grand total 372 168 540 126 195 321

Health for Life provided TA to D(P)HOs to carry out follow-up assessments which have shown improvements in compliance with standards (Figures 4.4-4.6).

Health for Life—Annual Report 32 FIGURE 4.4 READINESS OF HFs REGARDING IP/HCWM (HF MIDTERM SURVEY) 100 80 60 40 Percentage 20

Sterilizer Puncture Chlorine Disposable Soap Latex gloves Utility gloves Towel to dry proof syringe baby container

Baseline (2013) Midterm (2015)

FIGURE 4.5 COMPLIANCE WITH FOCUSED ANC SERVICE STANDARDS* IN BANKE (HIGH-PRIORITY VDCS) 100

80

60

40 Percentage

20

Holiya Betahani Matehiya Narainapur Bankatti Titihiriya Udharapur

1st Quarter (Jul‐Oct.2015) 2nd Quarter(Nov.2015‐Feb.2016) 3rd Quarter (Mar‐Jun. 2016)

* See QI Tool FIGURE 4.6 COMPLIANCE WITH STANDARDS* FOR CARE OF SICK CHILD (2-59 MO) IN SELECTED HFS OF JAJARKOT 100

80

60

40 Percentage 20

Sima Ragda Bhoor Dalli Sakala

1st Quarter (Jul‐Oct. 2015) 2nd Quarter (Nov. 2015‐Feb. 2016) 3rd Quarter (Mar‐Jun. 2016)

* See QI Tool IMPLEMENTATION OF HF QI SYSTEM IN THE ADDITIONAL FOUR DEMONSTRATION DISTRICTS

Health for Life—Annual Report 33 Beginning in December 2015, Health for Life started implementation of the HF QI system in four of the GoN’s demonstration districts for the Collaborative Framework (Jhapa, Chitwan, Kaski and Kailali). The District QAWC has been formed in all four districts and seven QAWC meeting have been conducted. Kailali and Chitwan could not organize QAWC meetings every four months. In the four demonstration districts, Health for Life has completed orientation of the D(P)HO and District Supervisors on QA policy, guidelines, tools and processes of the HF QI system and the District QAWCs have been reformed and revitalized (Figure 4.3).

Health for Life supported the introduction of the QI system in 37 HFs and oriented HF QI teams. An equal number of HFOMCs were oriented on the HF QI System so that they can help address gaps identified through the QI assessment. QI ACTIVITIES IN EQ-AFFECTED DISTRICTS Health for Life provided technical assistance to ten D(P)HOs to form and revitalize the District Quality Assurance Working Committees and HF- based Quality Improvement Teams. A Working Committee was formed and oriented in Rasuwa this reporting period. The Health for Life team is working with the D(P)HOs to form DQAWCs in nine remaining districts and are expected to be formed by July 2016. HF-based QI Teams are being formed in all priority VDCs with 89 QI Teams were formed during this reporting period.

Rolling Plans recruited 108 Community Health Assistants to be deployed to the 108 priority VDCs specifically to work in the areas of quality of care at the facility level. 108 newly-recruited Community Health Assistants (CHAs) have been trained on the QI-tools and self-assessment. QI assessments in all 108 priority VDCs will be conducted in July 2016.

OBJECTIVE 5: IMPROVE CAPACITY OF DISTRICT AND LOCAL LEVEL HEALTH WORKERS AND COMMUNITY VOLUNTEERS TO DELIVER HIGH QUALITY FP/MNCH AND NUTRITION SERVICES 5.1 COMMUNITY-LEVEL HEALTH INNOVATIONS AND PROGRAMS DELIVERING MNCHN/FP SERVICES SCALED UP AND MAINTAINED Health for Life gave assistance to FHD to celebrate the 'Second National Family Planning Day', specifically for planning main events, selecting individuals that have contributed significantly to FP programs for awards, identifying key advocacy messages, coordinating with HPP and key resource people at the Central level and by organizing district-level activities (see also Objective 6). Additionally, Health for Life provided TA to FHD to orient FP Supervisors on the FP QI tools on July 11, 2015 and the national QI system on June 16, 2016 during the National FP Supervisor's Review Workshop organized by FHD. The project supported FCHV Sub-committee meetings on various dates and helped plan the 12th FCHV Day Celebration (December 5, 2015) and review the FCHV Strategy. Similarly, during the Family Planning Sub- committee meeting, Health for Life briefed the Sub-committee on why the implementation guidelines on post- partum family planning are needed and how best to develop them. Health for Life also provided TA for the National ASRH program to provide input to the National Adolescent Health and Development (NAHD) strategy and AFS certification criteria. Similarly, Health for Life supported the FHD together with other partners in developing the NHSS IP on maternal and neonatal health, family planning and adolescent reproductive and sexual health. Health for Life also supported FHD in developing the AWPB for FY 2016-17. REVISION OF THE FCHV STRATEGY Health for Life helped the FHD review the FCHV strategy, drafting a concept paper on how to revise the FCHV strategy as well as organizing FCHV sub-committee meetings. A revised version of the strategy has been drafted and proposes that the primary role of FCHVs should be to serve as health promoters, that selection criteria must stipulate a higher educational background and that a compulsory retirement age be set. Most importantly, the strategy intends to transfer overall management of FCHV program to local government once the federal structure is put into place. Some of the key issues related to the FCHV program are:

Health for Life—Annual Report 34 Focal Division: The FCHV program is being managed by the FHD in rural areas and by the Primary Health Care Revitalization Division in urban areas, possibly leading to differences in implementation and activities. Overburdened: The responsibilities of FCHVs have increased since the program’s inception. FCHVs are now responsible for providing services in addition to health promotion, preventive activities and other health activities related to local groups (NGOs, INGOs etc.) Nonetheless, 2006 and 2014 survey findings show that FCHVs are willing to devote more time to their work. Role of FCHVs: The current strategy gives the same responsibilities and incentives to all FCHVs, yet the 2014 FCHV survey, shows a lot of variation in activities across geographic areas, suggesting the need to consider responsibilities. Urban FCHVs have been especially vocal in their desire to engage in more activities, including increasing demand and utilization of health services and other activities. Increasing use of facility-based services: Community-based programs like BPP and CB-IMCI are gradually being transitioned into facility-based programs. Policy directions: The National Health Policy 2014 suggests employing community ANMs and enhancing the capabilities of FCHVs. The NHSS 2015-2020, on the other hand, does not talk much about the roles of FCHVs. Commodities: Many FCHVs do not have commodities (FCHV Survey, 2014) Supervision of FCHVs: Because VHWs have been promoted to AHWs and now work in HFs, they travel to the FCHVs to support them less often than before. Some issues related to the FCHV Strategy (proposed):  Although it recommends giving a greater role to the Health Mother's Group (HMG), communities and local bodies in selecting FCHVs for vacant positions, the strategy does not adequately explain the criteria and process. Similarly, while the strategy proposes that local bodies should determine the role of FCHVs, no definitive changes have been set forth.  No clear basis for setting the number of FCHVs per VDC/municipality.  Some FCHVs are more active than others. It is unclear how engaged an FCHV must be in order to retain her status as FCHV. The proposed strategy should define what constitutes active and inactive FCHVs.  The strategy must define a mechanism for knowing which non-health-related activities FCHVs are engaged in for better coordination.  As the country is transitioning into a federal structure, and it is unclear how the health system and structures will be affected, it is important for the strategy to make provisions for this process.

POSTPARTUM FAMILY PLANNING (PPFP) IMPLEMENTATION GUIDELINES The need for PPFP implementation was discussed during the 45th Family Planning Subcommittee meeting on December 24, 2015) and it was decided that the guidelines should be developed based on new information from the NDHS 2016 and PPFP study (NESOG/FIGO/Harvard University). ASSESSMENT OF CEONC REFERRALS Health for Life continued providing TA to the D(P)HO of Dang to strengthen CEONC referral. An assessment of CEONC referral services at 10 referring sites and two receiving sites was conducted in February 2016. All sites provided 24/7 delivery services, but none of the sites provided Kangaroo Mother Care. Among the 10 referring health facilities, newborn care services is provided at only six facilities. Ambulances were available at seven health facilities, and all these HFs used ambulances to transport clients. However, recording the referrals was only done at six of the facilities. 'Emergency Obstetrics and Newborn Care Funds' are only available at four out of 12 sites for when the mother gets referred, while only one HF has a fund for when newborns are referred. For health facility-to-hospital referrals, two sites out of 12 have established funds for the referral of mothers and one site has funds for newborns. There are no funds available at CEONC sites to transport patients to higher centers or to refer back (Table 5.1).

Health for Life—Annual Report 35 TABLE 5.1 READINESS AND KEY FUNCTIONS OF HEALTH FACILITIES AND HOSPITALS PERTAINING TO CEONC REFERRALS NUMBER OF NUMBER OF REFERRAL REFERRAL RECEIVING INITIATING SITES* SITES** TYPE OF HF (N=10) (N=2) TOTAL Ambulance (108) 7 2 9 n/a Transport Fund From Community To HFs MOTHER 4 4 NEWBORN 1 n/a 1 Transport Fund From HF/CEONC To Referring MOTHER 2 0 2 Site NEWBORN 1 0 1 Telephone Number Of Referring Site And Key Service Providers Clearly Displayed 1 0 1 Record Keeping Referred Cases 6 2 8 Communication Before Referral To Service Provider At Referring Site 3 0 3 Confirm Completeness Of Referral 4 0 4 Receives Information That Cases Are Referred n/a 0 0 Preparation For Receiving Cases n/a 0 0 Priority Given For Referred Cases n/a 2 2

*Rampur HP, Manpur HP, Gadhawa HP, Sishahaniya HP, Kavre HP, Narayanpur HP, HP, Lamahi PHC, Shreegaun PHC and PHC ** Rapti Sub-regional Hospital and Rapti Zonal Hospital It was found that the most common form of referral modality is verbal (13 out of 14 responses), followed by referral slips (8 out of 14). It was also found no health facility provides escorts for the client being referred. Three out of 10 health facilities said that they communicate with the receiving site while referring patients, but neither receiving hospital confirmed this. Instead, they responded that referred cases take priority. In FY 2015/16, a total of 66 mothers and 43 newborns were referred in or out of these institution, but the percentage of referrals from 10 HFs (referral initiating sites) to 2 CEONCs (referral receiving sites) in Dang was 48 percent (n=32) and 16 percent (n=7) for mothers and newborns, respectively. Health for Life supported the D(P)HO in presenting and discussing the findings on Feb 24, 2016 and also assisted in preparing an action plan at 2 of these sites. Since the new Director has taken office at NHTC, he has initiated a revision of the strategy for in-service training. Several rounds of preliminary meetings have been conducted to conceptualize key steps that need to be considered by the NHTC Director and senior NHTC officials. A concept paper has been drafted for in-service training strategy development and Health for Life has been identified as one of the core members. It is expected to be formalized once approved. Along with this, Health for Life is supporting the development of NHTC's NHSS IP. In addition to contributing in general to the in-service training implementation plan, our focus has been training capacity development, strengthening training systems and assisting in the development of FP, MNH, ASRH and other RH trainings. Health for Life supported the NHTC in disseminating updates on the revised Infection Prevention and Health Care Waste Management Reference Manual on January 18, 2016 during the 35th annual NHTC TWG meeting QUALITY IMPROVEMENT SYSTEM AT FP TRAINING SITES As a part of establishing the QI system at FP training sites, Health for Life supported the NHTC to organize follow-up meetings at the ICTC in Nepalgunj (Dec 9, 2015) and at the CFWC in Kathmandu (January 5, 2016). The training at the maternity hospital could not be done due disruptions caused to services, including family planning, as a result of the earthquake. Rather, Health for Life provided an orientation on FP training site QI Tools to all USAID FP partners on April 27, 2016.

Health for Life—Annual Report 36 FIGURE 5.1 COMPLIANCE WITH STANDARDS AT FP TRAINING SITES 100 80 60 40 Perentage 20 0 ML IUCD NSV IP/HCWM Implants Physical Facility FP Counseling CoCs and DMPA

ICTC CFWC Classroom-Based Clinical...Training Site Management Clinical Instruction and Practice

NSV AND IUCD SELF-PACED TRAINING Along with the revision of the No-Scalpel Vasectomy training materials, preparations were made to organize a training and orientation of NSV trainers from FPAN, MSI and CFWC on the self-paced approach at the CFWC on April 8, 2016. Because the NSV client flow during non-winter months at FP training sites is low, and because of poor internet connectivity, the NHTC has decided to carry out this training early next fiscal year. Though it was planned for May 2016, due to the delay in hiring a master trainer to coach development at the district level, skill standardization of potential coaches in the districts could not be done and now has been planned for the first quarter of next fiscal year. PRINT MEDICAL STANDARDS, AND IP AND HCWM Health for Life printed 900 copies each of the Nepal Medical Standard Vol. I and Vol. III and IP/HCWM, which have been distributed to all 14 core Health for Life districts, including HFs, hospitals, D(P)HOs and training centers. Updated NSV materials are in the process of being printed. TECHNICAL ASSISTANCE TO THE CHILD HEALTH DIVISION Health for Life provided TA to the CHD in order to: • Finalize the CB-IMNCI package (Program Management Module and Program Management Training Manual), implementation guidelines of CB-IMNCI program and supervision/monitoring tools used by the CHD • Develop the NHSS-IP, IMNCI and CB-IMNCI program planning for the current fiscal year and AWPB for next fiscal year • Draft the report on the CB-IMNCI program Annual Report, DoHS (FY 72/73), CB-IMNCI report, program implementation guidelines and services offered by various levels of service delivery points • Roll out CB-IMNCI program in five more Health for Life core districts (Arghakhanchi, Rolpa, Pyuthan, Banke and Jumla). Provided technical assistance in facilitation of district planning and trainings. Also provided printed training-related materials (e.g. treatment chart booklets, participant handbooks and management training manuals) • Update CB-IMNCI program-related HMIS recording and reporting tools as per need of program. In addition, TA was given to send circulars to clarify the most common confusions related to recording and reporting in the districts as well as to send written feedback on HMIS service data to all districts. As a result, mismatches and errors in reporting and data entry was corrected • Prepare a presentation on the regional review meeting in the Western Region using PHAT • Furthermore, Health for Life supported the CHD on CB-IMNCI planning and development of a free newborn guidelines workshop held in Dhulikhel, and IEC review and remote area guidelines development

Health for Life—Annual Report 37 workshop in Godavari. Draft of options for providing IMNCI services (especially regarding treatment of pneumonia) in remote areas. • The CB-IMNCI facilitator’s workshop was also supported, and Health for Life provided TA to update the CB-IMNCI treatment chart booklet, participant’s handbook and facilitator’s guide. Moreover, Health for Life also provided supported and facilitated the CB-IMNCI TOTs in Butwal and Kathmandu. IMNCI TRAINING/COACHING SITE DEVELOPMENT Three joint visits (Annex 2) were conducted with the CHD at potential training site (MWRH and Mehalkuna Hospital) and coaching sites ( PHCD) in Surkhet. A baseline assessment was carried out and action plan developed. Proposed roles and responsibilities for the RHD, RHTC, and training/coaching sites have been agreed upon by the respective authorities. A preliminary visit was conducted to introduce the Hospital QI system in Mehalkuna Hospital based on learning from the WHO SEARO meeting on QI and will be implemented next fiscal year. QI Tools for IMNCI training sites has been drafted and is under CHD review. DEVELOPMENT OF REMOTE AREA GUIDELINES A preliminary draft has been prepared. CHD organized a workshop on July 11, 2016 to get input from the D(P)HOs, IMNCI partners and the technical committee. Highlights from this workshop include:  Make the guidelines context-specific rather than general  Among various options of providers, FCHVs were considered as best possible option for providing treatment of pneumonia in remote areas  Though amoxicillin is the first drug of choice for treatment of pneumonia, FCHVs can continue using Cotrim  D(P)HOs can identify remote areas within the district based on M/DAG mapping by the DDC. DEVELOPMENT OF MEDICAL STANDARDS A committee has been formed by the CHD consisting of CH partners (Health for Life, SNL, UNICEF, WHO) to carry out preparatory work. This activity could not be carried out as there was difficulty in recruiting an appropriate consultant. PRINTING PROTOCOL AND TRAINING MATERIALS Health for Life supported the CHD to print 2000 copies of the Treatment Chart Booklet, 1200 copies of the Program Management Manual, 1000 copies of the Participant’s Handbook and 200 copies of the Photograph Booklet. TECHNICAL ASSISTANCE TO MAINTAIN THE MSC PROGRAM Health for Life continued its support to maintain the MSC program in program implementation districts (excepting Bardiya). Health for Life provided TA to the D(P)HOs to enhance the capacity of HWs and FCHVs. Health for Life district-based staff visited 587 HFs, 262 jointly with D(P)HO staff, which is more than in the previous six months (Table 5.2). A total 1,003 HWs and 942 FCHVs were coached on MSC-related issues. As per the HF Readiness Midterm Review survey, 61 percent of FCHVs know the right time to use misoprostol. 75 percent of FCHVs in high-priority HFs know the right time to use misoprostol as compared to 50 percent of FCHVs at other HFs.

