HEALTH FOR LIFE

REPORT ON RAPID ASSESSMENT

OF DISTRICT HEALTH SYSTEMS 2013

ARGHAKANCHI A REPORT ON RAPID ASSESSMENT

OF DISTRICT HEALTH SYSTEMS 2013

ARGHAKHANCHI

MAY 2013

TEAM MEMBERS

FOCAL PERSON)

HEALTH FOR LIFE

HALL 401, OASIS COMPLEX

PATANDHOKA TABLE OF CONTENTS

ABBREVIATION………………………………………………………………………………………………….ii

KEY FINDINGS OF RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEM..……………………….….iii

1. RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS…………………………………………… 1

2. INTRODUCTION OF …………………………………………………………..…3

3. STRUCTURE AND SYSTEMS …………………………………………………………………..…4

4. SERVICE STATISTICS ………………………………………………………………………….…….. ……7

5. HEALTH FACILITY MANAGEMENT COMMITTEE AND LOCAL HEALTH GOVERNANCE …...9

6. SERVICE DELIVERY/QUALITY IMPROVEMENT ……………………………………………………11

7. LOGISTICS MANAGEMENT SYSTEM ………………………………………………………………….13

8. BEHAVIOR CHANGE COMMUNICATION …………………………………………………………….15

9. ADOLESCENTS AND YOUTH FRIENDLY SERVICES … ………………………………………… ….18

10. GENDER EQUALITY AND SOCIAL INCLUSION ……………………………………………………...19

Annexes Annex: 1 Contact information of DHO Program focal person…………………….21 Annex: 2 List of RHCC Members ………………………………………………………………21 Annex: 3 List of persons met during RA visit…………………………………………….22

i ABBREVIATIONS

AHW Auxiliary Health Worker ANM Auxiliary Nurse Mid-wife AFHS Adolescents Friendly Health Services AFS Adolescents Friendly Services BC Birthing centre BCC Behavior Change Communication BEONC Basic Essential Obstetric and Newborn Care BNMT Britain Medical Trust CB-IMCI Community-Based Integrated Management of Childhood Illness CB-NCP Community-Based Newborn Care Package CEONC Comprehensive Essential Obstetric and Neonatal Care DAG Disadvantaged Group FCHV Female Community Health Volunteer FEFO First expiry first out HFOMC Facility Management Committee FP Family Planning FY Fiscal Year GESI Gender Equality and Social Inclusion HA Health Assistant H4L Health for Life HF Health Facility HP Health Post HFOMC Health Facility Operation and Management Committee HMIS Health Management Information System I/NGO International/Non-Governmental Organization IT Information Technology IUCD Intra Uterine Contraceptive Device LDO Local Development Office LMIS Logistics Management Information System MO Medical Officer MNCHN Maternal Neonatal Child Health and Nutrition MgSO4 Magnesium Sulphate MSC Matri Surakshya Chakki M&S Monitoring and Supervision MWDR Mid-western Development Region N Number NPC National Planning Commission PHCC Primary Health Care Center QI Quality Improvement QAWG Quality Assurance Working Group RA Rapid assessment RHCC Reproductive Health Coordination Committee RHD Regional Health Directorate SAC Social Awareness Centre SHP Sub Health Post SN Staff Nurse USAID Unites States Agency for International Development VDC Village Development Committee WCDO Women and Child Development Office WDR Western Development Region KEY FINDINGS FROM RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS- ARGHAKHANCHI

TOTAL POPULATION 197,632 NUMBER OF VDCS 42 MUNICIPALITY 0 DHO STRUCTURE AND Public Health facilities: SYSTEMS  District Hospital-1, PHCCs-2, HPs -17 and SHPs-22 Private Health facilities:  Private hospitals -1, Community hospital-0 Meetings:  Ilaka Incharges monthly meeting- 2nd and 3rd of every month  QAWG- formed but no meeting held yet.  RHCC- Meets quarterly Health Workforce:  Following technical positions at DHO is not filled-in- Statistical assistant, FP focal person, Malaria focal person, and Health Educator and Computer operator.  Positions at HFs – 1 MO, 1 SN, 26 ANMs, 7 AHWs and 1 HA are hired on contract basis. Among total contracted (n=36), DHO hired 1 MO, 1 SN and 20 ANM whereas, each 5 ANM and AHW hired from VDC. Similarly, each 1 ANM and HA along with 2 AHW hired from NPC. Monitoring and Supervision:  M&S system and plan exists at district level and district from ilaka to SHPs. Integrated supervision is not practiced yet even it is developed. IT infrastructure at D/PHO:  Desktops-7, Laptops-5, Printers-6  Well established internet facility.  Two HFs has computers.  Supervisors skilled in using MS Word and Excel-6.  Health Facility level entry in HMIS software. Rapid Response Team:  Functioning well at the district and HF level SERVICE STATISTICS  BCG coverage is in increasing trend from FY 2065/66 to 2066/67 and decreased in FY 2067/68 and FY 2068/69. In the FY 2068/69 measles coverage was 79.49 percent which is decreased in compare to FY 2067/68 and 2066/67.  Data shows district is falls in problematic category as it is below the national average.  Severe pneumonia and dehydration cases shows fluctuating trend. More children having pneumonia are being treated with antibiotics in the FY 2067/68.However it decreased to some extent in FY 2068/69.  Drop out from ANC first to ANC fourth visits is highly significant and in the FY 2068/69 it was 51.59 percent and 28.97 percent respectively.  SBA deliveries are in increasing trend (11.39 percent in FY 2065/66 to 23.6 percent in FY 2068/69)  Contraceptive Prevalence Rate in FY 2068/69 was 22.01 percent HEALTH FACILITY  HFs are not handed over to VDC. MANAGEMENT COMMITTEE  Among formed all HFs’ (n=42) HFOMC, received capacity building

iii AND LOCAL HEALTH trainings and refresher in the last 3 years. GOVERNANCE  At community level groups such as -Forestry Users Group, Mothers’ Group, Drinking Water Users Group, Irrigation Users Group, Road Rural Users Group, Cooperatives, and Media are functioning. SERVICE  CEONC trained service providers are available but not providing service DELIVERY/QUALITY due to absence of blood bank and anesthesia in the district whereas, 3 IMPROVEMENT BEONC service sites (District hospital, PHCC, Balkot PHCC) are functional.  Community-based service delivery-MSC program is implemented in 2012 whereas, CB-NCP implemented in 2010 through HealthRight Int’l.  Satellite FP clinics-02  IUCD services - 13 HFs. Implant services - 12 HFs  Birthing centers - 14  Placenta pits - 4 LOGISTICS MANAGEMENT  All tracer drugs and commodities available on the day of visit. SYSTEM  Drugs with most problems of stock outs in the year- Cotim-P, ORS, Iron.  Drugs with most problems of over stock in the last year- Condom.  Functioning refrigerators-6, sufficient for maintaining cold chain, and have regular power back up system for the cold chain room.  First Expiry First Out (FEFO) -not maintained well.  Web-based LMIS reporting system. Data entry person not recruited. BEHAVIOR CHANGE  FM stations – 2 COMMUNICATION  Several I/NGOs engaged in BCC activities  In current FY 2069/070, total 130 school health program on HIV/AIDS, RH/FP, Menstruation Hygiene and Adolescent Health were organized in 130 schools (approximately 6500 students benefited).  Villages that were highly populated by DAG , Bangi, Rabawn, , Maidan, Kudalpani, Pokharathok.  Ethnic/Caste group derived from service utilization Gandharav, , Sarki, Magar, Kumal were the deprived castes group.  Villages that still practice early marriage and Early Child Bearing  Julukae, Gokhunga, Siddhara.  High Migrants VDCs–Thada,,Nuwakot, Siddhara ADOLESCENTS AND YOUTH  AYFS- 13 sites supported by DHO FRIENDLY SERVICES  NRCS conducted Peer Review training to 28 schools in the current FY.  WCO has formed ‘KISHORI SAMUHA’ to share RH related information and transfer life skill training to adolescent. GENDER EQUALITY AND  GESI committee is formed but no meeting has been held yet. OCMC has not SOCIAL INCLUSION been established.  GESI focal person has received orientation.  No GESI activities have been initiated. 1. RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS

1.1 HEALTH FOR LIFE

Health for Life (H4L) is a five-year bilateral agreement between the Ministry of Health and Population (MoHP) and the Unites States Agency for International Development (USAID) which focuses on Systems Strengthening and improving the Maternal Neonatal Child Health and Nutrition/Family Planning (MNCHN/FP) service delivery at district and sub-district levels in 14 districts. 12 of the 14 districts are in the Mid-western Development Region (MWDR) –Arghakhanchi , Bardiya, Arghakanchi, Surkhet, Salyan, Pyuthan, , Kalikot, , Rukum, Jajarkotand Rolpa and two are in the Western development Region (WDR) of Nepal- Argakhanchi and Arghakhanchi .The project will be implemented between 2012 and 2017.

1.2 RAPID ASSESSMENT AND ITS OBJECTIVES

Rapid assessment (RA) is a method of analyzing situation of a district where issues are not well defined and where there is not sufficient time or other resources for in-depth quantitative research. RA uses intensive team interaction in both the collection and analysis of data instead of prolonged field work and iterative data analysis and additional data collection to quickly develop a preliminary understanding of a situation from the insider’s perspective. The main purpose of carrying out the current Rapid Assessment is to understand the current situation of the health service delivery system and other associated systems of the so as to help in planning activities at district level. Specifically, the objectives of the RA includes  Understanding the demographic profile of the district  Understanding the existing health care delivery system of the district  Knowing the functionality of the Facility Management Committees  Understanding the status of health indicators  Analyze strengths and weakness of the DHO systems  Identification of potential Local Technical Assistance Partners (LTAPs)  Exploring feasibility for the implementation of specific programs for adolescents and youth  Exploring feasibility of using Information Technology in information management

1.3 METHODOLOGY

A mix of both qualitative and quantitative methods was used to execute Rapid Assessment in Arghakhanchi district. These includes  Visit to District/Public Health Offices (DHO)  Interaction and interview of key staff  Observation of DHO

A structured tool was developed to collect necessary information which was supplemented by qualitative tools to interview key informants at District Development Committee and Local Development Office (LDO), International/Non-Governmental Organizations (I/NGOs) working on different areas of health, Gender Equality and Social Inclusion (GESI), Behavior Change Communication (BCC), Information Technology (IT) in Health, Service delivery, and Governance.

1 A team was composed for carrying out RA which included H4L staff and Government counterpart staff. Skill mix was ensured while forming team where staff was skilled/knowledgeable on the following- Governance, service delivery, monitoring and evaluation, GESI and BCC. Involvement of Project Center, regional and district office was ensured.

Before carrying out of the RA, one day orientation on RA objective, methods and tools were organized for H4L staff together with orientation on H4L in Hotel Siddhartha, . RA in Arghakhanchi was completed by three Staff in ten days May 01-10, 2013. Information collected was verified on the same day and brief notes were developed for each thematic area for sharing with DHO and other line agencies and also for preparing report. After completing the RA, a half day sharing program was organized that was participated by DHO, DDC, LDO and I/NGOs.

1.4 ORGANIZATION OF THE REPORT

The findings of the RA are presented in nine Chapters. Chapter one presents the purpose of carrying out RA and the methodology followed. Chapter two presents the introduction of Arghakhanchi district. Chapter three explains the DHO systems and structures. Fourth and the Fifth chapter present the service statistics and the status of the HFOMCs in Arghakhanchi district. Sixth and the Seventh chapter present the findings on service delivery/quality of care and logistics management system. Chapter Eight, Nine and Ten reports the findings on BCC, AYFS and GESI in Argakhanchi district. 2. INTRODUCTION OF ARGHAKHANCHI DISTRICT

2.1 GEO-POLITICAL SITUATION

Arghakhanchi district is situated in mid hill of , and comes under Western Development Region of Nepal. Shandikharka is the district headquarters. Arghakhanchi covers an area of 1,193 square km.

Arghakhanchi is bordered on the west by Pyuthan and Arghakanchi district, on the north by Gulmi and Pyuthan and east by Palpa and Gulmi districts and south by Kapilvastu and Rupendhai districts. There are two electoral constituencies and 42 VDC in the district.

2.2 DEMOGRAPHIC INFORMATION

The 2011 Census reports total population Table 2.1: Population of Arghakhanchi District of Arghakhanchi district as 197,632. The Number Percent proportion of female is greater by 12 Total Population 197,632 - percent points than that of male. Male 86,266 44 Female Household 111,366 56 Table 2.1 shows the caste/ethnicity number Source: 46,835 - distribution of the population residing in Census 2011 Arghakhanchi district. The proportion of Caste/Ethnicity distribution Brahmin/ (56per cent) is greatest in Brahmin/Chhetri 116,431 56 Arghakhanchi district followed by Muslim 1,916 1 Disadvantaged Janajatis (20 per cent). The Relatively advantaged Janajatis 6,995 3 proportion of relatively Advantaged Other Origin 2,945 1 Janajatis and other Terai origin are nearly 37,074 18 same (3 and 1 percent). The proportion of Disadvantaged Janajatis Others 41,315 20 1,715 Dalit is 18 percent and others are about one Source: Census 2001 1 percent.

3 3. DHO STRUCTURE AND SYSTEMS

This chapter presents the findings related to the DHO structure and systems collected from the RA. The findings covers following areas: service delivery points, management system, health workforce, monitoring and evaluation system, information technology and health information management and disaster management system.

3.1 SERVICE DELIVERY POINTS

The District Health Office, located in Table 3.1: Number of service delivery points in is the main responsible Arghakhanchi district institution of the MOHP at Arghakhanchi Type of service delivery points Number to provide preventive, promotive and Government Hospital 1 curative health services to the people of PHCC 2 the district. There are a total of 41 Health Post 17 peripheral public health facilities Sub-health Post 22 excluding district hospital (2PHCCs, 17 Private hospital 1 Community hospital - HPs, 22 SHPs) in Arghakhanchi district. Birthing centers 14 There are 14 birthing centers out of which Functioning birthing centers 13 13 are functioning. There are 69 PHC Out-Reach Clinic 69 PHC/ORCs and 180 Immunization Clinics. Immunization Clinic 180 There are 8, 42 Female Community Health FCHVs 842 Volunteers (FCHVs) in the district. Source:DHO/Arghakhanci

There is one private hospital- Shandikharka hospital located in district headquarter.

3.2 MANAGEMENT SYSTEMS

3.2.1 Meetings Table 3.2 : Current Status of DHO Team DHO Arghakhanchi holds monthly DHO Team Status meeting of the health facility In-charge at a. District Health Officer Filled Illaka level. This meeting is held on 2nd b. Public Health Officer Filled and 3rd of every month. The c. Public Health Nurse Filled Reproductive Health Coordination d. Statistics Assistant/Officer Vacant Committee (RHCC) meets quarterly. The e. FP focal person Vacant recent meeting of RHCC was held in May f. Malaria focal person Vacant g. Health Education Tech/ Officer Vacant 17th 2013. The Quality Assurance h. DTLA/Officer Filled Working Group has been formed but it is i. EPI Supervisor/Officer Filled not functional. j. Cold Chain Assistant/ Officer Filled k. Computer Operator/Officer Vacant 3.2.2 Program Management Team l. Store Keeper Filled m. Child Health focal person Filled The DHO Arghakhanchi has most key n. Account officer Filled positions filled-in at the time of RA. o. Administrative officer Filled However, five major key positions- p. Nayab Subba Filled Statistics Officer, FP focal person, Malaria focal person, Health Education Technician and computer operator were vacant. Refer to Table 3.2. EALTH ORKFORCE 3.3 H W Figure 3.1: Human Resource status

Table 3.3 presents the current status of Vacant, 42 health workforce in Arghakhanchi district. Sanctioned In both the PHCCs, Medical Officer and staff post, 182 nurses are vaccant. At present, out of all the Filled in, sanctioned posts, 77% is filled-in, out of 140 which nearly 20% is filled on contact basis by DHO, VDC, and NPC.

Sanctioned post Filled in Vacant

Table 3.3: Current status of health workforce Type Number GoN Number supported from Sanctioned Filled-in VDC NPC Other( DHO contract) a. Medical Officer 02 0 01 b. Staff Nurse 02 0 01 c. ANM 47 36 05 01 20 d. HA/Sr. AHW 19 10 01 e. AHW 69 52 05 02 f. VHW 18 18 g. MCHW 10 10 h. Lab Assistant 02 01 i. Adm. Assistant 01 01 j. Store Keeper - - k. Peon 12 12 l. Vaccinator 20 Source: SO, DHO

3.4 MONITORING AND SUPERVISION DHO Arghakhanchi has Monitoring and Supervision System in place but the DHO does not monitor Illaka level HFs according to the Monitoring and Supervision Plan that is developed every FY. The main reason for not following the plan was duplication and overload of program and not enough substantial budgets for monitoring and supervision at DHO. However, there is monitoring and supervision system developed for Illaka level health facilities to monitor SHPs. DHO has integrated supervision plan but, it is not practiced yet.

3.5 INFORMATION TECHNOLOGY The RA also explored the existing Information Technology (IT) infrastructure at DHO. At present the DHO has 12 computers including five laptops. The internet facility is good and functioning. There are six functioning printers and six supervisors and focal person are skilled in MS word and Excel. Both the PHCCs- Balkot and Thada PHCC has computers.