Health for Life—Annual Report 38 TABLE 5.2 MSC VISITS TO HFs DURING REPORTING PERIOD

JOINT VISITS WITH HFs VISITED HWs COACHED FCHVs COACHED D(P)HO STAFF

DISTRICT

JULY– 2015 DEC JAN– JUNE 2016 TOTAL JULY– 2015 DEC JAN– JUNE 2016 TOTAL JULY– 2015 DEC JAN– JUNE 2016 TOTAL JULY– 2015 DEC JAN– JUNE 2016 TOTAL

Arghakhanchi 25 18 43 22 17 39 34 18 52 5 7 12 Banke 27 23 50 21 31 52 52 42 94 15 14 29 Bardiya 22 26 48 0 0 0 0 0 0 0 0 0 Dailekh 14 16 30 40 88 128 39 43 82 6 1 7 Dang 32 41 73 52 61 113 55 83 138 24 16 40 Jajarkot 16 14 30 38 81 119 20 56 76 12 4 16 Jumla 16 24 40 27 143 170 25 140 165 7 6 13 Kalikot 16 24 40 36 48 84 21 21 42 13 4 17 Kapilvastu 15 25 40 15 48 63 23 49 72 8 19 27 Pyuthan 23 15 38 0 47 47 34 25 59 0 2 122 Rolpa 30 22 52 6 18 24 15 53 68 17 48 65 Rukum 14 13 27 12 8 20 13 8 21 8 4 12 Salyan 18 21 39 19 3 22 29 4 33 5 2 7 Surkhet 16 21 37 55 67 122 17 23 40 5 10 15

TOTAL 284 303 587 343 660 1003 377 565 942 125 137 262

The Health for Life district team attended and supported 96 reporting TABLE 5.3 PERCENTAGE cluster (ilaka) meetings in 12 Health for Life districts (excepting OF WOMEN WHO Rukum and Jajarkot). The most common issues were related to data DELIVERED AT HOME & quality and logistics. These issues were discussed with the respective TOOK MISOPROSTOL, HF In-charges, and D(P)HO staff and provided AGAINST EXPECTED suggestions/feedback. LIVE BIRTHS, BY In addition, Health for Life supported and provided TA for a one-day DISTRICT MSC review in 13 districts (excepting Bardiya) in the presence of 603 HWs. Common issues discussed were availability of MSC at the MISOPROSTOL district level, HFs and FCHVs, data quality and monitoring and DISTRICT COVERAGE supervision. Participants pointed out that strips of 10 tablets instead of (%) three tablets is more difficult to distribute. In some districts there are Kapilvastu 52 Arghakhanchi 31 issues with the appropriate use and importance of MSC, particularly Pyuthan 6 among ANMs (mostly not trained as SBAs). Rolpa 25 Rukum 16 The HMIS data (Table 5.3) show that about 36 percent of women Salyan 58 delivered at home and were ensured to have taken misoprostol. Dang 41 Coverage ranges from 6 percent (Pyuthan) to 58 percent (Salyan). The Banke 41 HF Readiness Midterm Review Survey shows availability of Bardiya* 0 misoprostol at HFs has decreased from 64 (baseline) to 39 percent, Surkhet 7 Dailekh 24 which is 48 percent in high-priority HFs and 31 in other HFs. Jajarkot 51 Regarding availability of MSC in the community, the HF Readiness Jumla 30 Kalikot 42 Midterm Review Survey shows that only 17 percent of FCHVs have at least one dose of MSC (25 percent at high-priority HFs and 8 percent AVERAGE ૜૟ at other HFs. Despite this, HMIS service data shows relatively high Note: AVERAGE AMONG DISTRICTS coverage of miso in several Health for Life districts. The fact that this CALCULATED FROM TOTAL EXPECTED LIVE BIRTHS; THIS REPRESENTS 10 MONTHS is very unlikely suggests that strong monitoring of this program is HMIS DATA. *YET TO BE IMPLEMENTED necessary. In Bardiya, Health for Life helped the FHD introduce the MSC program (preventing PPH at home births) in selected VDCs. The FHD decided to implement programs in five VDCs with a high proportion of home delivery

Health for Life—Annual Report 39 as per CB-NCP data (, Suryapatawa, Mahamadpur, and Mathura Haridwar). TA was provided to carry out district orientation and meetings with key stakeholders (RHCC members and other partners). The D(P)HO prepared a plan to roll out the MSC program in these VDCs starting in July 2016. 5.2 D(P)HO ENHANCED FCHV KNOWLEDGE AND SKILLS IN CB-IMNCI AND FP COUNSELLING SERVICES IN ALL HEALTH FOR LIFE DISTRICTS CAPACITY BUILDING/LAFP COACHING Health for Life supported D(P)HOs in all 14 core districts in various ways to increase access to family planning services, particularly in identifying and selecting birthing centers for expansion of LAFP.

TABLE 5.4 BIRTHING CENTERS WITH LONG-ACTING FP (LAFP) IN HEALTH FOR LIFE DISTRICTS

IMPLANT TOTAL BIRTHING CENTERS IUCD ONLY ONLY BOTH NO LAFP

AS JUL JAN JAN JAN JAN DISTRICT ADDE ADDE JUL- JUL- JUL- JUL- OF - JUN - - - - D JUL- D JAN- DEC DEC DEC DEC JUN DEC TOTA JUN JUN JUN JUN DEC JUN 201 201 201 201 201 201 L 2016 201 201 201 201 2015 2016 5 5 5 5 5 5 6 6 6 6 Arghakhanch i 15 1 16 0 16 4 4 0 0 11 11 1 1 Banke 32 1 33 1 34 0 1 6 3 27 27 0 3 Bardiya 20 0 20 0 20 0 0 1 2 15 17 4 1 Dailekh 54 0 54 0 54 8 10 5 5 9 9 32 30 Dang 36 0 36 0 36 9 5 2 3 18 23 7 5 Jajarkot 24 2 26 0 26 2 2 4 4 12 12 8 8 Jumla 18 0 18 0 18 11 6 1 0 3 9 3 3 Kalikot 27 2 29 1 30 1 1 15 15 6 7 7 7 Kapilvastu 14 2 16 0 16 3 3 0 1 9 11 4 1 Pyuthan 41 0 41 1 42 0 2 14 14 6 7 21 19 Rolpa 51 0 51 0 51 5 7 5 7 18 20 23 17 Rukum 22 2 24 1 25 0 0 8 7 10 11 6 7 Salyan 39 -1 38 0 38 7 7 5 5 8 8 18 18 Surkhet 52 0 52 0 52 1 1 3 6 14 14 34 31

TOTAL 445 9 454 4 458 51 49 69 72 166 186 168 151 FIGURE 5.2 BIRTHING CENTERS WITH LAFP Health for Life coached D(P)HO staff in all 14 districts 500 in analyzing FP services, including LAFP, and helped identify birthing centers where LAFP services could be 400 strengthened. The number of birthing centers in Health for Life districts increased from 393 in the FY 2013-14 300 to 445 during FY 2014-15 and to 458 in FY 2015-16. Of these birthing centers, 67 percent (307) now offer at 200 least one LAFP method (49 centers provide IUCDs, 72 centers provide implants, and 186 provide both), while 100 33 percent (151) still do not, compared to 38 percent (169) last year. Health for Life’s Health Facility Readiness MTR Survey

FY 2013/14 FY 2014/15 FY 2015/16 has shown that HFs with at least one LAFP method # of BC # of BC withat least one LAFP have increase from 39 (n=120) to 52 (n=161) percent. The increase is slightly higher in priority VDCs.

Health for Life—Annual Report 40 FIGURE 5.3 LAFP IN HIGH-PRIORITY AND OTHER VDCs 60 VSC preparatory meetings were held in all 14 core districts. 40 Based on HMIS data collected up to March 2016, the 20 CPR in the core districts stands at 43 percent; 3.3 percent from IUCDs and 4.2 percent from implants. The contribution of IUCDs ranges from 0.1 percent in Rukum Priority VDC General VDC to 8.7 percent in Bardiya; similarly, the contribution of IUCD Implant implants ranges from 0.9 percent in Rukum to 10.9 percent in Rolpa.

TABLE 5.5 CPR AND LAFP CONTRIBUTION IN HEALTH FOR LIFE DISTRICTS (HMIS)

CPR OF MODERN METHODS DISTRICT IUCD % IMPLANT % AMONG MWRA Kapilvastu 29.9 0.9 2.2 Arghakhanchi 29.0 1.2 3.0 Pyuthan 40.5 1.5 4.2 Rolpa 40.8 2.0 10.9 Rukum 25.9 0.1 0.9 Salyan 42.0 3.6 5.3 Dang 52.0 5.9 4.5 Banke 48.6 3.8 4.8 Bardiya 64.5 8.7 5.4 Surkhet 59.6 3.0 3.3 Dailekh 28.3 1.4 1.2 Jajarkot 38.2 1.2 6.2 Jumla 18.8 0.7 3.0 Kalikot 36.4 1.0 3.9

TOTAL 43.0 3.2 4.2

TABLE 5.6 HEALTH FOR LIFE SUPPORT TO PRE-VSC MEETINGS AND VSC SERVICE UTILIZATION

VSC BY METHOD 2072/73 PRE-VSC INTERACTION DISTRICT (NUMBER OF VDCs) ML NSV Arghakhanchi 10 21 21 Banke 5 103 17 Bardiya 10 733 38 Dailekh 11 0 112 Dang 5 154 13 Jajarkot 9 0 180 Jumla 10 0 195 Kalikot 10 0 59 Kapilvastu 10 293 9 Pyuthan 10 29 15 Rolpa 10 0 0 Rukum 6 0 471 Salyan 8 0 96 Surkhet 10 89 119

TOTAL 124 1,422 215

Health for Life—Annual Report 41 Among MiniLap (ML) users, 9 percent were Dalits, 69 percent were Janajatis and 13 percent were Madhesis. RHCC MEETING The D(P)HOs in Health for Life core district conducted a total of 43 RHCC meetings during this period, among which 31 were directly supported by Health for Life FP ADVOCACY MEETING With support from Health for Life, the D(P)HOs organized district-level advocacy meetings on the occasion of FP Day in all the core districts except Kapilvastu. US ABORTION AND FP REQUIREMENT During FY 2015/16, a total of 666 government and stakeholders’ staff were oriented on US abortion and FP requirements during various events. Regular health facility readiness assessments (one year) show that 96% percent (n=587) of health facilities have displayed informed choice posters; additional posters were distributed to 69 health facilities. The Health Facility Readiness Midterm Review Survey shows that 76 percent (n=161) of sampled health facilities display the informed choice poster. SBA COACHING Health for Life supported the D(P)HOs to provide on-site coaching to nursing staff, particularly ANMs working in BCs of high-priority VDCs. After skill standardization (June 8, 9 and 11, 2016) for a team of four consultants, three were mobilized. A total of 17 ANMs from 10 BCs were coached on key SBA skills. Key gaps varied a lot in readiness, IP practices as well as counseling during ANC, use of the partograph, newborn resuscitation etc. Due to a contractual arrangement with IRHDTC, consultants could not continue this activity. CAPACITY BUILDING/COACHING ON IMNCI Health for Life continued strengthening the CB-IMNCI program in all Health for Life core districts, supporting the D(P)HOs to enhance the capacity of HWs and FCHVs. Health for Life district staff visited 587 HFs, 344 jointly with D(P)HO staff which is more than the previous six-month period. A total of 1,194 HWs and 1,110 FCHVs were coached on CB-IMNCI-related issues. TABLE 5.7 IMNCI VISITS TO HFs DURING REPORTING PERIOD

JOINT VISIT WITH HFs VISITED HWs COACHED FCHVs COACHED D(P)HO STAFF

DISTRICT JULY–DEC 2015 JAN–JUNE 2016 TOTAL JULY–DEC 2015 JAN–JUNE 2016 TOTAL JULY–DEC 2015 JAN–JUNE 2016 TOTAL JULY–DEC 2015 JAN–JUNE 2016 TOTAL Arghakhanchi 25 18 43 24 32 56 34 16 50 8 7 15 Banke 27 23 50 24 17 41 49 44 93 15 15 30 Bardiya 22 26 48 81 66 147 68 64 132 39 26 65 Dailekh 14 16 30 47 40 87 39 22 61 7 2 9 Dang 32 41 73 52 61 113 55 55 110 24 21 45 Jajarkot 16 14 30 38 38 76 22 62 84 10 5 15 Jumla 16 24 40 34 102 136 29 140 169 0 9 9 Kalikot 16 24 40 37 53 90 30 32 62 15 5 20 Kapilvastu 15 25 40 15 67 82 23 63 86 3 17 20 Pyuthan 23 15 38 64 48 112 34 25 59 13 15 28 Rolpa 30 22 52 16 42 58 17 60 77 17 23 40 Rukum 14 13 27 17 23 40 24 17 41 14 8 22 Salyan 18 21 39 21 13 34 30 16 46 6 5 11 Surkhet 16 21 37 55 67 122 17 23 40 5 10 15

TOTAL 284 303 587 525 669 1194 471 639 1110 176 168 344

Health for Life—Annual Report 42 FIGURE 5.4 STATUS OF ONSITE COACHING AND JOINT VISITS ON CB-IMNCI During HF visits, Health for Life district 1400 staff assessed knowledge of CB-IMNCI 1194 1200 1110 technical content, queried HW examination skills for sick neonates and 1000 783 under-5 children in OPDs, observed 719 800 IMNCI OPD registers to assess 600 recording and reporting compliance, NUMBER 344 400 304 appropriate diagnosis and treatment and whether mothers were properly 200 counselled on food/fluids and when to 0 return to the HF in case of an emergency Onsite coaching to Onsite coaching to Joint visit with and for follow-up. HWs FCHVs D(P)HO staff Furthermore, Health for Life provided 2014‐15 2015‐16 TA to the D(P)HO to implement the CB-IMNCI program an emphasis on district planning meetings and trainings. With the assistance of Health for Life, the Rolpa and Arghakhanchi D(P)HOs have developed three-year IMNCI program implementation plans. A total of 482 HWs and 387 FCHVs were trained in seven core districts (Arghakhanchi, Rolpa, Pyuthan, Banke, Rukum, Surkhet, and Jumla). Facilitation support was also provided for IMNCI program management trainings in four districts (Rukum, Surkhet, Arghakhanchi and Rolpa) and 83 non-clinical supervisors/staff were trained. In addition to facilitation, Health for Life also supported by supplying training materials like chart booklets, participant handbooks, program management training manuals, photographs, flexes, etc. SUPPORT FOR REVIEWS AND MONTHLY MEETINGS Health for Life supported D(P)HOs to review the CB-IMNCI program in all 14 core districts. During this period, Health for Life supported 14 district- level annual review meetings. Similarly, the Health for Life district team attended and supported 96 reporting cluster (ilaka) meetings in 12 Health for Life districts (excluding Rukum and Jajarkot). The most common issues were related to data quality and quality of care, which were discussed with the respective HF In-charges and D(P)HO staff. Health for Life then provided the suggestions/feedback Health for Life facilitator demonstrating newborn resuscitation accordingly. during HW training in Arghakhanchi. During a 10-month period (July 2015-April 2016), a total of 240,065 under-5 children with diarrhea were treated and 5,214 newborns with infections were treated. Health for Life support during training facilitation and quality monitoring as well as onsite coaching contributed to the management of childhood illness as per the new CB-IMNCI protocol. FCHVs’ ability to recite three home rules on the treatment of diarrhea increased from 93 percent to 99 percent from the previous reporting period. However, the HF Readiness Midterm Review showed this knowledge stood at 49 percent, possibly because that figure included non-high-priority VDCs as well. For high-priority VDCs, knowledge is 55 percent and in other VDCs, it is 47 percent. CB-IMNCI training, once it gets rolled out to the community level (FCHVs) is expected to mitigate this situation. VERIFICATION OF CB-IMNCI DATA IN BARDIYA Health for Life is closely monitoring IMNCI-related data via the HMIS. There were unusually high instances of infection among under-two-month old children being reported in Bardiya last FY (2014/15). A preliminary joint visit was made with the IMNCI Section Chief of Bardiya. Health for Life, together with the D(P)HO focal person,

Health for Life—Annual Report 43 visited six HFs where an unusually high FIGURE 5.5 IMNCI SERVICE UTILIZATION number of cases were reported. It was BY 2-59 MONTH-OLD DALIT CHILDREN observed that there was a mismatch in IN HIGH-PRIORITY VDCs, RUKUM (HMIS recording and reporting (mostly over- SERVICE REGISTER) reporting) at the HFs as well as data entry errors in the HMIS software at the district 60.0 level. Moreover, there was an issue of not 50.0 following treatment protocol, in some 40.0 cases.

30.0 SERVICE UTILIZATION BY

20.0 MARGINALIZED POPULATION (JUL-DEC. 2014) 10.0 PERCENTAGE Health for Life is making efforts to reach 0.0 members of marginalized groups, Khara Simli particularly in high-priority VDCs, in all 14 Bafikot Pokhara ChunwangGotamkot Kotjhari Purtimkanda core districts, and monitoring service Total (Average) Aathbisdandagaun utilization by marginalized population. The Population Proportion Service Utilization Proportion figure at right, for example, shows that IMNCI service utilization by Dalit children in Rukum is greater than their proportion in the general population. GESI KNOWLEDGE AND SKILLS OF HEALTH WORKERS ENHANCED GESI LESSONS LEARNED Health for Life staff did follow-up visits with doctors In Surkhet, Health for Life provided technical support to and nurses to assess the effectiveness of the GESI D(P)HO to conduct a one-day GESI orientation for 42 orientation and discovered that GESI learning is now Doctors and Nurses. Of the 42 participants, 12 were reflected in personal commitments, and health care Doctors, 19 were nurses, a medical recorder and lab providers are making attempts to apply GESI medical technicians from the Regional level, District principles to improve their practices. Dr. Ritesh Barnwal from Mehalkuna hospital, for example, Hospital and PHCC. This orientation was suggested by claims the GESI TWG. "Women and people who have traveled the greatest CONDUCT GESI ORIENTATION FOR SBAs distance are given priority during OPD visits so that AT TRAINERS’ RESOURCE CENTERS FOR they can return to their home in time. Otherwise they NHTC would have to stay for one or two days for checkups and lab reports. The OPD counter used to close by The main purpose of the activity was to strengthen the 12:30 pm, but now allows patients from far away to capacity of SBAs on GESI and was to be performed get OPD tickets until 2:00 pm. This has helped jointly by the Population Division and NHSSP. Due to patients a lot and they are happy and satisfied too. the Population Division's separation from the MoH and As a doctor, I not only try to treat patients, but also GoN's delayed budget approval process, this planned try to provide services on time, helping M/DAGs save money and time." activity could not be completed during the reporting period. from Dasarthapur PHCC stated that after attending the GESI orientation, a brief Health for Life continued technical support to the orientation session was organized among medical D(P)HOs to regularize GESI TWG meetings in 13 staff during their regular meeting. "Health providers districts (excluding Jajarkot) as provisioned in the who participated in the GESI orientation confirmed that they are more concerned about gender guidelines. During this reporting period, 22 meetings sensitivity, and sensitive to avoid gender were held (twice in Kalikot, Rukum and Salyan; three discrimination during treatment.” He further stated times in Banke, Kapilvastu and Surkhet). Key decisions that the medical staff are now paying more attention and results are summarized below. to people from underprivileged communities. In Banke, together we reviewed data analysis to improve The Staff Nurse at Mehalkuna Hospital stated that the knowledge and skills gained from the orientation outreach and agreed to establish two community health have been applied while counseling clients, and staff units in Sonbarsha of Gangapur VDC, and in Naya Basti are much more concerned about clients' satisfaction, Godenpurua of Baijanathpur VDC. During the reporting particularly those from M/DAG. period health services in these units started with the purpose of increasing health services to the M/DAG community.

Health for Life—Annual Report 44 As the accommodations of Narainapur HP are not sufficient to ensure privacy during delivery services, a GESI TWG member decided to ask INF, an INGO, for support to install a divider. The TWG decided to conduct new social audits in 10 VDCs where QI implementation was planned. In Salyan, early marriage rates are high so the GESI TWG decided to strengthen the peer education program implemented by the D(P)HO in coordination with the NRCS, WCO, DDC and other organizations. In Rukum, a statistical assistant was appointed as the new GESI focal person. In Dailekh, a local health and population teacher was inducted as a member of the Population and GESI Committee. In Kapilvastu, H4L conducted an orientation on GBV for service providers, particularly those from report collection centers at Pakadi, and . GESI ACTIVITIES FOR INCREASING SERVICE UTILIZATION AMONG M/DAGs AND HARD-TO-REACH GROUPS As a result of data analysis, D(P)HOs, HFOMCs, and service providers are expanding services among M/DAG and hard-to-reach groups. The following activities were carried out with Health for Life’s TA: In Banke, expanded EPI clinic in Molbipurwa, ward no. 6 of Bankatti VDC. All 34 children received immunization services. In Bardiya, HFOMCs conducted health promotional activities in four high-priority VDCs namely Thakurdwara, Suryapatuwa, and Mohamadpur in high priority VDCs. 4,361 marginalized/disadvantaged obtained FP/MNCH related information. The D(P)HO conducted a health camp at Bhimapur, Suryapatuwa and Newlapur. In Bhimapur, 306 (F 200/M 106), Suryapatuwa 269 (F 173/M 96) and Neulapur 369 (F 218/Male 151) M/DAG benefited. In Jajarkot, HFOMCs in Ragda, Sakla, , Sima, Karkigaon and Bhoor VDCs supplied kitchen utensils and beds for pregnant women from far-flung wards to deliver and overnight at the HFs. PHC-ORC building construction was completed in Ragda, Sakla, Karkigaon, and Bhagwati VDCs for pregnant women to access services during rainy days and maintain privacy during checkups. In Kapilvastu, the HFOMC initiated ambulance service in Rajpur, whereas in Siswa, the VDC committed NPR 50,000 for ambulance services. In Dang, the D(P)HO has established 22 Community Health Units and 19 Urban Health Centers, 4 PHC/ORC and 2 EPI centers to increase access to health services for remote communities and M/DAG which has resulted in an increase of institutional deliveries in VDCs. GESI ACTIVITIES AT THE NATIONAL LEVEL Health for Life provided technical assistance to prepare “GBV Response Integrated Guidelines 2072” for the MoH and provided input on GBV NHSS-IP for the Family Health Division. GESI COORDINATION GROUP FOR USAID PARTNERS The GESI coordination group for USAID partners (Health for Life, Suaahara, Shajhedari, Hariyo Ban, KISAN, Saath-Saath, SABAL, PAHAL and Baliyo Ghar) held routine meetings. Health for Life provided input to PAHAL, SABAL for their project GESI strategy and GESI analysis input for field assessments for Baliyo Ghar.

5.3 ANM PRE-SERVICE TRAINING IMPROVED AT 4 ANM SCHOOLS IN HEALTH FOR LIFE DISTRICTS COACHING An in-depth assessment of Auxiliary Nurse Midwife (ANM) pre-service education (PSE) indicated poor knowledge and skills. But Health for Life, being a health system strengthening project, was limited in what it could provide to strengthen ANM PSE. In order to improve their knowledge and skills on clinical teaching and learning techniques, faculty members were coached at all six ANM schools, during which 17 faculty members participated from February 1 to 25, 2016. Six consultants were oriented on how to carry out assessments of HFs and hospitals for referrals on January 29, 2016.

Health for Life—Annual Report 45 TABLE 5.8 COACHING AT ANM SCHOOLS NUMBER OF FACULTY The most common skills gap was in NAME OF SCHOOL MEMBER COACHED demonstration of neonatal resuscitation, Jiri Technical School, Dolakha Kapilvastu 2 infection prevention practices during Technical Institute, Kapilvastu Karnali 4 normal delivery, carrying out normal Technical School, Jumla 2 Rapti Health Institute, Dang 3 deliveries, and use of the partograph. Seti Technical School, Doti 3 Thus participants were coached on these Sushma Koirala Memorial Campus, Banke 3 clinic areas. Total 17

FOLLOW-UP ASSESSMENT OF ANM SCHOOLS The in-depth assessment of the six ANM schools collected information on both clinical aspect and environmental factors affecting teaching learning activities. The follow-up assessment was conducted to document any changes to clinical aspects in the six ANM schools following the introduction of the new curriculum. After orienting six consultants on May 16-17, 2016, a team of two consultants made field visits during May and June 2016. Analysis of the assessment will be done early next fiscal year. There were some delays in recruiting consultants with the result that it was difficult to coordinate with the ANM schools for availability of faculty members and students. TABLE 5.9 NUMBER OF ANM STUDENTS AND FACULTY ASSESSED ON KNOWLEDGE AND SKILLS

STUDENTS TEACHERS/PRECEPTORS ANM SCHOOL KNOWLEDGE SKILLS KNOWLEDGE SKILLS Sushma Koirala Memorial 10 10 3 2 Trust, Nepalgunj Kapilbastu Technical Institute 10 10 3 3 Jiri Technical School 13 13 6 3 Karnali Technical School, Jumla 10 10 3 3/2 Rapti Technical School, Dang 11 10 3 3/2 Seti Technical School, Doti 10 10 2 2/1

SUPPLEMENTARY MATERIAL The ANM curriculum was revised in 2014 by CTEVT to incorporate SBA skills with technical assistance from Health for Life, and the curriculum was implemented in September 2014 in all ANM schools. There is a need to provide reference reading materials based on the revised curriculum, so Health for Life supported CTEVT to develop ANM Supplementary Teaching Learning Materials. Health for Life also provided technical assistance to CTEVT to organize a two-day workshop (December 16-17, 2015) to develop a one-day workshop to finalize the materials. The following supplemental materials have been finalized and are in the process of being printed.

• Midwifery Part I (ANC) • Midwifery Part II (Delivery) • Midwifery Part III (PNC) • Communication/IPCC and Family Planning • Newborn and Child Health (IMNCI)

Health for Life—Annual Report 46 OBJECTIVE 6: IMPROVE KNOWLEDGE, BEHAVIOR, AND USE OF HEALTH SERVICES AMONG TARGET POPULATION 6.1 DEMAND FOR AND UTILIZATION OF MNCHN/FP SERVICES INCREASED AMONG M/DAGs AND ADOLESCENTS/YOUTHS DEVELOP AND PROMOTE ANDROID-BASED MOBILE APPLICATION TARGETING ADOLESCENTS (mHEALTH) ON ASRH The m4ASRH program was very successful in reaching a high number of adolescents and youths with sexual and reproductive health (SRH) messages. There were 2,683,250 interactions by users in the system. Together with other partners, in order to support the NHEICC, Health for Life developed a TOR to assess the outcome of the intervention, target groups’ perceptions towards the technology, made recommendations for the future scale-up of m4ASRH or similar interventions in Nepal and identified potential local consulting firms. Health for Life dropped the activity to develop an android-based application on adolescents’ sexual and reproductive health as UNFPA is supporting the NHEICC to conduct a similar activity under their ASRH health promotion program strategy. However, considering the successful partnership with GIZ and UNFPA on m4ASRH, Health for Life will provide technical support to the NHEICC for the development and roll-out of this mobile application. PRODUCE RADIO SPOTS/JINGLES ON FP CONTRACEPTIVE METHODS, DELAYED MARRIAGE, DELAYED PREGNANCY, MENSTRUAL HYGIENE, GBV AND AIR ON THE KHULDULI.COM RADIO PROGRAM Rapti FM of Salyan and Grubaba FM of Bardiya, in coordination with the D(P)HOs and Health for Life district teams, voluntarily continued airing jingles more than 4,144 times on various issues like family planning (1,166 times), newborn care (991 times), maternal and child health (1,269 times) and other health topics (712 times). PRODUCE AND BROADCAST TV PROGRAMS (12 EPISODES) PROMOTING FP CONTRACEPTIVE METHODS, DELAYED MARRIAGE, DELAYED PREGNANCY, PHYSICAL HEALTH, SANITATION AND GBV Nirman Sanchar Sewa led the production of the 12-episode TV drama Smart Saathi. The production and airing of the drama was successfully completed in FY 2015/16. The name Smart Saathi (“Smart Friend”) is linked to the Smart Jeewan family planning campaign supported by USAID. The drama received a very favorable response from the partners and was very popular among the target groups. After airing of the drama, Nirman Sanchar Sewa produced 500 DVDs. Health for Life is distributing 252 copies (18 in each districts) to each of the 14 Health for Life districts so that they can be screened at hospital OPDs, local events, cable TV channels and schools. The remaining DVDs are being distributed to various organizations working on ASRH for use during ASRH program implementation. CONDUCT TOT FOR RHTC TRAINERS ON RECENTLY DEVELOPED IPCC ORIENTATION GUIDEBOOK FOR HWs AND FCHVs Health for Life provided technical support to the NHEICC to revise the IPCC curriculum for health workers and FCHVs. The revision has been completed and has been forwarded to the NHEICC for final review. Since the endorsement of the IPCC curriculum did not happen, the planned training did not happen. REVIEW AND PRINT RECENTLY-DEVELOPED SCHOOL HEALTH SESSIONS GUIDE AND ILLUSTRATED BCC MATERIALS Revision of the School Health Sessions Guide developed by the NHEICC with technical support of Health for Life did not happen in the reporting year as Health for Life did not receive the request from the NHEICC. After

Health for Life—Annual Report 47 intensive piloting of the intervention, Health for Life has now received feedback from the districts. Health for Life will, in FY 2016/17, update the session guide and develop the implementation modality for the districts. Health for Life, being an invited member of the RH IEC/BCC Committee under the NHEICC, supported the NHEICC in revising the eight sets of IEC booklets for adolescents and contributed to planning and developing the contents of Ki ki ka Kura—an adolescent SRH related radio program of the NHEICC. PROVIDE TA TO D(P)HOs TO DEVELOP ANNUAL BCC INTERVENTION PLAN BASED ON DISTRICT HEALTH COMMUNICATION STRATEGY ENGAGING ALL STAKEHOLDERS WORKING IN HEALTH SECTOR Based on the previously developed District Communication Strategies of 13 districts, Health for Life supported 12 districts (Kapilvastu, Arghakhanchi, Dang, Rolpa, Rukum, Jajarkot, Pyuthan, Banke, Bardiya, Dailekh, Kalikot and Surkhet) in preparing their annual BCC Intervention plans for FY 2015/16 in the presence of the D(P)HO team, DDC, WCO, DWASH, UNFPA, HC3, Save the Children, UMN, FAO, FPAN, NRCS and other organizations. Altogether, 286 people from various organizations participated. One hundred organizations working in these districts committed to providing support for BCC interventions in M/DAG-focused VDCs. PROVIDE TA TO THE POPULATION DIVISION AND NHTC TO INSTITUTIONALIZE GESI IN AN ADDITIONAL 25 DISTRICTS; AND CONDUCT FOLLOW-UP TRAININGS IN DANG, PYUTHAN, KALIKOT AND AT RHDs TA to the Population Division and NHTC to institutionalize GESI in an additional 25 districts was dropped because the Population Division separated from the MoH to spearhead said activity. The MoH Public Health Administration and M&E Division (PHAMED) is a new MoH GESI Secretariat. Health for Life provided technical support and facilitated three days of GESI training jointly with the NHSSP. Altogether, 27 GESI Focal Persons from divisions, departments, centers and the Ministry attended the training convened by PHAMED. As an outcome of the GESI training PHAMED has decided to lead changes in the following areas: • Review and update the Health Sector GESI strategy 2009 in order to comply with the Nepal Health Sector Strategy (2015 -2020) and changing health context • Regularizing GESI Steering Committee meetings on a semi-annual basis at the Ministry and trimester review meetings in GESI TWG at centers, divisions and departments as provisioned in the GESI guidelines • GESI indicators in M&E • GESI activities in the Nepal Health Sector Strategy Implementation Plan and AWPB for a GESI responsive program • GESI in performance evaluation.