3.6 HEALTH INFORMATION MANAGEMENT DHO Arghakhanchi has a system to enter Health Facility level data in HMIS software. HF level data is available for the last three years. Recently the Statistics Officer received four days training on

5 web-based HMIS reporting. From this FY, HMIS data that received from health facilities are entered in the web-based HMIS software. The system for desegregation of data as regard to marginalized/disadvantaged group has not been practiced yet. DHO does not have an event of Data validation program in the current FY.

3.7 NATURAL DISASTER RESPONSE MECHANISM DHO Arghakhanchi has existence of Rapid Response Team (RRT) to act quickly to address in worse epidemic situation under the leadership of District Disaster Management Committee (DDMC) which is chaired by CDO. Similarly, Emergency Management Committee (EMC) of district is also functional which is supported by (NRCS) for addressing natural disasters. This committee is chaired by president of NRCS and also work under the supervision of DDMC. In order to promptly respond to disasters, a Community Rapid Response Team (CRRT) is formed at health facility level. So far, CRRT is formed in both the PHCCs in Thada, Balkot, which also maintains buffer stock of medicines for rapid response whenever needed.

3.8 STRENGTH AND OPPORTUNITIES

The major strengths of the DHO as observed during the RA are as following; System and Structure  Planning and conduct of RHCC meetings (Quarterly);  Plan and conduct of monthly Illaka level meetings;  FCHV monthly meetings conduction in all HFs;  Developed annual supervision plan.

3.9 KEY ISSUES AND CHALLENGES

Regarding system and structure, the major challenges and constraints are:  Although district level QAWG committee is formed it is not functional.  Meeting of Illaka In-charges at district level is not regular.  SHP in-charge meeting at ilaka level is regular but data analysis and feedback system is not effective. Integrated supervision of programs is lacking. 4. SERVICE STATISTICS

The RA also sought information on the service statistics of the following programs, Immunization, Child health, Safe Motherhood and Family Planning. HMIS data for the last four years were analyzed. The four year trend analysis of the selected indicators is presented in this section. Data for the years 2065/66 to 2068/69 is for one complete year.

4.1 IMMUNIZATION Trend analysis of BCG for the four-year period shows BCG coverage increased from 67 percent to 87 percent between FY 2065/66 and 2066/67 and then decreased and was maintained at 80 percent in the following two years. The measles coverage was also not uniform over the four year period. Drop out from BCG to Measles is not much high but the coverages of the antigens are below the national average, therefore the district falls in problematic category for child immunization.

4.2 CB-IMCI The proportion of new pneumonia cases treated with antibiotics increased until the Figure 4.1: Percent of severe third year and then declined in the fourth year. Pneumonia among new cases The trend in proportion of new diarrheal cases 0.59 0.6 0.580.58 treated with ORS and zinc shows drastic 0.5 0.5 0.4 increase in the FY 2067/68 and FY 2068/69. 0.25 (Table 4.1). This is because of implementation 0.1 of CB-IMCI program from 067/68. As a result of CB-IMCI more cases are being identified and 2065/66 2066/67 2067/68 2068/69 recording and reporting is improved. District National

Figure 4.1 shows that the proportion of sever Figure 4.2: Percent of Severe dehydration pneumonia cases varied by years but is less among new cases than one percent in all the FYs. Figure 4.2 shows the proportion of severe dehydration 0.6 case reported in the four year period. The 0.5 0.4 0.4 0.39 0.39 trend is not unifoirm but has been less than 0.17 0.1 0.09 one percent in all FYs. Both these figure shows significant effect of CB- IMCI that imparted 2065/66 2066/67 2067/68 2068/69 positive impact on the knowledge and skills of District National health worker and FCHV enabling them to better identification, classification and Figure 4.3: ANC 1st visit/4th visit as percent treatment of diarrheal diseases and ARI cases. of expected pregnacy 100 4.3 SAFE MOTHERHOOD 55.97 52.88 Data on safe motherhood displayed in the 46.55 51.59 50 Figure 4.3 shows that ANC first visit as percent 28.75 33.64 27.87 28.97 of expected pregnancy increased from 2065/66 to 2066/67 and then after it is 0 declining. Similar trend is observed for ANC 65/66 66/67 67/68 68/69 four visit. Drop out from ANC first to ANC four ANC 1st visit ANC 4th Visit

7 is very high. Similarly, PNC first visit as percent of expected live births is in increasing CPR as % of MWRA trend upto FY 2066/67 but, from FY 2067/68 80 42 43 44 43.14 it is also decreasing. However in the FY 2068/69 few increments have been observed. 60

40 24.96 TT coverage (both TT2 and TT2+) among 20.83 20.91 22.01 pregnant women has increased from 53% in Percent 20

2065/66 to 87% in FY 2066/67 and then decreased in in the following years. Similar 2065/66 2066/67 2067/68 2068/69 trend is observed for postpartum mothers receiving Vitamin A within 6 weeks. Data of District National pregnant mother receiving iron tablets is 57% in the most recent year which is below national average (80%, NDHS 2011). The delivery conducted by SBA is in increasing trend except in the FY 2067/68 but is below national average (36%, NDHS 2011).

4.4 FAMILY PLANNING The graph shows that the CPR (all modern methods) as percentage of MWRA of Arghakhanchi (22.01% in FY 2068/69) is below the national average 43% whereas, trend is increasing except in FY 2065/66. During RA, FP Focal person and PHN of DHO also asked about CPR status. They emphasized the higher migrating trend of married age group to abroad be key reason for low CPR of district besides presence of adequate service site of FP. Regular reporting of the services provided from the private sector is essential in computing the actual CPR of Arghakhanchi district.

Table 5.1: Trend in utilization of services SN Indicators 2065/66 2066/67 2067/68 2068/69 2069/70 1 BCG coverage 66.79 87.21 80.88 80.06 2 DPT 3 Coverage 68.05 81.15 87.83 80.92 3 Measles coverage (9-11 months) 66.15 86.73 80.64 79.49 4 TT2 & TT2+ coverage among pregnant women 53.28 86.73 68.99 66.01 5 Percent of postpartum mothers receiving Vitamin A 43.11 62.31 43.11 47.21 within 6 weeks 6 Percent of pregnant mothers receiving iron tablets 48.19 64.09 54.79 57.12 Proportion of new pneumonia cases treated with 31.34 30.05 54.98 43.39 7 antibiotic 8 Percent of severe pneumonia among new cases 0.59 0.1 0.25 0.58 9 Percent of new diarrheal cases treated with ORS+ 55.46 48.91 99.17 98.07 Zinc (under 5 years children) 10 Percent of severe dehydration among new cases 0.17 0.1 0.09 0.39 11 ANC 1st visit as percent of expected pregnancy 46.55 55.97 52.88 51.59

12 Four ANC visits as percent of expected pregnancy 28.75 33.64 27.81 28.97 13 Delivery conducted by SBAs (both home and 11.39 16.50 14.71 23.6 institutions) as percent of expected live births 14 PNC First visit as percent of expected live births 39.80 48.57 31.02 34.82 15 Contraceptive prevalence rate (CPR) (modern 24.96 20.83 20.91 22.01 methods) as percentage of MWRA 5. HEALTH FACILITY MANAGEMENT COMMITTEE AND LOCAL HEALTH GOVERNANCE

Information on Health Facility Operation and Management Committee was sought from both DHO and DDC. Both quantitative and qualitative methods were used for collecting information. Information was collected on the following topics: HFOMC functionality, capacity building, presence of different community-based groups at VDC level and their federations at district level. This chapter presents the major findings of the assessment on HFOMC.

5.1. FUNCTIONING HFOMC

The DHO supervisors expressed that only few HFOMCs The top five functional HFOMCs; (<25%) of the district are functional. Some of the HF in- 1. Thada PHCC charges were also asked to rate their HFOMC based on the 2. Siddhara HP following three criteria- 1) regular meeting, 2) meaningful 3. Suvarnakot HP participation of members, 3) service utilization and support 4. HP of HFOMC to health related activities and the results 5. Pokharathok HP showed that 21 percent HFOMCs are functional and among the total functional HFOMCs, 5 are supported by The bottom five HFOMCs; HealthRight Int’l whereas, another 4 HFOMCs are 1. Dhamchour SHP supported by DDC in the support of UNFPA. The top five 2. Tholopokhara SHP functional HFOMCs as judged by the district supervisors 3. Pataudi SHP include – i) Thada, ii) Siddhara, iii) Suvarnakhal, iv) 4. Argha SHP Narapani, and v) Pokharathok. DHO observed that almost 5. Dharapani HP (upgraded) all the HFOMC of the district are non-functional. The bottom five HFOMCs in terms functionality are – i) Dhamchour, ii) Tholopokhara, iii) Pataudi, iv) Argha, and v) Dharapani (upgraded). Mr. Ram Pd. Gautam (EPI officer) is responsible to look for the HFOMC program in the district as a focal person.