FOLLOW-UP ON TRAININGS IN DANG, PYUTHAN, KALIKOT AND AT RHDs In the reporting period, Health for Life financially and technically supported the Population Division and NHTC to conduct an MTOT on GESI to develop trainers from 16 districts in five regions. Master trainers from MW RHTC, Surkhet subsequently convened a GESI training in Kalikot for 46 service providers from health facilities, PHCCs and district hospitals as per GoN's plan. Follow-up in Dang and Pyuthan was dropped since the HF In- charges from all VDC were not able to convene. With the purpose of understanding the level of effectiveness of GESI training by master trainers, Health for Life staff convened an interaction session among 30 HF In-charges in Kalikot from 30 health facilities. Of the 30 HF In-charges consulted, only 12 were from high-priority VDCs while the majority were transferred to other districts. While the HF In-Charges were gathered for the training organized, H4L took the opportunity to orient them on GESI. Based on the discussion, GESI learning has been linked with health services and programs as follows: Awareness generated through the Laligurans women's saving groups has supported an increase in ANC and PNC visits in Gela VDC; PHC/ORC has been strengthened in wards; reporting is based on service utilization of cast/ethnicity and analysis of service use and identifying gaps; in order to make health services more inclusive

Health for Life—Annual Report 48 Health for Life has been supporting the implementation of GESI concepts through different activities. One such activities is Annual Village Health Planning. Identification of M/DAGs through ward-level discussions; GESI learning has been linked to OPD health services; GESI learning can be found at different levels- knowledge, attitude and practice; service providers are more knowledgeable about GESI than before, their attitude towards women, elderly, people with disability and excluded groups have changed and they treat all patients equally while providing health services. Most of the respondents stated that they are now familiar with the basic ideas and significance of GESI. Though they have different levels of understanding, they are knowledgable and sensitive to how the health system and services operate more equitably in a context of socio-economic and geographic disparities. STRENGTHEN SCHOOL HEALTH PROGRAMS IN HIGH SCHOOLS IN THE 141 PRIORITIZED VDCs BASED ON AN ASSESSMENT (ADDITIONAL MITIGATION BY GIZ AND UNFPA) Health for Life provided technical support to the D(P)HOs and DEOs in all core districts to carry out school health programs based on the School Health Session Guidebooks developed by the NHEICC with the technical support of Health for Life. Health for Life provided orientations to the teachers and health workers of 75 VDCs in 14 districts on the school health sessions. A total of 7,4104 students participated (3,408 male; 4,002 female) in the first session, of whom 7,386 (99.67 percent) participated in the pretest. 61 percent of participants (n=7,698) correctly answered the appropriate legal age of marriage without parents’ consent during the post-test, compared to 9 percent on the pretest, a seven-fold increase. Participants in Dailekh reported the highest change (16 times higher) in knowledge of legal age of marriage followed by Bardiya (14.8 times higher). The lowest increases were seen in Jajarkot (2.35 times higher) and Pyuthan (2.45 times higher) (Figure 6.1). FIGURE 6.1: PERCENT OF ADOLESCENTS WHO KNOW THE LEGAL AGE OF MARRIAGE

100

80

60

40

20

Total Dang Rolpa Jumla Banke Salyan Kalikot Rukum Dailekh Bardiya Surkhet Jajarkot Pyuthan Kapilbastu Arghakhanchi Pre Test PostTest

N (PRETEST) =7,386, N(POST-TEST)=7,698 Additionally, the district team also supported the D(P)HOs in carrying out an additional 151 ASRH sessions in schools of six other districts (Kapilvastu, Salyan, Banke, Surkhet, Jajarkot and Bardiya) through the Redbook (NHEICC program) budget. While doing so, health workers used the NHEICC’s School Health Session Guidebooks. The improvement in knowledge on the legal age of marriage without parents’ consent was slightly higher among girls (7.34 times) than boys (6.28 times). Health for Life supported the D(P)HO and NHEICC in school health programs for 75 schools in the core districts including printing, collection and distribution IEC/BCC materials for these sessions. The following table shows the type and number of materials distributed.

4 Students attending first session. This is the number of adolescents who have taken at least one session.

Health for Life—Annual Report 49 Health for Life—Annual Report 50 TABLE 6.1 BCC MATERIALS DISTRIBUTED IN VARIOUS DISTRICTS

MATERIAL TYPE TOTAL DISTRIBUTED School health session flex posters (calendar type) 70 sets (5/district) 350 Legal age of marriage flex poster (24/district) School Health Session Guidebooks 800 GESI posters 800 PROVIDE IEC/BCC MATERIALS AND FACILITATE TRAINING FOR DWCO/KISHORI SAMUHA (PEER-TO-PEER EDUCATION FOR GIRLS) AND CONDUCT HEALTH PROMOTION EVENTS UNDER THE LEADERSHIP OF HFOMCs OF THE 141 HIGH- PRIORITY VDCs Health for Life worked closely with District Women and Children Office (DWCO) to incorporate the content on delayed marriage/pregnancy, family planning/use of contraceptives and healthy timing and spacing of pregnancy (HTSP) through their Kishori Samuha activities. The following activities were conducted in this reporting period: • Health for Life district team in Kapilvastu provided ASRH-related materials to the DWCO’s Kishori Samuha (adolescent girls’ group) in coordination with the D(P)HO, oriented 30 Kishori members from VDC on delayed pregnancy, FP commodities and GBV during the DWCO’s training. • Health for Life district team in Kalikot discussed ASRH, family planning, delayed marriage and pregnancy, GBV etc. at the DWCO meeting in December 2015, and agreed to support the Kishori Samuha to plan and design the RH classes and to provide IEC/BCC materials on RH and GBV. • Health for Life district team in Rolpa facilitated two Kishori Samuha and HMG meetings in Kotgaun VDC, In-charge of Kotgaun HF, Rolpa, together with the HF In-charge, on adolescent facilitating an ASRH session to Kishori and Aama reproductive health, FP and age of marriage with 58 Samuha members. adolescents and mothers participating. • Health for Life district team in Banke regularly participated in monthly DWCO meetings to ensure that the facilitator of Kishori Samuha meetings got enough updates and motivation to integrate messages related to delayed marriage, delayed pregnancy and HTSP into the program. As reported in the meetings, 350 Kishoris gained knowledge on the legal age of marriage, family planning, sanitation and HTSP over the course of 16 regular sessions. GENERATE DEMAND AND INCREASE UTILIZATION OF FP/MNCHN SERVICES WITH HFOMCs' CAP/Rs IN THE 141 HIGH-PRIORITY VDCs Health for Life district teams provided technical support to HFOMCs to organize health promotion activities (street drama, health song competitions, health quizzes, interactions with pregnant women and mothers-in-law on the importance of family planning, ANC, institutional delivery and PNC) in 58 VDCs. These health promotion activities reached 12,375 community members and were linked with services at particular satellite clinics through which 96 clients received implants. 6.2 MISSED OPPORTUNITIES REDUCED AT SERVICE DELIVERY POINTS TO PROVIDE EDUCATION AND COUNSELING ON HEALTHY BEHAVIORS FOR MNCHN/FP Health for Life organized IPCC trainings and rolled out the Learning Circle program in remaining five districts.

Health for Life—Annual Report 51 The Community Action Promoters/Reporters (CAP/Rs) followed up on the use of the trainings by visiting Health Mothers’ Group (HMG) meetings a total of 7,575 times (including repeat visits) in all 14 core districts to ensure the use of Learning Circle tools in all high-priority VDCs. CAP/Rs also helped to regularize mothers’ group meetings. The Health for Life district team attended monthly FCHV meetings (592 FCHVs attended) and discussed IPCC practices, the regularity of HMG meetings and accuracy of the recording/reporting system. Participants observing the exhibition in Thakurdwara VDC. Compared to the previous year, there was an increase in the number of mothers’ group meetings in 2072/73 in all districts. In Jumla, Surkhet and Arghakhanchi, however, there was slight decrease in the number of HMG meetings between the first two years in the chart below. Between the past two fiscal years there has been an increase in all districts. In three districts, however, there was a decrease between FYs 2013/14 and 2014/15. It is possible that before CAP/Rs started encouraging mothers to join the meetings and reported to the HF, there may have been underreporting (Figure 6.2). FIGURE 6.2 PERCENTAGE OF MOTHER GROUP MEETINGS HELD vs THOSE PLANNED 103.4 102.7 102.4 102.2 100.3 99.3 98.9 98.8 98.0 96.0 95.6 93.8 93.6 92.0 91.4 89.2 87.1 87.0 85.9 85.4 85 83.5 83.3 82.4 81.9 81.9 81.9 81.7 81.7 81.5 80.8 76.7 76.6 74.0 74 73.9 73.7 70.7 70.3 66.9 64.1 54.9

Dang Jumla Rolpa Banke Bardiya Dailekh Jajarkot Kalikot Pyuthan Rukum Salyan Surkhet Kapilvastu Arghakhachi

2070/071 (Srawan to Ashad) 2071/072 (Srawan to Jestha) 2072/073 (Shrawan to Jestha)

In FY 2072/73, a number of Mothers’ Groups held at least 10 meetings. In both Arghakhanchi and Jajarkot, 8 high-priority VDCs had Mothers’ Groups that conducted at least 10 meetings. In every Health for Life district, the number of Mothers’ Groups meeting this threshold in high-priority VDCs has increased dramatically since the project started (Figure 6.3).

Health for Life—Annual Report 52 FIGURE 6.3 NUMBER OF VDCs CONDUCTING AT LEAST 10 HMG MEETINGS PER YEAR 8 8 7 7 6 6 6 5 5 5 4 3 3 3 2 2 2 2 2 2 2 2 2 2 2 1 1 1 1 1 1 1 0 0 0 0 0 0 0

Dang Jumla Salyan Banke Dailekh Jajarkot Kalikot Pyuthan Rolpa Bardiya Kapilvastu Rukum* Surkhet Arghakhachi

2070/71 2071/72 2072/73

*Rukum data were not available for the year 2070/71, 2071/72. REDUCE MISSED OPPORTUNITIES AT SERVICE DELIVERY SITES BY ENGAGING HWs AT ILAKA MEETINGS The Health for Life district team in Arghakhanchi, Banke, Bardiya, Dang, Dailekh, Jumla, Kalikot, Kapilvastu, Pyuthan, Rolpa and Salyan facilitated 37 cluster meeting (292 HWs participated) and stressed the need to reduce missed opportunities at service delivery sites by focusing on post-partum family planning (PPFP) and encouraged HWs to provide proper counseling to post-partum mothers during EPI, PHC/ORC and other services; the district team in Banke also facilitated to fill the gaps in HMIS recording and reporting. The teams in Kapilvastu and Jumla supported the analysis and use of data on FP/MNCH and IPCC. INTEGRATE HEALTH SERVICES DURING OUTREACH CLINICS, IMMUNIZATION DAYS AND ANC/PNC VISITS UTILIZING CAP/Rs The Health for Life district team conducted CAP review meetings in all core districts in June 2016, where a total of 92 CAP/Rs out of 101 participated. The D(P)HO and district focal person facilitated the review meeting. The main objective of the meeting was to review the performance of the CAP/Rs, as well as their relationship with the HFOMC, Citizen Ward Forum, FCHVs and Health Mothers’ Group. FIGURE 6.4 EXAMPLES OF GOOD PRACTICES BY CAPs IN PARTICULAR VDCs

VDC ACTIONS OF CAP/Rs Khana, Arghakhanchi Coordinated to get stretchers in all wards after raising this issue in the HFOMC meeting Khanadaha, Arghakhanchi Coordinated to hire female health worker (nursing staff) at PHC/ORC Jukena, Arghakhanchi Supported regular operation of PHC/ORC in wards 4, 5 and 8 Supported the Dalit community in ward 8 to receive ANC checkups and institutional Jukena, Arghakhanchi delivery Dhakawang, Arghakhanchi Supported scrapping the registration fee Introduced innovative methods like games, songs and dance with the result that Karkigaun, Jajarkot women’s participation in the HMG increased significantly Sima, Jajarkot Conducted counseling sessions for FCHVs on how to use the Learning Circle Conducted home visits and advocated for a mobile clinic where 26 males received Malikabota, Jumla vasectomy services and 15 women got IUCDs Supported the HMG and conducted home visits that increase FP and immunization use Ramnakot, Kalikot significantly

Health for Life—Annual Report 53 OBJECTIVE 7: STRENGTHEN LIFELINE'S CAPACITY FOR LOGISTICAL SUPPORT

In order to build the institutional capacity of Life Line Nepal (LLN), T.R. Upadhya & Co., Chartered Accounts (TRU) was subcontracted during the reporting period. TRU was mandated to strengthen LLN’s existing financial management capacity, working with the LLN team on their business planning, accounting, financing and budgeting. TRU conducted an organizational gap analysis and agreed upon the major areas of improvement with LLN management. TA support was provided to develop a standard compliance risk register for LLN defining the key compliance areas, risk grading, and implications of non-compliance issues. In addition, a training needs assessment of LLN employees and development of a training calendar was initiated in order to build the financial management capacity of LLN. The TA support for the revisions/updates to policies and procedures with the consultation of LLN Team was in progress. Moreover, a review of accounting and record keeping, internal control system for financial management, planning and budgeting, cash control and management was in also in track. However, these initiatives could not be continued due to discontinuation of Objective 7.

HEALTH FOR LIFE STAFF COMPOSITION Health for Life has met its goal of having at least 1/3 women and minorities on its staff. FIGURE 8.1 HEALTH FOR LIFE STAFF CATEGORIZATION BY ETHNICITY 3% 6% Others Muslim Dalit 2% Madhesi 7%

Bhramin/Chettri 54% Janajaties 28%

Bhramin/Chettri Janajaties Madhesi Muslim Dalit Others

FIGURE 8.2 HEALTH FOR LIFE STAFF COMPOSITION BY LEVEL AND GENDER 120 100 80 60 40 20 0

Senior (n=18) Mid-level (n=88) Support (n=19) Program (n=77) H4L total staffs (n=125) Admin/Finance (n=29)

Male Female

Health for Life—Annual Report 54 FIGURE 8.3 HEALTH FOR LIFE STAFF COMPOSITION BY PROGRAM AND ETHNICITY 120

100

80

60

40

20

0 Program (n=77) Admin/Finance Support (n=19) Total (n=125) (n=29)

Non-DAG MDAG

B. MAJOR CHALLENGES AND CONSTRAINTS FACED DURING THE PERFORMANCE PERIOD THAT RESULTED IN DELAYS OF ACHIEVEMENT OF OUTCOMES, IF APPLICABLE REDUCED ADDITIONAL LOCAL RESOURCES COMMITMENTS BY COUNCILS The total local health budget commitment by the concerned Councils for the 141 high-priority HFs of the core program districts has decreased by 8.3 percent compared to FY 2015/16 (from NPR 35,284,000 to NPR 32,342,000). This is mainly due to structural changes within the local bodies. In other words, due to the recent merger of a number VDCs into Municipalities, changes to the institutional homes for HFs created confusion in setting priorities (such as more emphasis on infrastructural development than service areas), the planning process and service delivery. These factors led to reduced local resource commitments. FACTORS AFFECTING FUNCTIONALITY OF HFOMCs Structural changes to local bodies and the introduction of new HFOMC guidelines by the MoH’s Curative Division have adversely affected the functionality of HFOMCs and the graduation process. A few HFs came under the newly-formed Municipalities where Executive Officers have not been adequately instructed in regards to HFOMC reformation. As an interim provision, D(P)HOs have to chair the HFOMCs for PHCCs, but are reluctant to do so. In practice, it not easy to chair a number of PHCCs despite her/his responsibilities. REASONS FOR LOW BURN RATE OF LOCAL RESOURCES COMMITTED IN LOCAL HEALTH PLANS • The expenditure status of local resources in a majority of HFs includes expenditures through May 2016; the expenditure status through June has yet to be updated. Consequently, we cannot provide a full picture of expenditure • Delays in releasing the budget from the VDCs to HFOMCs due to the absence of VDC secretaries is another element affecting the burn rate • To expedite the expenditure status, the district team is continuously discussing the allocated budget with VDC Secretaries and HF In-charges, including the issue of low burn rate • In the demonstration districts, mainly Chitwan and Jhapa, the budget disbursement to the HFs by the DHGSTF has been delayed despite Health for Life's persistent follow-up. Though the position of QA Section chief was recently filled, the position was vacant for most of the reporting period. This resulted in significant delays in organizing TWG meetings to review progress, steer QAI TWG to strengthen the District QAWCs and to inform QI TAC and stakeholders periodically. Likewise, there were changes in QA focal persons at several divisions and centers such as the CHD, NHEICC, FHD, PHCRD, LMD

Health for Life—Annual Report 55 and NCASC which also contributed to delays in organizing the QAI TWG. In addition, changes of the DG and directors also hampered coordination of the QI TAC meetings. The health facility QI assessment in field testing districts (Dang, Jumla and Surkhet) were delayed due to general strikes in those districts. In addition, delays in recruiting a consultant also affected the timely assessment of the field testing. Some of the QI follow-up activities were delayed due to the unrest and general strikes in the Terai and the resulting fuel crisis. Directors of the FHD, CHD and NHTC and some of the key focal persons were changed. As a result some of the activities were delayed or not completed. For example: • FHD: RH review, MSC roll-out in Bardiya and FCHV strategy • CHD: Development of remote area guidelines and medical standards • NHTC: FP training sites QI system In addition, because of delays in recruiting a consultant, activities, including family planning activities such as NSV self-paced training and LAFP coaching and safe motherhood activities like SBA coaching at birthing centers, ANM coaching and the ANM follow-up assessment experienced delays. The early resignation of the ANM PSE specialist delayed finalization of ANM PSE supplemental materials. Due to general strikes and the fuel crisis, the D(P)HOs could not organize IMNCI program activities like district planning and training in a timely manner. We could not organize the IMNCI review (one day additional), as the GoN did not plan the quarterly and semiannual reviews at the District and Sub-District levels. The change in the directorship at the NHEICC caused a delay in the endorsement of the IPCC guidelines for health workers and FCHVs. As a result, there were also delays in the training of the trainers of the RHTC. After reorienting him we expect this process will progress. After the sudden demise of the BCC focal person for RH at the NHEICC, most BCC-related activities were delayed. Similarly, the BCC at Health for Life was vacant for about six months, also adversely affecting the timely implementation of some of the planned activities. Development of a catalogue of various IEC/BCC resource materials/publications of the NHEICC was not done as NHEICC is already planning an online storage system with the support of GiZ. Radio Bahas was not continued because Health for Life could not come to an agreement with the agency concerning renewal of the contract. However, some radio stations voluntarily continued to air radio jingles, as reported. MAJOR CONSTRAINTS IN EQ-AFFECTED DISTRICTS Many of the activities planned for the EQ-affected districts could not be carried out due to delays in signing the modification of the Health for Life project contract. Health for Life prepared work plans anticipating the modification would be signed in August 2015, but the project modification was signed only in October 2016. Because the contract modification was signed in October, health recovery planning at the district and VDC levels could not be carried out as planned, as the 14-step local level planning process was already underway. Implementation of local health governance-related activities was delayed due to the new HFOMC guidelines introduced by the MoH, which created confusion for the D(P)HOs regarding formation/reformation of the HFOMCs. As a result, it took longer to reform HFOMCs and build their capacity than anticipated. As a result, only 47 VDC health recovery plans could be prepared during this reporting period. In some VDCs, HFOMCs could not be reformed as per the guidelines due to conflicts between political parties. In response, the D(P)HOs have had to assign new VDCs for Health for Life’s implementation of activities. This occurred in a number of districts, including Nuwakot (2 VDCs), Ramechhap (1 VDC) and Dhading (1 VDC). Health for Life could not assist D(P)HOs in preparing district health recovery and reconstruction plans in the ten EQ-affected districts since a kind of health recovery and reconstruction plan had already been prepared and submitted to the DDRC for approval by the time Health for Life started implementation. Due to such delays, Health for Life has had to shift many activities planned for this reporting period to next year.

Health for Life—Annual Report 56 C. HIGHLIGHTS OF THE INTERNSHIP PROGRAM AS DESCRIBED IN SECTION C.2.8.1D. With the aim of building the professional capacity of women and marginalized groups in the project districts, two interns, in Dang and in Kapilvastu, completed their internships. This opportunity led them to gain practical programmatic and project experience. They are now better prepared to assume more technical and decision-making roles in their communities and professional lives. During the course of the internship, worked in the area of quality improvement and focused on local governance at the local level (Annex 3).

Health for Life—Annual Report 57 D. CUMULATIVE QUANTITATIVE MONITORING AND EVALUATION DATA, INCLUDING INFORMATION ON PROGRESS TOWARDS TARGETS AND EXPLANATIONS OF ANY ISSUES RELATED TO DATA QUALITY In this year’s annual report we have not continued reporting from Section F from the contract. It repeats the narrative in Section A of the annual report that follows Section C of the contract. Modifications to Section C of the contract seem to have outdated Section F of the contract. However, Health for Life has extracted all tasks and deliverables from the modified Section C of the contract and will be prepared to report on all tasks and deliverables in the project’s last year.

CAPACITY BUILDING BENCHMARKS Objective 1: Improve health systems governance of district health offices and sub-district level facilities Key Component Year-3 Benchmark (July 2015-June 2016) Status as of June 30, 2016 Remarks

HFOMC Performance 1. HFOMCs in high-priority VDCs are Nearly 96% of HFOMCs met all functionality New HFOMC Revitalization Package. functioning and a significant number are criteria, and 58% are “progressive” by meeting Early attention will focus on performing as “progressive” or “model” all functionality criteria and at least four revitalization of HFOMCs and later on performance criteria at the time evaluated in 141 demonstrating performance at HFs. Measurement: HFOMC performance criteria are high priority VDCs. 14% of HFOMCs achieved Benchmarks in later years will focus on applied to HFOMCs at 39 sentinel sites, HFOMCs “model” status in priority VDCs. achieving all performance criteria. in other high-priority VDCs, and other HFOMCs in VDCs visited

Districts implement new 2. MOH flexible health grants are allocated to 150 VDCs/UHCs of 6 demonstration districts Benchmarks in later years will focus on MoH/MOFALD local VDCs in 6 demonstration districts based on the received MoH flexible health grant (Chitwan HFOMC performance and health governance policy in VDCs to formula and a majority of annual village health NPR 1,798,000; Dang NPR 1,632,000; Jhapa- facility readiness, quality of care, and strengthen HFOMCs and health plans are approved by VDC Councils NPR 1,897,000; Jumla, NPR 1,250,000; Kailali performance. facilities 1,889,000; and Kaski NPR 1,534,000) totaling Measurement: Allocations verified by VDC Executive of NPR 10,000,000 for FY 2015/16. All 150 Committee and approvals by VDC Councils VDCs/UHCs prepared annual health plans and secured Councils’ approval for the FY 2016/17.

Health for Life—Annual Report 58 Objective 2: Develop evidence-based health policy Key Component Year-3 Benchmark (July 2015-June 2016) Status as of June 30, 2016 Remarks

3. D(P)HO continue the practice of analyzing All the D(P)HOs used the PHAT manual as Benchmarks in later years will focus on Analytical capacity of District data using PHA techniques for further reference to analyze data from HMIS and other expansion, data quality, annual district (Public) Health Offices improvement of health services; data from 39 sources. The PHAT review template developed and regional reviews, including sentinel sites and HF readiness assessments are in collaboration with HMIS Section was used in interpretation and actions. also used during their regular review process all 14 districts and two regional health directorates to assess the district annual review Measurement: Assessment reports of district and regional meetings of last year. Based on the assessments, performance reviews by using PHAT review checklist two districts have achieved “model” status, and developed jointly with HMIS and other partners) nine have achieved “progressive”.

4. NHRC’s knowledge management capacity is From published health journals in Nepal, more Benchmarks for NHRC in later years NHRC collaborative research enhanced by an updated web-portal than 300 abstracts have been prepared will focus on an expanded knowledge network and knowledge according to 12 priority areas and are ready for management role that supports the management Measurement: Updated web-portal functional and in use uploading. SoW has been developed for AWPB through upgraded web-portal. upgrading NHRC’s web-portal.

Objective 3: Strengthen national level stewardship of the health sector Key Component Year-3 Benchmark (July 2015-June 2016) Status as of June 30, 2016 Remarks

MoH policy making 5. MoH finalizes draft of NHSP III and NHSS (NHSP III) drafted based on evidence Benchmarks in later years will focus on recommends to Cabinet for approval. The sector gathered by a thematic group and approved by evidence-based policy making. plan is in force July 15 cabinet. Measurement: Cabinet approval and gives guidance to AWPB for fiscal year

Health for Life—Annual Report 59 Objective 4: Institutionalize nationwide system for quality improvement Key Components Year-3 Benchmark (July 2015-June 2016) Status as of June 30, 2016 Remarks

QA/QI system 6. MD and D(P)HOs expand to the remaining 231 HFs have reported QI assessment data to Benchmarks in next years will focus on 11 H4L districts and 4 additional demonstration D(P)HOs from the 14 H4L districts and 4 designing and developing QAI districts based on piloting the QI system under additional demonstration districts. monitoring system (QIMIS) and guidance of QA TAC and QAI TWG Information from QIMIS shared with Divisions, Centers and Districts. Measurement: Number of Health Facilities reporting QI assessment data to D(P)HO

Objective 5: Improve capacity of district and local health workers and community volunteers to deliver quality family planning, maternal, newborn and child health, and nutrition services Key Components Year-3 Benchmark (July 2015-June 2016) Status as of June 30, 2016 Remarks

Family Planning 7. D(P)HO expands LAFP at all birthing centers In the 141 high-priority VDCs there are 120 Benchmarks in next year will focus on of the high-priority VDCs birthing centers, of which 64 offer both LAFP maintaining LAFP services in existing methods, 24 offer IUCDs only, and 15 offer birthing centers and expanding LAFP in Measurement: Number of clients receiving LAFP service implants only. The number of birthing centers remaining birthing centers of priority by birthing center in high-priority VDCs in H4L districts has increased from 445 in the VDCs. last reporting period to 458 in this period, of which 67% (307) now offer at least one LAFP method. 10,933 married women of reproductive age are currently using LAFP from 120 birthing centers of the high-priority VDCs as of May 2016.

ANM school strengthening 8. ANM Schools enhance faculty members’ skills 17 faculty members from six ANM schools Benchmarks in next year will focus on on SBA core competencies to impart knowledge were coached on SBA core skills. Follow-up documentation of experiences and sharing and skills to students assessments of knowledge and skills with stakeholders. completed, and data entry in process. Measurement: Number of faculty members using teaching techniques learned from SBA and CTS training

Health for Life—Annual Report 60 Objective 6: Improve knowledge, behavior and use of health services among target population Key Components Year-3 Benchmark (July 2015-June 2016) Status (as of June 30, 2016) Remarks

Awareness through Mass Media 9. D(P)HOs will, together with local FM radio A few D(P)HOs and FM radio stations Benchmarks in later years will focus on stations, produce and air health programs and Public continue to program and air ASRH restarting the mechanism for Service Announcements (PSA) throughout the year programming following H4L’s and Antenna developing and airing Radio Bahas Foundation’s support. H4L will resume Radio program in the leadership with Measurement: Frequency of airing radio programs and PSAs Bahas in FY 2016/17. D(P)HOs. per day throughout the year at FM radio stations

District communication 10. D(P)HOs develop annual intervention plans With the support from the H4L district teams Benchmarks in next years will focus on strategies and annual with district stakeholders and schedule community- and other stakeholders, 13 districts developed incorporating the planned BCC intervention plans based communication interventions to reach annual intervention plans and scheduled activities in calendar of operation of M/DAG populations community-based communication D(P)HOs based on district health interventions to reach M/DAG populations. communication strategies in core Measurement: Number of such interventions developed and districts. executed by D(P)HO and district stakeholders

mHealth for ASRH 11. NHEICC allocates additional financial resources Instead of SMS based text messaging decision Benchmarks in next year focused on and uses mobile telephone operators to push at least was made to develop android-based mobile development of Android-based mobile 5 text messages and rolls out ASRH mobile applications in collaboration with partners application in collaboration with application such as UNFPA and GIZ under leadership of UNFPA, GiZ and VASP. NHEICC. This is in process of development. Measurement: Record of partnership with telephone operators, record of text messages pushed and number of adolescents using

Objective 7: Strengthen capacity of USAID’s contractor for logistical support activity Key Components Year-3 Benchmark (July 2015-June 2016) Status (as of June 30, 2016) Remarks Organizational development for 12. LLN has developed the capacity to conduct H4L provided financial analysis and H4L Logistics contract cancelled. LLN financial analysis and manage resources strategically management consultation to LifeLine to be competitive in the workplace through the local subcontractor, TRU, a well- known financial planning and audit firm. Measurement: Reports from audit firm subcontracted by H4L

Health for Life—Annual Report 61 PMP AND PPR INDICATORS

PERFORMANCE MANAGEMENT PLAN (PMP) REPORT, JULY 2015-JUNE 2016

YEAR 3 (2015-16) PERCENT BASE- BASELINE S ACTUAL OF INDICATOR DEFINITION LINE DATA DATA STATUS JUSTIFICATION N TARGET JUL 2015- ANNUAL SOURCE SOURCE JUN 2016 TARGET

OBJECTIVE 1-IMPROVE HEALTH SYSTEM GOVERNANCE OF DISTRICT HEALTH OFFICES AND SUB-DISTRICT LEVEL HEALTH FACILITIES

Intermediate Result 1.1 : HFOMCs hold health providers accountable for delivery of services by better mobilizing and management of local resources 1 Percent of health facilities that Core 30% HF Readiness 30% 31% HF 103% Target undertook Social Audits in the last 12 Survey 2013 Readiness achieved months Survey 2015 EQ 6.7% District report N/A 6.7% District N/A N/A No target was set for this report reporting period. Results will be shared next year.