5.2. CAPACITY BUILDING OF HFOMC The HFOMCs of Arghakhanchi district (altogether 9 HFOMC) has received capacity building training in the last three year period. Among the total 5 HFOMC have received 3 days capacity building training along with 2 time refresher orientation through support of HealthRight Int’l which are i) Thada PHCC, ii) Siddhara HP, iii) Suvarnakot HP, iv) Narapani HP, & v) Pokharathok HP. Similarly, 4 HFOMC have received only first time 3 days capacity building training in initiation of DDC ( UNFPA support) which are i) Bangla SHP, ii) Kimdanda SHP, iii) HP (upgraded) & iv) SHP.

5.3. COMMUNITY GROUPS/FEDERATION According to the district supervisors’ different type of community groups exists at VDC level of Arghakhanchi district. These groups include Forest Users Group, Mothers’ Group, Drinking Water Users Group, Irrigation Users Group, and Road Rural Users Group, Cooperatives, Media and Other. As per the DDC Arghakhanchi there are existence of the federation/alliances of Forestry Users Group and Press and Media at district level.

9 5.4. STRENGTH AND OPPORTUNITIES HFOMC have been formed in all 42 VDCs. Nine of the HFOMCs have received capacity building training from DDC in which nine was supported by UNFPA and five by Health Right International. Focal person to look after HFOMC has been assigned in the DHO. DDC and Health Right Int’l are supporting DHO in strengthening HFOMCs. DHO should collaborate with them to explore opportunities in expanding HFOMC strengthening activities in the remaining HFOMCd. The five HFOMCs supported by Health Right International- Siddhara, Narapani, Thada, Suvarnakal, and Pokharathok are acknowledged as being top functioning HFOMCs by the DHO. These HFOMCs can be studied to understand what modalities made them better functioning than others so that the learnings could be replicated in other HFOMCs.

5.5. KEY ISSUES AND CHALLENGE

 No HFs has been handed over to the local bodies but HFOMC is formed in all HFs. Only around 21% of HFOMC has received capacity building training in last 3 years that clearly indicates that for introducing local governance activities, the capacity of HFOMCs has to be built.  Functionalize HFOMC- Although HFOMC has been formed, the key challenge is its functioning. The functionality of HFOMCs can be measured by regular monthly meetings, minute keeping practices and increased service utilization, and active participation of all members. It is a challenge to district to assure that these functions are taken care of by the HFOMCs. There is also gap between health workers and HFOMC members where both the parties do not want to be controlled by the other.  Although DDC/VDC has been supporting in expansion of health service in terms of recruiting staffs, infrastructure expansion, a common integrated mechanism of joint monitoring and supervision by DHO and DDC/VDC is lacking, which is a barrier for HFOMC

functionalization.  Although the HFOMC are formed as per the national guidelines that ensure participation of women, Dalit and Janajati, it does not guaranteed meaningful participation of these groups. This is a key challenge for good governance practice.  Lack of knowledge of bottom up planning among HFOMC members makes HFOMC less functional. Ensuring participation of HFOMC in resource pooling and ensuring understanding of the mechanism of demand creation by HFOMC in the planning process of DDC and DHO is also a challenge.

Efforts required overcoming the problem-  Reformation of HFOMC which need to be initiated by DHO;  Joint supervision has to initiate by DDC and DHO for HFOMC strengthening;  Need-based orientation or refresher training to HFOMC members focusing on members responsibilities and bottom up planning  There should be provision of replacing leadership in absence of VDC secretary to lead HFOMC activation as well knowledge transfer from old committee to new once.

DDC role in HFOMC strengthen-  Allocate substantial budget for HFOMC to support infrastructure;  Build environment of coordination between I/NGO and monitoring by DDC;  Build ownership to HFOMC for planning and implementation of activities. 6. SERVICE DELIVERY AND QUALITY IMPROVEMENT

This chapter presents the RA findings related to service delivery and quality of care. Information on the quality of ANM schools, infection prevention practices at HFs, implementation of community- based interventions, and the provision of IUCD and Implants services were collected at district level. The major finding of the assessment is presented hereunder.

6.1. SERVICE DELIVERY

The RA sought information on the availability of satellite clinics, CEONC and BEONC services, long acting FP methods, implementation of community-based interventions such as CB-NCP, MSC and Calcium. It also includes information on service integration.

In Arghakhanchi two HFs have satellite clinics and district does not provide CEONC services in absence of blood bank, anesthesia and baby warmer (insulator) even available of trained human resource in the district hospital whereas, three BEONC service site are available at District hospital, Thada PHCC and Balkot PHCC. There are 14 birthing centers in the district. With regards to providing long acting reversible FP methods, IUCD and Implant are being provided from 13 and 12 sites respectively including district hospital. In Arghakhanchi, CB-NCP and MSC were implemented by DHO in support of HealthRight International in 2010 and 2012, respectively.

Table 6.1: IUCD and Implants Insertion and Removal Sites S.N IUCD Birthing Center? S.N Implants Birthing Center? Y/N Y/N 1 Thada PHC Y 1 Thada PHC Y 2 Balkot PHC Y 2 Balkot PHC Y 3 Pokharathok HP Y 3 Pokharathok HP Y 4 Hansapur HP Y 4 Hansapur HP Y 5 Khana HP Y 5 Khana HP Y 6 Arghatosh HP Y 6 Arghatosh HP Y 7 Siddhadhara HP Y 7 Siddhadhara HP Y 8 Suvarnakhal Y 8 Suvarnakhal Y 9 Narapani HP Y 9 Khilji SHP Y 10 Pali HP Y 10 Jaluke SHP Y 11 Khilji SHP Y 11 Jukena SHP Y 12 Jaluke SHP Y 12 District hospital Y 13 District hospital Y

6.2. ANM SCHOOLS

H4L intends to improve the quality of pre-service ANM trainings but in Arghakhanchi there is no ANM school.

6.3. INFECTION PREVENTION AND WASTE MANAGEMENT PRACTICES AT HFS

Few questions related to infection prevention (IP) and waste management practices followed at HFs were also asked to district supervisors during RA. It was found that different HFs practice different type of infection prevention and waste disposal practices. Only four birthing centers have

11 placenta pit out of 14 birthing centers. The collection, separation, handling and, transportation of waste generated in district hospital is not satisfactory.

6.4. STRENGTH AND OPPORTUNITIES

There are 13 functional birthing centers out of 14 and 63 nursing staff are trained in SBA in the district. Out of 13 birthing centers, 4 have placenta pit for the proper disposal of placenta. In the remaining birthing center where placenta pits are not available placenta and other waste products are dumped inside HF premises. Out of total 43 HFs, 13 and 12 HFs have been providing IUCD and Implant services regularly. In addition, there is there BEONC service centers. Programs like CB- IMCI, CB-NCP, MSC are already implemented in the district which is very good opportunity to improve the health status of mother and child of Arghakhanchi district.

NRCS and MSI are also working in the sector of FP and RH in the district. NRCS is providing awareness session to the adolescents regarding FP and STI including HIV/AIDS through its VDC level network. In the same way, MSI is providing FP service from their static clinics and mobile clinic on regular basis.

6.5. KEY ISSUES AND CHALLENGES A. Key issues The HMIS data of 2068/69 shows the sharp decline from ANC 1st visit (52%) to ANC 4th visit (29%). Likewise, PNC 1st visit during the same year is 35% which possess serious challenge in improvement on MNCH. BEONC and CEONC service sites in a district are not adequate as the settlements in the district are scattered and many areas are hard to reach. Dues to geographic terrain women are not able to come to health institutions for delivery. Other key issues include:  Strengthen CEONC service site to make CEONC site fully functional including provision of blood bank, anesthesia and insulator;  Construct placenta pit in all birthing centers. Ten out of 14 birthing centers do not have placenta pit;  Need of clinical supervision and MNH update and RH review for HFs nursing staffs;  Provide infrastructures and equipment support such as for SBA services, infection prevention practices and for delivery room etc.

B. Challenge  Expansion of satellite clinics over the district;  Establish blood bank in coordination with NRCS;  Fulfillment of vacant sanction post of health workers;  Frequent transfer of HWs;  Regularizing timely clinical supervision by PHN;  Building infrastructure in remaining birthing centers;  Provision of specific focal person for specific program.

Efforts required overcoming the problem  Technical staff must be fulfilled as soon as possible;  Necessary equipment should be fulfilled and infrastructures build to maintain privacy;  Make HFOMC active by transfer skill to overcome problems;  Provision of necessary support staff from VDC;  Focused and regular clinical supervision from DHO. 7. LOGISTICS MANAGEMENT SYSTEM

Logistics management is an important part of district health systems. Efficient logistics management is required to smoothly run all the public health programs at district, sub-district and the VDC levels. The RA also sought information from DHO on the logistics management system. The major findings of the assessment are presented below.

7.1. AVAILABILITY OF KEY DRUGS AND COMMODITIES

During RA, the DHO store room was also visited and the store keeper was interviewed. The availability of ten tracer drugs/commodities (Injectable, Oral Contraceptive, Condom, ORS, Vitamin A, Iron Folate Tablets, Cotrim (Pediatric), Oxytocin, MgSO4, and Zinc in the district store at the time of visit was checked. It was found that all essential commodities and drugs were available. The store keeper was also asked whether the 10 drugs/commodities were out of stock anytime in the last 12 months, and it was found that Cotimoxazole (Pediatric), ORS, Iron were stock out in the last 12 months. It was also found that Condom was over stock in the last 12 months. The RA team members also checked the expiry dates of the eight drugs/commodities and it was found none of the drugs/commodities had expired during the day of visit.

Table 7: Availability of key drugs/commodities and their expiry dates S Drugs/Commodities Availability at the Stock out in the last Expired drugs in stock N time of visit 12 months at the time of visit 1 Injectable Contraceptive Y N N 2 Oral contraceptive Y N N 3 Condom Y N N 4 ORS Y Y N 5 MgSo4 Y N N 6 Oxytocin Y N N 7 Vitamin A Y N N 8 Iron Folate Tablets Y Y N 9 Cotrimoxazole (Ped) Y Y N 10 Zinc Y N N

The Store keeper was also asked to list the drugs that have most problems with stock outs in the FY 2069/70.Cotimoxazole (Pediatric), ORS, and Iron had most problems with stock outs in the year.

7.2. COLD CHAIN AND FEFO MANAGEMENT

DHO Arghakhanchi has six functioning refrigerators, which were sufficient to DHO for maintaining cold chain. The management of few drugs in the store was checked and found that it is not maintained in First Expiry First Out (FEFO) order.

7.3. LMIS REPORTING

DHO have web-based LMIS to report to center and it is functional. However, DHO has not recruited separate staff for LMIS reporting due to lack of fund.

13 7.4. STRENGTH AND OPPORTUNITIES

DHO Arghakhanchi has managed district store and cold chain system with regular power back up system. PULL system have been implemented in the district for the proper management of drug supply to the HFs. Essential key drugs/commodities were available during RA and also found that web-based LMIS reporting system is functioning.

7.5. KEY ISSUES AND CHALLENGES A. Ker Issues

 FEFO/Order is not fully maintained. Store management was not systematic because there is no store-keeper in the DHO.  Web-based LMIS is available but reporting from peripheral HFs in time is a problem.  Condom was over stocked in the last FY  Quarterly supply of drugs/commodities at peripheral health facilities is not maintained.

B. Challenges

 Human resource is not adequate for logistics management;  Collecting LMIS report in time from health facilities;  Supplying drugs/commodities as per pull system to the health facilities;  Channelize inventory mechanism system from district to periphery;  Proper store management and re-arrangement of drugs and segregation of expired drugs.

Efforts required for overcoming the problems

 Effective monitoring to HFs for timely reporting;  Support staff can be arranged from DHO;  Available budget should be allocated according to requirement with proper planning.  Orientation to newly recruited health worker for Logistic management.  Coordinate with different organization to provide palate for managing store. 8. BEHAVIOR CHANGE COMMUNICATION

H4L aims to understand legal, cultural/religious, and policy dimensions of GESI inequities on health service access and use and design interventions to ensure sustainable, high-quality BCC and IEC approaches that respond to local realities, and include groups not commonly targeted, but crucial to meeting Nepal’s health goals by mobilizing local partners.

One of the objectives of the RA was to explore the range of BCC interventions that is being implemented for healthy behaviors. Following are the major findings on BCC:

8.1. EXISTING DHO PROGRAMS ON BCC DHO Arghakhanchi has been organizing BCC program activities as per the DoHS yearly plan provided from the National Health Education Information and Communication Center (NHEICC) such as production and distribution of IEC materials, short massages broadcasting through local FM radio, school health program, day celebration etc.

8.2. FM STATIONS/CABLE TELEVISION NETWORKS In Arghakhanchi there are two FM stations. Following are the name and address of the FM stations: Radio Deurali 101 MHZ and Radio Arghakanchi 105.8 MHZ. DHO Arghakhanchi has partnered with both the FM stations for airing radio health programs and Public Service announcements (PSAs) on following topics:  Family planning;  Immunization, including national immunization days, national campaign information;  ANC, PNC check up;  Nutrition, tobacco consumption, health related days celebration are major topics covered.

There is one Cable TV networks in Arghakhanchi which have been broadcasting district-based programs as per need.

8.3. ORGANIZATIONS WORKING IN IEC/BCC ACTIVITIES RA identified following organizations working in IEC/BCC in Arghakhanchi;  Lumbini Health Service co-operatives;  UNFPA supporting street drama on (HIV/AIDS);  Health Right Int’l supporting community level BCC activities.

H4L plans to use mobile phones to reach target groups with messages on health in selected district. The RA also explored whether any organization has used mobile phones to communicate health messages to target groups or entire district population together with DHO. It was found that DHO has not collaborated with any external agency to use mobile phones in disseminating health messages to any target groups, so far.

8.4. COUNSELING SERVICE One area of intervention of H4L is to improve the quality of counseling provided by health workers and community-based health workers to clients. It is therefore essential to find out whether there is pool of resources available at district level to improve counseling services. Hence, RA also collected

15 information on the district health staff who received training on COFP in the last three years. According to the PHN, no health staff has received COFP training in Arghakhanchi.

8.5. SCHOOL HEALTH PROGRAM Conducting health education classes at schools is one of the activities of DHO. In the current FY 2069/70, school health sessions were organized in more than 130 schools reaching around 6,500 students in total. In Arghakhanchi, the topics mostly covered during the School Health Education were as following: awareness on HIV and AIDS, menstruation hygiene, RH/Family planning, and adolescents’ health.

According to the focal person of DHO beside school health education program, BCC activities such as street drama, folk songs, health day celebration are also effective means to reach the adolescents. Developing integrated package covering all aspects of health care will be effective for adolescents.

8.6. MAPPING OF DAG AND EXPLORING CULTURAL PRACTICES AFFECTING HEALTH During the RA, information on DAG communities residing in Arghakhanchi district was also collected. Focal person of BCC was interviewed for this. It was found that DAG mapping hasn’t been carried out in Arghakhanchi. However, the focal person identified the VDCs that are highly populated by DAG, VDCs where early marriage are common and VDCs populated by ethnic caste groups A. Villages of VDCs that were highly populated by DAG Following VDCs are highly populated by DAG in the Arghakhanchi district: Village/Communities VDC/Wards Household number Caste groups 1. Argha Ward #01 ≤100 Gandrava ( Dalit) 2. Pali Ward # 02,03 ≥100 Muslims ( Religious minorities) 3. Raban Ward # 04 ≥100 Kami (Dalit ) 4. Siddhara Ward #05,06 ≥100 Kami ,Sarki (Dalit ) 5. Midhan Ward #09 ≤100 Magar (Disadvantage Non-dalit) 6. Kudalpani Ward #08 ≤100 Disadvantages Group 7. Thoka Ward # 08,09 ≤100 Magar (Disadvantage Non-dalit)

B. Villages that still practice early marriage and Early Child Bearing Following VDCs practices early marriage and early child bearing in the Arghakhanchi district: Village/Communities VDC/Wards Caste groups 1. Jaluke All Kumal, Magar ( Disadvantaged Non-dalit) 2. Gokunda All Magar ( Disavantaged Non-dalit) 3. Siddhara All Kami,Damai, ( Dalit group)

C. Ethnic/Caste group deprived from service utilization Following VDCs are deprived from health service utilization due to geography, economy and other factor in the Arghakhanchi district. Village/Communities VDC/Wards Caste groups Reason for deprivation 1. Siddhara Ward # Dalit, Janajati Takes approx 8-10 hours to reach HFs due to 5,6,7,8 topography. 2. Jaluke Ward#04,05 Janajati HF is approx 5 KM far from nearest village. 3. Thada Ward #05 All groups HF is approx 3 KM far from nearest village 4. Maidan Ward #09 Dalit, Janajati HF is approx 8 KM far from nearest village. D. Migration pattern:

According to the program focal person, seasonal migration to is in increasing trend in Arghakhanchi. Most of the migrants are youth, and belongs to Chhetri, Kumal, and Magar caste/ethnicity groups. In-country migration to Kapailbastu, Rupendhai and other districts is also common. The Information Officer ) of the DDC reported that in last FY:  24 households (approximately 100) from Jukena VDC migrated to Terai region.  About 85 people from Thada VDC migrated to Terai region.  23 households (approximately 79 people) from Nuwakot VDC migrated to Terai region.  13 households (approximately 60 people) from Siddhara VDC migrated to Terai region.  14 households (approximately 43 people) from Jaluke VDC migrated to Terai region.