Sub-Intermediate Result 1.1.1 Health Facilities in 24 Health for Life districts have functioning HFOMCs. 2 Percent of HFOMCs mobilizing Core 59% HF Readiness 75% 88% HF 117% Surpassed H4L’s TA has led to resources to support health services in Survey 2013 Readiness the target better performing the last FY Survey HFOMCs, and HFOMCs 2015 that are more receptive to evidence-based annual planning. However, VDCs transitioning to municipalities has interfered with this process EQ 30% HF readiness N/A 30% HF N/A N/A No target was set for this (priority assessment (priority readiness reporting period. Results VDCs) 2016 VDCs) assessment will be shared next year. 2016 Sub-Intermediate Result 1.1.2. Sub-Intermediate Result 1.2.1 Village health plans are prepared using evidence and approved by Village Councils as an integral part of Village Development Plan

Sub-Intermediate Result 1.1.3 District Health Governance Strengthening Task Forces (DHGSTFs) are functional and effective

Sub-Intermediate Result 1.1.4 Best practices (communitized programs, local resource mobilization, local procurement and logistics management, local human resource management, flexible financing and local innovation) adapted for local health governance in Health for Life districts Health for Life—Annual Report 62 YEAR 3 (2015-16) PERCENT BASE- BASELINE S ACTUAL OF INDICATOR DEFINITION LINE DATA DATA STATUS JUSTIFICATION N TARGET JUL 2015- ANNUAL SOURCE SOURCE JUN 2016 TARGET 3 Percent of clinical staff positions filled Core 80% HF Readiness 90% 72% HF 80% Target not Upgrading SHPs to HPs against sanctioned position Survey 2013 Readiness achieved created many new Survey positions which remain 2015 unfilled. EQ 57.5% District report N/A 57.5% District N/A N/A No target was set for this (priority (priority report reporting period. Results VDCs) VDCs) will be shared next year. 3a Number of additional clinical staff Core N/A District report N/A 225 District N/A N/A hired locally in priority VDCs report EQ 16 District report N/A 16 District N/A N/A No target was set for this (priority (priority report reporting period. Results VDCs) VDCs) will be shared next year.

Intermediate Result 1.2 Local health governance strengthened to restore services and repair/reconstruct damaged health facilities and reduce inequities of access and use of health services in Health for Life EQ districts

Sub-Intermediate Result 1.2.1 District health recovery and reconstruction plans prepared using evidence and implemented in collaboration with partners 4 Number of Districts that prepared EQ N/A District report 10 0 District 0% Target not By the time Health for health recovery & report achieved Life started implementing reconstruction plans program activities, recovery plans had been prepared and approved by D(P)HOs and DDRCs. This activity has been planned for next year.

Sub-Intermediate Result 1.2.2 Village health recovery plans are prepared using evidence and approved by Village Councils as an integral part of the Village Development Plan 5 Number of high-priority VDCs that EQ N/A District report 30 47 District 157% Surpassed H4L mobilized regional, prepared health recovery plans in EQ report the target district and VDC staff districts faster than expected, and the D(P)HOs and DDCs prioritized health recovery planning at high-priority VDCs. The 6 Number of local health plans Demo 277 District report 237 150 District 63% MoH flexible health prepared and approved by Councils (All HFs) report grants decreased from where flexible health grants are NPR 50m to NPR 10m, provided thereby forcing the DHGSTF to prioritize HFs. Health for Life—Annual Report 63 YEAR 3 (2015-16) PERCENT BASE- BASELINE S ACTUAL OF INDICATOR DEFINITION LINE DATA DATA STATUS JUSTIFICATION N TARGET JUL 2015- ANNUAL SOURCE SOURCE JUN 2016 TARGET

Sub-Intermediate Result 1.2.3 District level structures and systems strengthened for effective coordination and collaboration of health recovery and reconstruction

OBJECTIVE 2- DEVELOP AND IMPLEMENT NATIONAL EVIDENCE-BASED HEALTH POLICY

Intermediate Result 2.1 Guidelines developed and implemented for National and Regional Performance Review Meetings of MoH programs (A Framework for Analysis) 7 Comprehensiveness of MoH’s information Multiple Good Very good Good (21) Various 84% Target not Int’l health regulations system as measured by Health (Score: 25- sources; achieved not implemented Information System Performance Index 30) checklists according to standards; (HISPIX) no nat’l data archive established; no burden of disease study in past 5 years; and no health systems performance assessment in past 5 years. 8 Number of district reviews Core N/A Project report Acceptable: 3 Acceptable, HF Surpassed Health for Lifeprovided conducted in accordance with PHA 4 of 14; 9 Progressive Readiness the target TA to 14 districts and 2 performance Progressive and 2 Model Survey RHDs on the use of : 4 of 14 2015 PHAT during review meetings. EQ N/A District report N/A N/A District N/A N/A District review meetings report conducted prior to H4L TA.

Sub-Intermediate Result2.1.1 Data routinely used at all levels to review program performance, identify prioritized actions, and develop plans to improve performance 9a Percent of HFs displaying up-to-date Core 18% HF Readiness 75% 53% HF 71% Target not Health for Lifeprovided monthly service coverage information Survey 2013 Readiness achieved data display flex at year 1 on wall on the day of visit Survey & 2 which were intended 2015 for multi-year use. However, over-writing was not appropriate and some districts requested replacements. New data display flex could only be made available in Feb-Mar 2016. EQ N/A District report N/A N/A District N/A N/A No target was set for this report reporting period. Results will be shared next year.

Health for Life—Annual Report 64 YEAR 3 (2015-16) PERCENT BASE- BASELINE S ACTUAL OF INDICATOR DEFINITION LINE DATA DATA STATUS JUSTIFICATION N TARGET JUL 2015- ANNUAL SOURCE SOURCE JUN 2016 TARGET 9b Percent of health facilities in 10 EQ 93.6% HF readiness N/A 93.6% HF N/A N/A earthquake-affected districts assessment readiness submitting complete HMIS reports to 2016 assessment the district on time by high-priority 2016 and other VDC

Intermediate Result 2.2 NHRC prioritizes, oversees and regulates research based on established practice of Health Sector Planning and Budgeting 10 NHRC policy role revised to reflect N/A Project report NHRC Prioritization Project Consultant compiled and management of health sector research network Network of published reports prepared more than and expanded knowledge management with and health 300 abstracts from Health for Life TA Research research different published Clearing house articles health articles according operational completed & toareas 12 andpriority NHRC is others in preparing to upload them process to its website.

OBJECTIVE 3-STRENGTHEN NATIONAL LEVEL STEWARDSHIP OF THE HEALTH SECTOR

Intermediate Result 3.1 MoH’s next Health Sector Strategy, Third Long Term Health Sector Plan (2018-2038) and Comprehensive Health Sector Plan (2016-2021) developed in collaboration with EDPs and TA programs 11 Nepal Health Sector Strategy (NHSS) 2016- N/A Project reports NHSS in NHSS Project NHSS-IPs are nearing 2020 developed with Health for Life’s TA force developed reports completion and Health guiding and for Life is providing TA. MoH approved by and cabinet EDPs

Intermediate Result 3.2 State Non-State Partnerships are identified in Health for Life districts documented and shared for MoH scale-up 12 NHEICC and/or D(P)HOs establish N/A Project NHEICC H4L and Cost overruns for partnerships with Telecom and/or FM Radio Reports and/or GiZ m4ASRH led to to develop and implement mHealth and/or D(P)HOs anticipate rebudgeting; D(P)HOs radio BCC activities fund mHealth and FM radio stations mHealth evaluation in continued broadcasting or FM early FY ASRH messages during Radio 2016/17. FM past year in two districts. BCC radio activities programming and Radio Bahas to

Health for Life—Annual Report 65 YEAR 3 (2015-16) PERCENT BASE- BASELINE S ACTUAL OF INDICATOR DEFINITION LINE DATA DATA STATUS JUSTIFICATION N TARGET JUL 2015- ANNUAL SOURCE SOURCE JUN 2016 TARGET resume FY 2016/17

OBJECTIVE 4-INSTITUTIONALIZE NATIONWIDE SYSTEM FOR QUALITY IMPROVEMENT

Intermediate Result 4.1 Consensus built on National QI system and piloted in in Health for Life districts for MoH scale-up 13 Number of districts QAWC that carry Core 0 District report 14 14 District 100% Target out action plan in the last reporting report achieved period (trimesterly) EQ N/A District report N/A N/A District N/A N/A No target was set for this report reporting period. Results will be shared next year. 14 Number of HF QI teams formed and Demo 0 District report 150 118 District 79% Target not Progress is made functional where local health plans are report achieved cautiously to ensure the prepared and flexible grants are QI assessment process is provided clear and HFOMC and HF are prepared to implement. H4L staffing is also limited.

Intermediate Result 4.2 D(P)HO rolls out facility-based QI system in all Health for Life districts 15 General Service Readiness Index of Core 41% HF Readiness 60% 42% HF 70% Target not Readiness index highly health facility Survey 2013 Readiness achieved influenced by two Survey domains, particularly 2015 standard precaution for prevention of infection, and medicines and commodities. Scores for both domains continue to be low. Scores for amenities and equipment domains increased. EQ 16.3% HF Readiness N/A 16.3% HF N/A N/A Assessment Readiness 2016 Assessment 2016

OBJECTIVE 5- IMPROVE CAPACITY OF DISTRICT AND LOCAL HEALTH WORKERS AND COMMUNITY VOLUNTEERS TO DELIVER QUALITY FAMILY PLANNING, MATERNAL, NEWBORN AND CHILD HEALTH, AND NUTRITION SERVICES

Health for Life—Annual Report 66 YEAR 3 (2015-16) PERCENT BASE- BASELINE S ACTUAL OF INDICATOR DEFINITION LINE DATA DATA STATUS JUSTIFICATION N TARGET JUL 2015- ANNUAL SOURCE SOURCE JUN 2016 TARGET

Intermediate Result 5.1 Community level health innovations and programs delivering MNCHN/FP services scaled-up and maintained 16 Percent of deliveries conducted by skilled birth 42% HMIS 65% 45.5%5 HMIS 70% Target not Reports from major attendant (doctor, nurse or ANM) 2012/13 achieved hospitals either not received or incomplete (For example, no reporting from Bheri Zonal Hospital). 16a Percent of deliveries conducted by Core N/A Mobile N/A 79.7% Mobile skilled birth attendant (doctor, nurse or tracking (n=3,297) tracking ANM) in sentinel sites (live births EQ N/A Mobile N/A N/A Mobile Results will be among registered women) tracking tracking reported next year. 17 Percent of newborns receiving postnatal health 50% HMIS 2013 56% 48%1 HMIS 86% Target not Reports from major check-up within 24 hours of birth (New achieved hospitals either not Indicatoreffective from 2014/15) received or incomplete (For example, no reporting from Bheri Zonal Hospital) Sub-Intermediate Result 5.1.1 D/PHO managed/implemented Matri Surakshya Chakki program in 1 district and CB-IMNCI in 8 Health for Life districts 18 Number of districts implementing a 0 District report 7 9 District 128% Target Based on the CHD’s comprehensive integrated management of Report surpassed IMNCI nationwide roll- childhood illness and newborn care (CB- out plan, GoN and IMNCI) package (NewIndicator effective from partners have started 2014/15). implementing CB- IMNCI in 9 H4L districts (Surkhet, Jajarkot, Rukum, Kalikot, Arghakhanchi, Rolpa ,Jumla, Banke and Pyuthan). 19 Percent of pregnant women protected from 47% PPH survey 68% 50.3%1 HMIS 74% Target not Reports from major PPH report achieved hospitals either not received or incomplete (For example, no reporting from Bheri

Health for Life—Annual Report 67 YEAR 3 (2015-16) PERCENT BASE- BASELINE S ACTUAL OF INDICATOR DEFINITION LINE DATA DATA STATUS JUSTIFICATION N TARGET JUL 2015- ANNUAL SOURCE SOURCE JUN 2016 TARGET Zonal Hospital). Short supply of MSC from district to community (FCHVs).

Intermediate Result 5.2 D/PHO enhanced FCHV knowledge and skills in CB-IMCI, and FP counseling services in all 14 Health for Life districts 20 Number of people trained on FP/RH and N/A Project Report N/A N/A Project Target Target achieved previous MNCH for the reporting period report achieved reporting period. 21 Annual protection against pregnancy afforded 250,072 HMIS 267,980 250,0271 HMIS 93% Target by contraceptives distributed (couple-years achieved protection) 22 Percent of reproductive age women in union 43% NDHS 2011 45% 43%1 HMIS 95% Target who are currently using a modern method of achieved contraception (New Indicator effective from 2014/15) Sub-Intermediate Result 5.2.1 Knowledge and skills of FCHVs enhanced 23 Percent of FCHVs able to recite 3 home rules 83% Readiness 90% 87% Readiness 97% Target for treatment of diarrhea assessment assessment achieved visits visits (non- (non- representative) representat ive=975)

Sub-Intermediate Result 5.2.1 Knowlegde and skills of health workers ehanced 24 Percent of health workers who performed all of 40% Readiness 70% 66% HF 94% Target the six actions during counseling assessment Readiness achieved visits Survey (non- 2015 representative)

Intermediate Result 5.3 ANM pre-service training improved in 4 ANM schools of Health for Life districts 25 Percent of ANM with high level of proficiency Knowledge: ANM 75% Unavailable ANM assessment 17.5% in core SBA skills scored 65% Assessment at this time completed and data and above report entry in process. Skills: 0% scored 65% and above

OBJECTIVE 6-IMPROVE KNOWLEDGE, BEHAVIOR AND USE OF HEALTH SERVICES AMONG TARGET POPULATIONS

Health for Life—Annual Report 68 YEAR 3 (2015-16) PERCENT BASE- BASELINE S ACTUAL OF INDICATOR DEFINITION LINE DATA DATA STATUS JUSTIFICATION N TARGET JUL 2015- ANNUAL SOURCE SOURCE JUN 2016 TARGET

Intermediate Result 6.1 Demand and utilization for MNCHN/FP services increased among M/DAG and Adolescents/Youths 26 Percent of Dalit women who delivered at health 26.4% NDHS 2011 35% 42.3%1 HMIS 120% Target Target may be too low. facilities further surpassed Last year achieved 116%. (Revised indicator effective from 2014/15) analysi s N/A N/A 78% Mobile H4L introduced CAP/Rs 26a Percent of Dalit women who delivered Core at health facility in sentinel sites Mobile tracking (n=614) tracking to track pregnant women at sentinel sites a year ago. To date, 81% of the expected pregnant women are registered. Analysis shows a significant increase in equitable use of services. EQ N/A Mobile N/A N/A Mobile Results will be reported tracking tracking next year.

Sub-IntermediateResult 6.1.2GBV and earlymarriage are mitigated in10 districts 27 Percent of adolescents and youth that know the 10% Rapid >90% 61.3% School 68% Target not Results to date suggest legal age of marriage assessment in health pre achieved that students, especially schools by and post younger students, are not D(P)HO assessment retaining lessons learned staff (GESI regarding legal age of focal person) marriage and reproductive health. In certain communities, teaching in Nepali is less effective than in local language. There is a possibility some students participated in post-test without attending sessions on legal age of marriage.