8.7. STRENGTH AND OPPORTUNITIES

There are two community radios (FM stations) in Arghakhanchi district which can be used for the airing of different health massages. Different organizations like HealthRight, UNFPA, and WCO have been working on BCC programs in this district which will be very much helpful to improve community awareness on health issues.

8.8. KEY ISSUES AND CHALLENGES A. Key Issues  Timely and appropriate recording and reporting of BCC activities;  Proper storage of BCC materials;  Addressing district-based issues in BCC activities and IEC materials.  Updating training records of COFP and CB-IMCI training.

B. Challenge  Reducing early marriage and pregnancy  Addressing the health needs of marginalized groups;  Integration of BCC activities with other components.  Inclusion of Out-of-school adolescents.

Efforts required overcoming the problem-

 BCC activities such as street drama, folk songs, day celebration that meets local social and cultural issues;  District specific BCC materials could be made and supplied by DHO itself;  Ensuring and mobilizing the participation of community, I/NGO, local bodies, social workers and individuals;  Strengthening monitoring and supervision activities;  Establishment health education corner in the HFs;  Use of audio/video aids at HFs level.

17 9. ADOLESCENTS AND YOUTH FRIENDLY SERVICES

H4L will also work with DHOs in selected district to improve service accessibility of Adolescents and youths under its Objective 6. The RA also explored different aspects of Adolescents and Youth friendly services in the public health facilities of Arghakhanchi district. Following are the major findings;

9.1. EXISTING SERVICES FOR ADOLESCENT

In Arghakhanchi, there is focused program for Adolescents such as Youth Information Centre, Service sites which are especially targeted for youth.

In Arghakhanchi, there is focused program for Adolescents in 13 sites (including district-based) established by DHO. Mostly WCO and NRCS is found providing support to the youth clubs. WCO is providing support to the adolescent girls of four VDCs through “KISHORI SAMUHA” in which RH related information is shared and life skill training is provided. Each ‘KISHORI SAMUHA’ comprises of 30 girls. WCO has also been providing services to the adolescents through three counseling/information centers at Bangla, Kimdhada, Pokharathok, Sandikahara. These centers provide FP counseling and referred services to clients.

Following are the NRCS and DHO supported Information Sites for Adoescent: 1. Sitapur VDC 8. Arghatosh VDC 2. Thada VDC 9. Chitrajung VDC 3. Siddhara VDC 10. Bagee VDC 4. Jalukae VDC 11. Hanspur VDC 5. Dewarna VDC 12. Dhanchour VDC 6. Balkot VDC 13. Sandikhara VDC 7. Chideka VDC

9.2. ORGANIZATION WORKING FOR ADOLESCENT

In Arghakhanchi, DHO, WCO, and NRCS are actively working for adolescent’s health. DHO has established 13 AFS centers in the district.

Women and Child Office (WCO)

WCO is providing support to the four AFS sites in the different VDC. WCO is providing support to the adolescent girls of four VDCs through ‘KISHORI SAMUHA’ in which RH related information is shared and life skill training is provided. FP counseling and referral service is also provided. Following are the VDCs having “KISHORI SAMUHA” Supported by WCO: 1. Balga 2. Sandikhara 3. Kimdhada 4. Pokharathok, Nepal Red Cross Society

NRCS is providing adolescent focused service through their information sites in 13 VDCs in collaborating with DHO. The focused intervention area of NRCS besides adolescent health is Community Based Development Program, Reproductive Health, Disasters Response, Health Education, First Aid training and awareness on HIV/AIDS. The program covers all 42 VDCs of the district. Adolescent’s health is too linked with other components such as life skills, employment generation and comprehensive sexual health education. After implementation of adolescent’s friendly service there have been significant changes in service utilization which includes increase of utilization of condom and treatment of STI. Teachers find that the awareness on sex education and its prevention has increased and attitude has changed among students.

Marie Stops Service International -

MSI has been providing clinical service to adolescents and youth in Arghakanchi with special focus on RH, FP and abortion but these services are broadly based on clinical services.

9.3. STRENGTH AND OPPORTUNITIES

DHO provides AFHS in 13 health facilities, WCO supports 4 sites through ‘KISHORI SAMUHA’ and some local NGOs also support in adolescents health. WCO have female adolescent groups to enhance life-skill trainings and give information on RH issues. NRCS has been working in adolescent’s health following comprehensive approach.

9.4. KEY ISSUES AND CHALLENGES

 Need of AFHS expansion to all VDCs but there are financial constraints;  Need of HR/space/materials for AFHS;  Collaboration with other organization working for adolescent friendly service;  Timely recording and reporting of data related with AFHS;  Inclusion of Out-of –School adolescents.

Efforts required overcoming the problem

 Coordinate with HFs as well as with concern stakeholders who are working in the adolescent issues for managing infrastructure and logistics ;  Strengthen HFOMC along with youth/adolescent mobilization;  Inform on socio-cultural issues through BCC;  Inclusive approach in BCC program with equal focus on out -of- school adolescents. 10. GENDER EQUALITY AND SOCIAL INCLUSION

H4L is designed to support the ’s stated commitment and responsibility to ensure that quality health services are accessible to all citizens. As such, it is critically important that sound, ongoing GESI-sensitive analysis and gender integration underpin H4L program interventions. H4L’s GESI Objectives are designed to redress gender and social inequities, and dove-tail with the objectives set forth in the MOHP’s 2009 Health Sector Gender Equality and Social Inclusion Strategy as follows:  Objective 1: Support existing MOHP policies, strategies, plans and programs that create a favorable environment for integrating GESI in Nepal’s health sector;  Objective 2: Support MOHP’s efforts to enhance the capacity of service providers and ensure equitable access and use of health services by the poor, vulnerable and marginalized castes and ethnic groups; and  Objective 3: Improve health-seeking behavior of the poor, vulnerable and marginalized castes and ethnic groups in collaboration with local government partners, community-based organizations (CBOs) and other stakeholders.

The first objective is related to policy while the latter two are directly related to DHO systems.

The RA also included assessment and analysis of the health programs of the DHO Arghakhanchi from GESI perspective. The major findings were as follows;

10.1. FORMATION AND FUNCTIONALITY OF GESI COMMITTEE

In DHO Arghakanchi, GESI committee was formed on February 22, 2013 in accordance with the GESI institutional guidelines and support from the Western Regional Health Directorate GESI focal person . The committee has 10 male and three female members (Public Health Nurse from DHO, representative from Police (women cell) and representative from WCO). EPI Officer is given the responsibility of GESI focal person. He has received orientation on GESI.

The GESI focal person reported that no meeting and activity related with GESI has been undertaken by the committee till date. It was mentioned that the committee was formed as per the guidelines but the members are not aware of its importance. GESI focal person mentioned that despite the non-functioning committee, a letter has been sent to all HFs to launch community health awareness program incorporating GESI concept in their catchment area. The letter basically requested HFs in- charge to ensure participation of marginalized/disadvantaged groups and women in every program activities.

Similarly, DHO Arghakanchi does not have reporting system that analyse data disaggregated by age, caste, ethnicity, wealth quintile and region. DAG mapping has not been done. The GESI focal person realizes that GESI integration in program activities is lacking in the district. One-stop Crisis Management Center (OCMC) has not been established in Arghakhanchi.

3 10.2. ORGANIZATIONS WORKING ON GESI

Women and Child Office

WCO was visited during RA. It was found that it mostly focus on mitigating Gender-Based Violence. Interaction with the staff at WCO revealed that GESI committee is formed at DHO but it is not functioning. WCO has worked on following modalities to mitigate Gender-Based Violence.

 Training: 3 days training for couples mainly related with Gender-based violence was conducted in 5 VDC. Each session was participated by 30 participants (15 couple).  Coordination: WCO strongly coordinate with DDC and DHO for implementation of activities.  Women Co-operatives: In 18 VDCs, Women Co-operatives are established that support credit program for women where pregnant women are given priority. It has also established Reproductive Health Fund in eight VDCs: Kimdhada, Sandikarha, Debharna, Walaga, Karunga, Chhetragunj, Jukena and Thada. It is emergency fund for pregnant wome to support during delivery where the needy do not have to pay the interest. Ministry of Women and Child Development provides Rs 25,000 yearly which is the base for emergency fund. Two VDCs has established emergency fund through self- initiation (Arag and Sitapur).  Committees: 5-7 members committee is formed at VDC level that work for implementation of activities of the WCDO.

District Development Committee

DDC has formed a GESI committee a year ago which has 25 members under the chairmanship of LDO. This committee is functional. It has conducted 3 days interaction program at DDC where 150 participants (3 sessions) were oriented on GESI. The participant were mainly VDC secretary, social mobilizers of VDC, DHO GESI focal person, WCO focal person, representative of Dalit and Janajati, leaders of political parties and DDC staff. In this FY, DDC is going to conduct GESI orientation in six VDCs.

The major problem/constraints of integrating GESI in D/PHO programs are as following:  Although GESI committee has been formed at DHO only few activities regarding GESI has been launched,  No work has been done for GESI integration,  No resource has been allocated for GESI program,  DAG mapping is not prepared due to lack of sufficient budget.

The efforts required to overcoming the problems

 DHO should initiate to integrate GESI in its programs;  Manage fund from DHO resources or coordinate with DDC for DAG mapping;  Orientation regarding GESI to all DHO staffs;  Co-ordinate with DDC for GESI activities.

************** Annex# 1: Contact information of DHO Staff, Arghakhanchi Years of Years of service Cell Phone D/PHO Team (current) Name service in district no. District /Public Health Officer 36 1 Public Health Officer 36 19 Public Health Nurse 20 03 Public Health Inspector( Transfer 18 16 from hospital), Statistician Officer & HFOMC Focal Person DTLA/Officer 18 10 EPI Supervisor/Officer & GESI 24 19 Focal Person Cold Chain Assistant/ Officer 16 15 Store Keeper 29 12 13 10 Child Health focal person 36 08 FCHV Focal person 24 07 (hospital) Lab Technician(DHO) 07 02 Public Health Officer 4m 4m (Temporary) Statistics Assistant/Officer Vacant - - - FP focal person Vacant - - - Malaria focal person Vacant - - - Health Education Tech/ Officer Vacant - - - Computer Operator/Officer Vacant - - -

Annex # 2: List of Organizations and Individuals visited/contacted during RA SN Name of Organization Individuals Visited Designation 1 District Public Health Officer 2 Public Health Officer 3 Public Health Nurse 4 Public Health Inspector, Statistician Officer & HFOMC Focal Person 5 DTLA/Officer 6 EPI Supervisor/Officer & GESI DHO, Arghakhanchi Focal Person 7 Cold Chain Assistant/ Officer 8 Store Keeper 9 Store Keeper 10 Child Health focal person 11 FCHV Focal person 12 Lab Technician(DHO) 13 Public Health Officer 14 DAO, Arghakhanchi CDO

5 15 LDO 16 DDC, Arghakhanchi Program officer Nayab subba 17 WDO WCO, Arghakhanchi 18 Supervisor 19 UNFPA, Arghakhanchi District Officer 20 NRCS, Arghakhanchi Program Officer 21 Marie Stops, Arghakhanchi Clinic In-charge 22 HealthRight Int’l, Program Officer Arghakhanchi Supervisor 23 Media Journalist

ANNEX # 3: List of RHCC members SN Name Post 1 Local Development Officer , District Development Committee 2 Chief District Officer, District Administration Officer 3 District Super tendent of Police, District Police office 4 Women Development officer 5 District Education Officer 6 Red Cross Society, Arghakhachi 7 Program officer, District Development Committee 8 Planning Officer DDC 9 Coordinator Marie Stops 10 District Health officer 11 District AIDS Coordination Committee Coordinator 12 Medical Officer, DHO 13 Representative Health Right International 14 Rresentative Sakriya Sewa Samaj 15 Representative Prerena Arghakhachi 16 Representative UNFPA 17 Representative Safe Motherhood Federation / NGO Federation 18 Public Health Officer 19 Public Health Officer 20 Public Health Nurse HEALTH FOR LIFE

REPORT ON RAPID ASSESSMENT

OF DISTRICT HEALTH SYSTEMS

2013 BANKE

i A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BANKE A REPORT ON

RAPID ASSESSMENT

OF DISTRICT HEALTH SYSTEMS

2013 B ANKE

MAY 2013

TEAM MEMBERS

ii TABLE OF CONTENTS

ABBREVIATIONS ...... iii

KEY FINDINGS FROM RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS...... iv

1. RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS ...... 1 1.1 Health for Life ...... 1 1.2 Rapid Assessment and its Objectives ...... 1 1.3 Methodology ...... 1 1.4 Organization of the Report ...... 2

2. INTRODUCTION OF ...... 3 2.1 Geo-Political Situation ...... 3 2.2 Demographic Information...... 3

3. DPHO STRUCTURE AND SYSTEMS ...... 4 3.1 Service Delivery Points ...... 4 3.2 Management Systems ...... 4 3.3 Health Workforce ...... 5 3.4 Monitoring and Supervision ...... 6 3.5 Information Technology ...... 6 3.6 Health Information Management ...... 6 3.7 Natural Disaster Response Mechanism ...... 6 3.8 Strength and Opportunities ...... 6 3.9 Key Issues and Challenges ...... 7 3.10 Possible ways to overcome the problems/issues ...... 7

4. SERVICE STATISTICS ...... 8 4.1 Immunization ...... 8 4.2 CB-IMCI ...... 8 4.3 Safe Motherhood ...... 9 4.4 Family Planning ...... 9

5. HEALTH FACILITY MANAGEMENT COMMITTEE AND LOCAL HEALTH GOVERNANCE ...... 11 5.1 Functioning HFOMC ...... 11 5.2 Capacity Building of HFOMC ...... 12 5.3 Community Groups/Federation/Alliance ...... 12 5.4 Strength and Opportunities ...... 12 5.5 Key Issues and Challenges (Based on discussion with D/PHO and DDC personals) ...... 12 5.6 Efforts are required to overcome the problems/constraints ...... 13

6. SERVICE DELIVERY/QUALITY IMPROVEMENT ...... 14 6.1 Service Delivery ...... 14 6.2 ANM Schools ...... 15 6.3 Infection Prevention and Waste Management Practices at HFs ...... 15

i A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BANKE 6.4 Strength and Opportunities ...... 15 6.5 Key Issues and Challenges ...... 15 6.6 The possible ways to overcome the problems/issues ...... 16

7. LOGISTICS MANAGEMENT SYSTEM ...... 17 7.1 Availability of Key Drugs and Commodities ...... 17 7.2 Cold Chain and FEFO Management ...... 17 7.3 LMIS reporting ...... 18 7.4 Strength and Opportunities ...... 18 7.5 Key Issues and Challenges ...... 18 7.6 Possible ways to overcome the problems/Issues ...... 18

8. BEHAVIOR CHANGE COMMUNICATION ...... 19 8.1 Existing D/DPHO PROGRAMS on BCC ...... 19 8.2 FM Stations/Cable Television Networks ...... 19 8.3 Organizations working in IEC/BCC activities ...... 20 8.4 COUNSELING SERVICE ...... 20 8.5 School Health Program ...... 20 8.6 Mapping of DAG and Exploring Cultural PRACTICES AFFECTING Health ...... 21 8.7 Strength and Opportunities ...... 21 8.8 Key Issues and Challenges ...... 22 8.9 Possible ways to overcome the issues and challenges ...... 22

9.ADOLESCENTS AND YOUTH FRIENDLY SERVICES ...... 23 9.1 Existing Services for Adolescent...... 23 9.2 Organization working for Adolescent ...... 24 9.3 Strength and Opportunities ...... 25 9.4 Key Issues and Challenges ...... 25 9.5 Possible ways to overcome the issues and challenges ...... 25

10.GENDER EQUALITY AND SOCIAL INCLUSION ...... 26 10.1 Formation and Functionality of GESI Committee ...... 26 10.2 Organizations working on GESI ...... 27 10. 3 OPPORTUNITIES ...... 27 10. 4 Major problem/constraints: ...... 27 10.5 Possible ways to overcome the problems: ...... 27