Intermediate Result 6.2 Missed opportunities reduced at service delivery points to provide education and counseling on healthy behaviors for MNCHN/FP 28 Percent of post-partum women receiving 58% HF Readiness 80% 33% HF 41% Target not 78% of pregnant counseling on comprehensive FP services Survey 2013 Readiness achieved women delivered in Survey sentinel sites and all 2015 received FP counselling. Last year, non- Health for Life—Annual Report 69 representative HF YEAR 3 (2015-16) PERCENT BASE- BASELINE S ACTUAL OF INDICATOR DEFINITION LINE DATA DATA STATUS JUSTIFICATION N TARGET JUL 2015- ANNUAL SOURCE SOURCE JUN 2016 TARGET readiness assessments revealed 63% and 53% this year.

OBJECTIVE 7: STRENGTHEN CAPACITY OF USAID’S CONTRACTOR FOR LOGISTICAL SUPPORT ACTIVITY

Intermediate Result 7.1 Strengthened logistics system 29 29a. Percent of USG-assisted service delivery points 13% LMIS 9% 5%2 LMIS 180% Target Stock-outs ranged from (SDPs) that experience a stock out at any time surpassed 0% at facilities in Bardiya during the reporting period of a contraceptive and Dang to 13% at method (Condom, oral pills, injectable) that the facilities in Salyan. 1.2% SDP is expected to provide of HFs reported stock- outs of Depo-Provera 29b. Percent of USG-assisted service delivery while 4% reported stock- points (SDPs) that experience a stock out at any N/A N/A N/A Implants = outs of condoms or pills. time during the reporting period of a 69%2 Supply of FP contraceptive method (Implant, IUCD) that the IUCDs = commodities and SDP is expected to provide 76%2 essential tracer drugs increased after the end of the blockade. 30 Percent of USG assisted service delivery points 52% LMIS 40% 21%2 LMIS 190% Target Kalikot has the highest (SDPs) that experience a stock out at any time surpassed level of stock-outs of during the defined reporting period of specific tracer drugs (46%) and tracer drugs that the SDP is expected to provide Dang, Jajarkot, Surkhet have the lowest levels (1%). Supply of FP commodities and essential tracer drugs increased after the end of the blockade. 1 Ten months data (July 2015 to April 2016). Only Salyan and Kalikot districts have completely entered ten months data in the HMIS online system 2 Third quarter (January-March 2016) only and two districts namely Jumla and Kapilvastu data are not available.

Health for Life—Annual Report 70 PROJECT PERFORMANCE REPORT (PPR), JULY 2015 - JUNE 2016

YEAR 3 (2015-16) PERCEN TARGE ACTUA T OF BASELI DATA T 2015- L JULY- DATA ANNUAL SN INDICATOR DEFINITION NE SOURCE 16 JUNE SOURCE TARGET STATUS JUSTIFICATION 1 Number of newborn infants receiving 4,742 HMIS 5,181 5,2141 HMIS 101% Target antibiotic treatment for infection through 2012/13 achieved USG-supported programs 2 Number of women giving birth who 50,290 HMIS 64,199 50,5851 HMIS 79% Target not Reports from major hospitals either not received uterotonics in the third stage of 2012/13 achieved received or incomplete (For example, no labor through USG-supported programs reporting from Bheri Zonal Hospital). 3 Number of cases of child diarrhea treated in 347,896 HMIS 391,336 240,0651 HMIS 61% Target not CB-IMNCI yet to be rolled out completely USG-assisted program 2012/13 achieved except in Kalikot; stock-outs of zinc and ORS during 1st and 2nd quarters reported (13% & 18%). 4 Number of children under five years of age 248,425 HMIS 287,583 141,3651 HMIS 49% Target not Community-level treatment of pneumonia with suspected pneumonia receiving 2012/13 achieved by FCHVs ended following implementation antibiotics by trained facility or community of new policy in 2014/15; health workers in USG-assisted programs 17% and 15% stock-outs of Cotrim P reported during first and second quarters, respectively. 5 Number of babies who received postnatal 53,033 HMIS 66,835 40,7071 HMIS 61% Target not Reports from major hospitals either not care within two days of childbirth in USG- 2012/13 achieved received or incomplete (For example, no supported programs reporting from Bheri Zonal Hospital). 6 Couple Years protection in USG supported 250 HMIS 307 2501 HMIS 81% Target not Incomplete data entry from VSC camps; programs (in thousands) (Health for Life (HMIS 2012/13 achieved likely to be reported Oct 2016. districts) 2012/13) 7 Couple Years protection in USG supported 1,730 HMIS 1,756 1,3261 HMIS 75% Target not Incomplete data entry from VSC camps; programs (in thousands) (National) 2012/13 achieved likely to be reported Oct 2016. 8 Percent of USG-assisted service delivery sites 100% HMIS 100% 100% HMIS 100% Target providing family planning (FP) counseling 2012/13 achieved and/or services 9 Number of people trained in FP/RH N/A N/A N/A N/A Achieved Already achieved. through USG supported programs Males N/A N/A Females N/A N/A 10 Number of people trained in Health System N/A N/A 1,250 352 TraiNet 28% Target not Domestic allowance issues in the first half of Strengthening through USG-supported achieved FY 2016 slowed down activities. Political programs (Custom PPR) agitations in certain districts and the Health for Life—Annual Report 71 YEAR 3 (2015-16) PERCEN TARGE ACTUA T OF BASELI DATA T 2015- L JULY- DATA ANNUAL SN INDICATOR DEFINITION NE SOURCE 16 JUNE SOURCE TARGET STATUS JUSTIFICATION Males 890 304 34% blockade at the border affected supply of fuel and commodities preventing mobility. Females 360 48 13% Only two batches of basic training and five batches of revitalization training were conducted. 11 Percent of USG-supported primary health 97% HMIS 98% 98%1 HMIS 100% Target care (PHC) facilities that submitted routine 2012/13 achieved reports (HMIS) on time (Custom PPR) 12 Percent of women that had four ANC check- NA NA 58% 47.4%1 HMIS 82% Target not ANC check-ups in sentinel sites averaged ups, as per protocol in USG-supported achieved 65.2%. Reports from major hospitals either programs not received or incomplete (For example, no reporting from Bheri Zonal Hospital) 13 Percent of women from marginalized groups 29% NDHS 41% 36.3%1 HMIS 88.5% Target not 78% of Dalits delivered in health facilities in that delivered in health facility National 2011 achieved sentinel sites. Reports from major hospitals either not received or incomplete (For example, no reporting from Bheri Zonal Hospital) Ten months data (July 2015 to April 2016). Only Salyan and Kalikot districts have completely entered ten months data in the HMIS online system

Health for Life—Annual Report 72 E. INFORMATION ON THE STATUS OF FINANCES, INCLUDING EXPENDITURE DATA BASED ON THE BUDGET AND ACCRUALS, AS WELL AS, WHEN APPROPRIATE, ANALYSIS AND EXPLANATION OF COST OVERRUNS OR HIGH UNIT COST

Health for Life—Annual Report 73 F. INFORMATION ON MANAGEMENT ISSUES, INCLUDING ADMINISTRATIVE PROBLEMS, OR PROBLEMS WITH BENEFICIARY GROUPS, OR IMPLEMENTING PARTNERS AND WHAT STEPS OR ACTIONS WERE TAKEN TO MANAGE THESE AND LESSONS LEARNED FOR FUTURE DOMESTIC ALLOWANCE AND RESOURCE PERSONS • As in the previous reporting period, we occasionally receive complaints from the government regarding the daily allowance paid by Health for Life. In particular, this past year has seen more frequent complaints regarding “Resource Persons”. • Travel allowances for HFOMC members and FCHVs have sometimes emerged as an issue. District-level meetings such as the QAWC, DHGSTF and GESI-TWG where government line agencies are in attendance as participants and facilitators, have led to vocal demand for DA. • GoN staff often accompany Health for Life staff during field visits for community-level trainings and provide technical assistance to local health facilities, receiving the standard GoN domestic allowance during such events. Although Health for Life supports GoN travelers in accordance with MoF guidelines and shows preference for full room and board, GoN travelers often demand greater support. Some districts have established their own rates which may be at variance with MoF guidelines. BLOCKADE Field travel: The 2015 blockade, which began on September 23, 2015, severely affected the availability of fuel, limiting field movement. Many trips and events had to be rearranged or postponed due to the shortage. Delays in vehicle delivery: Health for Life ordered 5 Vehicles, 3 for the EQ Program. Due to the blockade, the border was closed for several months causing delays in delivery. As a result, there were delays in executing field activities. Delay in motorcycle delivery: Health for Life ordered motorcycles for district staff members. Due to the blockade there was a delay in delivery which caused delays in executing field visits. EQ-AFFECTED DISTRICTS Around half of the high-priority VDCs assigned to Health for Life in the earthquake-affected districts are in the most remote areas of the districts. High-priority VDCs in some districts, such as Dhading, are clustered in one location and very far from the district headquarters. In such districts, Health for Life decided to station the Program Coordinator at the sub-district level near the cluster for better coordination and technical support to these VDCs.

Health for Life was asked to produce an MoU with the MoH to facilitate Health for Life implementation in the earthquake-affected districts. All D(P)HOs have welcomed Health for Life and are cooperating with the project except in Sindhuli. To resolve the matter, Health for Life will visit the Sindhuli D(P)HO with the Regional Health Director in January to solve the problem. In the meantime, USAID is forwarding a letter of implementation to the MoF and copying the MoH regarding Health for Life’s expansion. Health for Life, together with USAID, met with the PPICD in June 2016, discussed the issue and requested the PPICD to issue a letter to the ten EQ- affected districts.

Health for Life staff in the districts are being pressured by local leaders and groups to provide jobs to people representing the local leaders’ interests. District staff are advised that recruitment of local staff is being managed by a subcontractor and selection of staff will be competitive based on applicants’ qualifications.

The new Domestic Allowance policy of the MoF has caused disruptions to scheduled activities between Health for Life and some D(P)HOs. Health for Life has reviewed the new policy and is now implementing a new reimbursement policy aligned to the MoF’s.

Health for Life—Annual Report 74 G. ANTICIPATED FUTURE PROBLEMS, DELAYS, OR CONDITIONS THAT MAY ADVERSELY IMPACT IMPLEMENTATION OF THE PROJECT AND WHAT MEASURES ARE IN PLACE TO DEAL WITH THESE GOVERNANCE Political instability: The new constitution, promulgated in September 2015, has several time-bound provisions for its implementation. However, those reforms have been delayed and recent political developments which indicate an imminent change in government, has added further uncertainty. The agitation being carried out in the Terai and elsewhere is ongoing and protestors are awaiting the new government to address their grievances, including province demarcation. The Restructuring Commission is working to restructure the local government units to align them with the new constitutional provisions. It is expected that the report will come out before March, 2017. It is also expected that local government elections will take place after the restructuring process leading to significant changes in the roles and responsibilities of government entities, and will have major implications for the current functional assignments and institutional settings. These will certainly create more opportunities as well as challenges to the project. MoH’s alignment and compatibility with the new structure: An MoH team has been working for quite some time to restructure its national and sub-national structure. Many national, regional and district-level functions are likely to be realigned with provincial and local government units. It will take quite some time to functionalize sectoral mindsets to the federal reality and the immediate future may be uncomfortable as the country adjusts. The timeframe for functionalization will be determined by political changes in the upcoming days and may be prolonged if there is significant dissent. These changes will have an impact on existing vertical functions and staff arrangements, as well as on roles and responsibility, which may have implications for project activities. Choice for health professionals: Health workers in Nepal, like any other groups of civil servants here, are strongly affiliated with trade unions. Once positions are classified as federal, provincial or local, a certain degree of dissatisfaction is likely to be seen among trade unionists, possibly resulting in agitation against the restructuring process in the health sector. All of the above scenarios could create difficulties in the implementation of project activities, beginning in late 2016 or early 2017. EQ-AFFECTED DISTRICTS Local elections, federalism and re-structuring of VDCs may impact the TA program, especially in high-priority VDCs. Merging VDCs into rural municipalities may necessitate revisiting our prioritization of VDCs. Many of the VDCs assigned to Health for Life in the EQ-affected districts have a shortage of clinical staff so our TA program will have little impact on access to and use of services, particularly by M/DAG. Health for Life is continuously working with the D(P)HOs for placement of clinical staff in those VDCs in all ten EQ-affected districts.

H. INFORMATION ON SECURITY ISSUES, ESPECIALLY AS THESE AFFECT PROGRAM INTEGRITY AND SAFETY OF BENEFICIARY GROUPS AND IMPLEMENTING PARTNER Two members of the “All Nepal People’s Health Workers’ Federation” affiliated with Nepal Communist Party visited the Health for Life office in June 2016. They delivered a letter and sought to meet directly with the head of the organization. They were informed that such a letter could not be delivered directly. Through their letter they sought financial support, stating that they represented Biplob’s Maoist Party and that the recent incidents carried out at the Save the Children office in Chautara and torching of World Vision’s vehicle were carried out by them. Having said that, they left the office saying that they would call back later to meet the

Health for Life—Annual Report 75 head of the organization. They did call twice seeking an appointment but they were informed that Health for Life does not have a mandate for providing any kind of support. This incident was reported to the COR and USAID and a briefing on the incident was made to the RSO and USAID. Following this meeting, the Jawalkhel Police were informed of the incident. The landlord of the Health for Life office has added extra guards to be placed at the main doors of the building. Health for Life has added access control at the main door along with CCTV cameras. The EQ Regional Office will install access control in its offices along with CCTV cameras. Extra precautions are being taken during field visits.

I. OTHER INFORMATION, SUCH AS NEW OPPORTUNITIES FOR PROGRAM EXPANSION, LESSONS-LEARNED AND SUCCESS STORIES, AND PROSPECTS FOR THE FOLLOWING YEAR’S PERFORMANCE Health for Life, together with RTI’s Global Health Division, will be proposing several activities to receive funding from RTI research and development grants.

Activity 1: To further develop Health for Life’s mobile tracking system so that the HFOMCs and health facilities receive automated feedback. A pilot of the mobile tracking system is already being implemented in sentinel sites and has led to successful results: for example, this year, 60 percent of Dalit women in sentinel sites completed 4 ANC visits, compared to the national average of 39.9 percent.

Activity 2: To develop and conduct a micro-survey tool in selected Village Development Committees (VDCs) in which the project operates, including earthquake-affected VDCs. The purpose of this survey is to gather key information from selected indicators to track the project’s progress to date. The current data pain point that the project faces is that it does not have data available within its targeted districts and VDCs to help determine the project’s successes or shortcomings. In turn, this lack of data hinders the project’s ability to make tactical programmatic decisions and changes, especially in regard to recovery and reconstruction in Health for Life’s 10 earthquake-affected districts where USAID will be “rebuilding better”.

Activity 3: To assess whether and how Health for Life TA to Village Development Committees (VDCs), and specifically Health Facility Operations and Management Committees and Ward Citizen Forums, contributes to financial savings (at either the household or VDC level in Nepal). A sub study aim could be: To assess how specific TA to community and citizen provider committees leads to reduced out of pocket expenses among beneficiaries. The deliverables could include a Theory of Change and evidence that the project is contributing to tangible financial benefits for stakeholders.

Health for Life—Annual Report 76 ANNEXES

ANNEX 1: COUNCIL BUDGET ALLOCATIONS

COUNCILS BUDGET ALLOCATION VS. EXPENDITURE BY END OF JUNE 2016 (FY 2015/016) IN HIGH- PRIORITY HFs Expenditures by the end of June 2016 ( FY 2015/2016) in NPR Budget allocation for FY 2015/016 in QI related Expansion & strengthening Districts NNPR HR* activities** services*** Others*** Total Burn rate (%) Arghakhanchi 1,730,135 430,000 169,373 227,500 24,000 850,873 49.2 Banke 2,216,800 - 87,000 157,000 - 244,000 11.0 Bardiya 2,264,880 216,000 1,097,180 439,900 - 1,753,080 77.4 Dailekh 2,939,958 313,244 231,925 904,970 20,000 1,470,139 50.0 Dang 2,713,290 233,000 485,500 106,800 - 825,300 30.4 Jajarkot 6,675,960 601,500 4,596,000 707,100 185,000 6,089,600 91.2 Jumla 1,185,500 766,500 290,000 - 25,000 1,081,500 91.2 Kalikot 2,150,559 1,188,459 549,000 212,600 96,000 2,046,059 95.1 Kapilvastu 2,123,045 140,000 921,565 1,031,480 12,000 2,105,045 99.2 Pyuthan 1,349,396 - 191,533 307,000 72,883 571,416 42.3 Rolpa 2,605,000 557,667 807,000 199,500 - 1,564,167 60.0 Rukum 3,006,200 653,100 719,200 95,012 20,000 1,487,312 49.5 Salyan 2,591,469 777,299 730,400 294,200 25,000 1,826,899 70.5 Surkhet 1,733,100 430,000 331,000 519,500 150,000 1,430,500 82.5 Total 35,285,292 6,306,769 11,206,676 5,202,562 629,883 23,345,890 66.2 Note:  HR*: Hire human resources locally (ANMs, AHWs, Lab Assistants, Office Assistants, contribution for stipend to CAPs/CARs etc.)  QI related activities** : QI fund, furniture, equipment, fencing, BC construction/ repairing/ maintenance, medicines, drinking water, solar electricity, placenta pit construction etc.  Expansion & strengthening of services*** : Child health, immunization, safe motherhood promotion, FCHV related, ambulance related, mental health, health camp, elderly health etc.  Others**** : Support to HFOMC, HIV/AIDS related etc.

Health for Life—Annual Report 77 ANNEX 2: JOINT VISITS WITH GON STAFF FROM JULY 2015 AND JUNE 2016

HEALTH FOR LIFE AND GON JOINT VISITS FROM JULY 2015 TO JUNE 2016 IN HEALTH FOR LIFE'S CORE DISTRICTS Name of Visitors from Visitor from Date GoN and USAID Organization Health for Life Districts Purpose Results From To MD/DoHS 10 Aug 15 12 Aug 15 Kapilvastu To discuss the concept of preparing Concept and methods of preparing Public Health Calendar of Operation and its usefulness Calendar of Operation and agreed on Administrator in implementing activities effectively dates to prepare in all Health for Life (both GON and partner's activities) core districts RHD, Surkhet 3 Nov 15 4 Nov 15 Banke To facilitate the workshop to prepare Calendar of Operation District Calendar of Operation prepared RHD, Surkhet 10 Apr 16 10 Apr 16 Banke To facilitate Leadership and Management Workshop on Leadership and Acting RD workshop Management successfully completed USAID, 10 Dec 15 14 Dec 15 Jajarkot, Banke, Monitoring visits to Health for Life Kathmandu Surkhet, VDCs (Kudu and Dallu HF/Jajarkot, Observed and facilitated evidence-based Bardiya Raniyapur and Titehariya HF, Banke, local planning process, discussed with Health for Life Sahare HF, Surkhet, Surya Patawa, HFOMCs and updated functionality and Bardiya) performance of HFOMCs MD/DoHS, 12 Jun 16 17 Jun 16 Jumla and To observe web-based LMIS (Jumla) and Field activities observed and report Public Health MoH Kapilvastu PPP initiatives (Kapilvastu) and Health shared Administrator for Life's field level activities in both districts

Public Health Administrator

Health for Life—Annual Report 78 Name of Visitors from Organization Visitor from Health Date District Purpose Results GoN and Partners for Life From To CHD/DoHS 22 Jun 16 26 Jun 16 Surkhet To visit IMNCI potential training site Preliminary visit carried to introduce Hospital QI system in Mehalkuna Hospital

CHD/DoHS 31 May 16 2 Jun 16 Rolpa To facilitate/monitor quality CB-IMNCI -District planning meeting successfully PHO district planning meeting completed and three years IMNCI implementation plan developed - MWRHD -CB-IMNCI introduced in the district -District stakeholders and private pharmacies are oriented on CB-IMNCI program CHD/DoHS 27 Apr 16 29 Apr 16 Arghakhanchi To facilitate/ monitor quality CB-IMNCI -CB-IMNCI program management training IMNCI Officer Program Management Training successfully completed

FHD/DoHS 17 Apr 16 20 Apr 16 Rukum To supervise and Monitor of QI activity - HF QI activities with support of Health for Life monitored with focus on MNH

CHD/DoHS 6 Apr 16 8 Apr 16 Arghakhanchi To facilitate/ monitor quality CB-IMNCI -District planning meeting successfully district planning meeting completed and three-year plan is developed -CB-IMNCI program introduced in district -District stakeholders and private pharmacies are oriented on CB-IMNCI program CHD/DOHS 5 Apr 16 7 Apr 16 Surkhet To visit IMNCI potential training sites -Baseline assessment of potential IMNCI IMNCI Section Chief training sites (MWR and Mehalkuna hospital) carried out -Role and responsibility of different GoN organization (NHTC, CHD, MWRHD, RHTC, MWRH, Mehalkuna Hospital, DHO) Surkhet and IMNCI partners involving in IMNCI training site development discussed and final draft prepared (for director’s approval)

CHD/DoHS 9 Feb 16 10 Feb 16 Butwal To monitor quality of CB-IMNCI -District level trainers from four districts Training of Trainer (Rolpa, Pyuthan, Arghakhanchi and CHD/DoHS Rupandehi) trained -District roll out plan prepared

JSI/CNCP

Health for Life—Annual Report 79 CHD/DoHS 30 Nov 15 2 Dec 15 Surkhet and -To organize preliminary preparatory -Hospital management agreed to develop Section Bardiya meetings at proposed IMNCI training as IMNCI training site on preliminary Chief and coaching sites preparatory meeting IRHDTC -Unusually high reported cases of PSBI and LBI (HMIS) among under two-month child discussed and decided explore further PO JSI/CNCP with DHO team - Joint visit (Health for Life and DHO) to HF for data verification planned

HEALTH FOR LIFE AND GON JOINT VISITS FROM JULY 2015 TO JUNE 2016 IN DEMONSTRATION DISTRICTS

Name of Visitors from Visitor from Date GoN Organization Health for Life Districts Purpose Results From To MD/DoHS 9 Sep 015 11 Sep 015 Chitwan To facilitate CF provision orientation DPHO's supervisors and DHGSTF to DPHO's supervisors and DHGSTF members oriented on CF provisions

MD/DoHS 28 Nov 30 Nov 015 Kailali To facilitate CF provision orientation DPHO's supervisors and DHGSTF 015 to DPHO's supervisors and DHGSTF members oriented on CF provisions

MD/DoHS 21 Dec 015 23 Dec 015 Chitwan To facilitate district TOT session on Newly formed Municipal Executives officer evidence-based planning for Executive oriented on CF provisions Officers of newly formed Municipalities MD/DoHS 28 Dec 015 30 Dec 015 Jumla To facilitate district TOT session on Newly formed Municipal Executives officer evidence-based planning oriented on CF provisions

MoFALD 8 Jan 2016 8 Jan 2016 Jhapa To facilitate CF provision orientation DPHO's supervisors and DHGSTF to DPHO's supervisors and DHGSTF members oriented on CF provisions Secretary MD/DoHS 22 Feb 016 24 Feb 016 Kaski To supervise local HFs, facilitate DDC DDC and DHGSTF members supported to and DHGSTF for local health planning local health planning process

Health for Life—Annual Report 80 NEW EXPANSION OF SERVICE DELIVERY POINTS - COMMUNITY HEALTH UNITS (CHUs) AND URBAN HEALTH CENTERS (UHCs) TARGETING M/DAGs IN HEALTH FOR LIFE DISTRICTS

Community EPI Urban Health PHC/ORC PHC/ORC Name EPI Clinic S.N District Health Unit CHU in Name of the VDC UHC in Municipality Clinic Center No. No. of the VDC VDC Name (CHU) NO. No. 1 Salyan 0 0 0 0 2 Arghakhanchi 0 0 0 0 3 Bela (Patauti)-1, Bela VDC Dang 2 1Lamahi 1 0 1 VDC (Chillikot)-1 (Patauti) 4 Buddhabatika, VDC, Dhankhola VDC, Barganga, Kapilvastu 4 4 0 0 Gugauli VDC, Jababairag VDC Shivaraj and Krishnanagar 5 Liwang Nuwagaun (Piuri), Iribang Rolpa 2 2 Khumel(Khewase) and 1Kotgaon-7 0 (Bagmara) Liwang (Harikatna) 6 Musikot VDC Rukumkot VDC, (Khubichar), Rukum 2 2 (Sumikot), Sankh VDC 0 Lukum VDC(Kankri) (Jhija) 7 Dakhakwadi Pyuthan 2 Puja, Dharampani 2 0 0 Bijayanagar 8 Banke 2 Gangapur, Baijapur 0 0 1 Raniyapur 1 Bankatti 9 Sanoshreetarala (Satipur), Bardiya 1 Patabhar 4 Basgadhi (Thumuni), 0 0 0 0 Basgadhi (Damauli), Rajapur (Bhalufat 10 Kudari, Jumla 1 1 2 0 0 Mabaipattarkhola 11 Basnepati -6, and Dailekh 2 Bisalla and Kasikandh 2 0 0 0 0 Simada- 8, Narayan 12 Jajarkot 1 Bhagwati 0 0 0 0 0 0 13 Kalikot 1 Raku 0 0 0 0 0 0 14 Sahare (botechaur) and Salkot Surkhet 2 1 Babai (veriganga) (Hasegau) Total 22 19 4 2 NB: Health for Life high-priority VDCs appear in bold

Health for Life—Annual Report 81 ANNEX 3: INTERN TESTIMONIALS Internship Report from

Introduction I did my schooling at Gyan Jyoti Higher Secondary School. After my SLC, I did PCL in nursing from Nursing Campus, Nepalgunj. During my study and practical course, I realized that a clinical approach alone may not be sufficient to improve the health of people in my community; health education/promotion and preventive approaches are equally important and I desired to gain practical experiences at the grassroots level and contribute to improving the quality health services. Fortuitously, Health for Life provided me an excellent opportunity to achieve my dreams as an intern in Dang. I was lucky for the opportunity, where I acquired some of the most valuable experience in my life, improving my skills in many areas. As my interest was in quality improvement, I gained practical experience in QI which has enhanced my capacity to support quality improvement in health service delivery. I am heartily thankful to the Health for Life family, the district team, D(P)HO and peripheral health units for providing a supportive and fruitful milieu to hone my skills that I dreamed of in my earlier days. What I did with Health for Life As this was field-based work, I travelled to many VDCs and visited health facilities where I supported the regularization of QI meeting, assisted in setting agendas, and did follow-up on the decisions made and action plans. I conducted client exit interview with postpartum mothers to know about quality of delivery services, postpartum care and FP services. I took part in preparing and conducting orientations for the QI team and HFOMC members on QI system and QI tools; identified gaps and provided inputs for carrying out QI self-assessments using the QI tools and preparing action plans to address gaps and do regular follow-up for the execution of the action plans. I supported linking QI issues to HFOMC meetings for improvements. Now I'm able to conduct QI reviews and follow up independently, carry out FCHV readiness and on-site coaching, analyze service coverage among MDAGs, participate in meetings and support agenda setting and decision making. Most importantly, I learned the importance of recording and reporting as well documenting evidence for transparency and accountability. What I learned This internship was a new exposure for me. In particular, field experience in HFs, VDCs and working with D(P)HOs and focal people was a great source of meaningful learning. Now I’m familiar with health facilities and their planning processes, staffing patterns and roles and responsibilities of HF staff, target-setting and recording and reporting processes. Other skills I have acquired include applying QI tools for quality improvement and that quality of services can be improved by mobilizing local resources and identifying the best solution to a problem. I also learned that without the involvement of local forums like the FCHVs, mothers groups, QITs and HFOMCs, quality improvement in health services is almost impossible. In the past, HF staff were more concerned about service delivery than providing quality care. Application of the QI tools has helped them to plan, identify resources, manage situations and assure the coverage and quality of services being delivered. Having grown much more interested in the area of quality improvement, I am able to prepare and conduct orientations with QI teams at health facilities and HFOMC members on the QI system and QI tools; find gaps and provide input on carrying out QI self-assessments using the QI tools and prepare action plans to address gaps and do regular follow-up for the execution of action plan. My expectations for the future My year with Health for Life has been very influential. I have a greater understanding of quality improvement, as well as knowledge of how to work effectively with local organizations. My responsibilities at Health for Life in Dang have made me capable for QI assessment; planning and follow-up of pre-planned events in terms of reviewing and sharing them with the DQAWC. My leadership and organizational skill have improved, and I now feel confident working independently on QI issues. Almost as important as the skills I gained are the relationships that I have built. My colleagues at Health for Life have become good friends; I expect their professional support will be invaluable in the future. It has truly been a pleasure to work with the team. My intention is to put the skills I have gained through this internship to greater use in the health facilities.

June 2016

Health for Life—Annual Report 82 Internship Report from Introduction I did my Master’s in English at Tribhuvan University. Being from a socially and economically deprived minority group, I do not have access to any civil or GoN services, nor could I approach any high-level authorities to get a job or gain job-related experience for professional development. Fortunately, I got the opportunity to join Health for Life as an Intern, where I have acquired some of the most valuable experiences of my life, improving my skills in many areas. I was particularly interested in local health governance and getting acquainted with the local health system strengthening process. What I did with Health for Life My aim was to work in the education sector, but getting the chance to interact with different marginalized groups has illustrated to me that Muslims and Dalits who are economically backward consistently have lower health indicators. Many of those I visited were ignorant of the available health services and their health-seeking behavior and utilization is generally lower than other groups. This has inspired me to focus my career on local health governance and strengthened my resolve to contribute to strengthening local health governance and improve the health of marginalized people. I assisted in facilitating Health Facility Operation and Management Committee (HFOMC) meetings, setting agendas, coaching and mentoring HFOMC members, preparing VDC periodic health plans, updating the VHSAR, verification of data, coordinating and supporting HFOMCs for health promotional activities and facilitating leadership trainings for HFOMC members. Subsequently, HFOMCs are supported in mobilizing resources and implementing elements of the Collaborative Framework on the ground. What I learned Before I joined Health for Life, I was shy and had little confidence speaking in public. This internship has been instrumental to building my confidence and ability to do well and consider myself prestigious at a local level among my community members. Now I am able to interact and influence Muslim Gurus and Maulana on the use of FP in pre-VSC interaction programs and garner a positive response to improve family planning in the Muslim community. The most valuable thing I got was to improve my leadership capacity, management skills and learning about coordination with different level stakeholders. I’ve become acquainted with the role of the HFOMC in strengthening the local health governance and planning process, among other skills that I acquired to collect disaggregated data and analyze and identify the disparities among different caste/ethnic groups, using an evidence-based approach to address these gaps through the participation of different social groups and the HFOMC in mobilizing resources. I have also familiarized myself with GON policy, protocols and guidelines, the tools which are important instruments required for system strengthening. My Expectations for the Future All the skill I acquired through this internship have made me confident. I am able to prepare and conduct orientations/trainings at different levels, facilitate meetings, mobilize the community and coordinate and plan processes independently. I will use this skill in bringing change to the community, particularly by working with HFOMCs at the local level. I would not have succeeded without the support of the district, regional and central teams of Health for Life as well as the D(P)HO, HF staff and HFOMCs. I am very thankful for the opportunity and support extended during the tenure of my internship.

June 2016

Health for Life—Annual Report 83