ANNEX 1 ...... 28 ANNEX 2 ...... 29 ANNEX 3 ...... 30

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BANKE ii ABBREVIATIONS

AHW Auxiliary Health Worker AIDS Acquired Immunodeficiency Syndrome ANC Antenatal Care ANM Auxiliary Nurse Mid-wife AYFS Adolescent youth friendly service BC Birthing centre BCC Behavior Change Communication BEONC Basic Emergency Obstetric and Newborn Care BNMT Britain Nepal Medical Trust CAC Compressive Abortion Care CB-IMCI Community-Based Integrated Management of Childhood Illness CB-NCP Community-Based Newborn Care Package CEONC Comprehensive Emergency Obstetric and Neonatal Care CH Child Health CPR Contraceptive Prevalence Rate DAG Disadvantaged Group DDC District Development Committee DPHO District Public Health Office DOHS Department of Health Service FCHV Female Community Health Volunteer FEFO First expiry first out FM Frequency Modulation FMC Facility Management Committee FP Family Planning FY Fiscal Year GBV Gender Based Violence GESI Gender Equality and Social Inclusion HA Health Assistant H4L Health for Life HF Health Facility HP Health Post HFOMC Health Facility Operation and Management Committee HIV Human Immunodeficiency Virus HMIS Health Management Information System ICTC Institutionalized Clinic and Training Center IUCD Intra Uterine Contraceptive Device I/NGO International/Non-Governmental Organization IT Information Technology IUCD Intra Uterine Contraceptive Device LDO Local Development Officer LMIS Logistics Management Information System LTAP Local technical Assistant Partner M/DAG Marginalized/Disadvantaged group MO Medical Officer MOHP Ministry of Health and Population MNCHN Maternal Neonatal Child Health and Nutrition MgSO4 Magnesium Sulphate

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BANKE iii MSC Matri Surakshya Chakki M&S Monitoring and Supervision MWDR Mid-western Development Region N Number NFHP II Nepal Family Health Program II NGO Non-Governmental Organization NPC National Planning Commission NRCS Nepal Red Cross Society PAC Post Abortion Care PHCC Primary Health Care Center PHC/ORC Primary Health Care / Out-Reach Clinic PHN Public Health Nurse PNC Postnatal Care PSA Public Service Announcement QI Quality Improvement QAWG Quality Assurance Working Group RA Rapid assessment RH Reproductive Health RHCC Reproductive Health Coordination Committee RHD Regional Health Directorate SAC Social Awareness Centre SBA Skilled Birth Attendance SHP Sub Health Post SN Staff Nurse USAID Unites States Agency for International Development VDC Village Development Committee WCO Women and Children Office WDR Western Development Region

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BANKE iv KEY FINDINGS FROM RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS TOTAL POPULATION 491,313 NUMBER OF VDCS 46 MUNICIPALITY 01 (Nepalgunj) DPHO STRUCTURE AND Public Health facilities: SYSTEMS  Zonal Hospital-1, PHCCs-3, HPs -13 and SHPs-31, Regional police

hospital-1 and Army hospital-1 Private Health facilities:  Private hospitals and nursing homes-6, Medical college-1, Dental hospitals-2 Meetings:  Monthly meeting of Ilaka In-charge at District- 7th of every month  QAWG- No meeting held in the last one year  RHCC- Meets quarterly Health Workforce:  All technical positions at DPHO filled in except PHN and FP focal person  Unfilled positions at HFs – MO, SN, ANM, AHW and Lab-Assistant. Twenty seven ANMs and few Vaccinators and SN hired on contract basis. Few health workers hired from NPC Monitoring and Supervision:  M&S system and plan exists at district level only. Integrated supervision tools are in use. IT infrastructure at D/PHO:  Desktops-14, Laptops-4, Printers-10  Well established internet facility.  Two HFs has computers.  Supervisors skilled in using MS Word and Excel-5.  Health Facility level entry in HMIS software.  Social Inclusion reporting system pilot district. Data are being reported but not analyzed at district Rapid Response Team: Functioning well at the district and HF level SERVICE STATISTICS  BCG and Measles coverage is in increasing trend. In the year FY 2068/69 measles coverage was 90 percent.  Severe pneumonia and diarrhoeal cases shows fluctuating trend. More children are being treated with antibiotics  Drop out from ANC first to ANC fourth visits is high and in the FY 2068/69 it was 95 percent and 45 percent respectively.  SBA deliveries are in increasing trend (20 percent in FY 2065/66 to 86 percent in FY 2068/69)  Contraceptive Prevalence Rate in FY 2068/69 was 47 percent HEALTH FACILITY  All HFs handed over to local bodies. MANAGEMENT COMMITTEE  All HFOMCs received capacity building trainings and refreshers training AND LOCAL HEALTH with the support of NFHP II but at present most of the HFOMC are non- GOVERNANCE functional..  At community level groups such as -Forestry Users Group, Mothers’ Group, Drinking Water Users Group, Irrigation Users Group, Road Rural Users Group, Cooperatives, Media and Pregnant Mother group are functioning.

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BANKE v SERVICE  Regular CEONC services has been providing through 04 Hospitals and DELIVERY/QUALITY BEONC services providing through 02 PHCs. IMPROVEMENT  Community-based service delivery-MSC piloted in Banke in 2005, CB-NCP implemented in 2008  Satellite FP clinics-3  IUCD services- 14 health facilities and Implant service- 08 HFs.  Birthing centers-27  Birthing sites having Placenta pits-17 LOGISTICS MANAGEMENT  All the tracer drugs and commodities were available on the day of visit. SYSTEM  Drugs have most problems of stock-outs in F/Y 2069/70 - Tab Ibuprofen, Metronidazole and Hyosine Bromide.  Drugs with most problems of over stock in the last year- MgSO4 and Syrup Metronidazole  Functioning refrigerators-7, sufficient for maintaining cold chain, and have regular power back up system for the cold chain room.  First Expiry First out (FEFO)- maintained well  Using Web-based LMIS reporting system. Data entry person recruited. BEHAVIOR CHANGE  FM stations-9 COMMUNICATION  Several I/NGOs engaged in BCC activities  DPHO had used mobile phone to send text messages to people to inform about Polio Program the FY 2069/70  In the FY 2068/069, total 140 session of school health program on HIV/AIDS, RH, GBV, early marriage etc were organized in 140 schools (3,451 students benefited). In current FY 2069/70, no any activities were planed and conducted for school health program.

 Villages that were highly populated by DAG- Samsherganj, , Baijapur, Titihiriya, , Holiya, Gangapur, , Laxmanpur, Udharapur, , Bankatti

 Ethnic/Caste group deprived from service utilization- , Muslims, Yadav, Kurmi of Rapti-Pari VDcs like Matehiya, Narainapur, Kalaphata, Katkuiya, and Laxmanpur were the deprived castes group.

 Villages that still practice early marriage and Early Child Bearing- Matehiya, Narainapur, Kalaphata, Katkuiya, Laxmanpur

 High Migrants VDCs- , Rajhena, Naubasta, Chisapani, Bankatuwa, Bageshwari, Sitapur, Radhapur ADOLESCENTS AND YOUTH  AYFS- 13 sites supported by GIZ and 4 by FPAN FRIENDLY SERVICES  DPHO conducted Peer Review training to 10 schools in last FY 2068/69.  WCO have female adolescent youth clubs to enhance life-skill trainings and give information on RH issues. GENDER EQUALITY AND  15 membered GESI committee formed but not active. The committee SOCIAL INCLUSION received partial orientation from the GESI focal person.  GESI focal person assigned to a district supervisor.  DDC, WCO and GIZ have GESI related activities in Banke.  At DDC, GESI committee under the chairmanship of LDO was also formed in 2068/02/19.

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BANKE vi 1. RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS

1.1 Health for Life

Health for Life (H4L) is a five-year bilateral agreement between the Ministry of Health and Population (MoHP) and the Unites States Agency for International Development (USAID) which focus on Systems Strengthening and improving the Maternal Neonatal Child Health and Nutrition/Family Planning (MNCHN/FP) service delivery at district and sub-district levels in 14 districts. 12 of the 14 districts are in the Mid-western Development Region (MWDR) –Banke, Bardiya, Dang, Surkhet, Salyan, Pyuthan, Dailekh, Kalikot, Jumla, Rukum, Jajarkot and Rolpa and two are in the Western development Region (WDR) of Nepal- Arghakhanchi and Kapilvastu. The project will be implemented between 2012 and 2017.

1.2 Rapid Assessment and its Objectives

Rapid assessment (RA) is a method of analyzing situation of a district where issues are not well defined and where there is not sufficient time or other resources for in-depth quantitative research. RA uses intensive team interaction in both the collection and analysis of data instead of prolonged fieldwork and iterative data analysis and additional data collection to quickly develop a preliminary understanding of a situation from the insider’s perspective. The main purpose of carrying out the Rapid Assessment was to understand the current situation of the health service delivery system of the Banke district to help in planning activities at district level.

Specifically, the objectives of the RA included the following:  Understanding the demographic profile of the district  Understanding the existing health care delivery system of the district  Knowing the functionality of the Health Facility Operation and Management Committees  Understanding the status of health indicators  Analyzing the strengths and weakness of the D/PHO systems  Identification of potential Local Technical Assistance Partners (LTAPs)  Exploring feasibility for the implementation of specific programs for adolescents and youth  Exploring feasibility of using Information Technology in information management

1.3 Methodology

A mix of both qualitative and quantitative methods was used to execute Rapid Assessment in Banke district. These include visit to DPHO, District Development Committee (DDC), WCO, and NGOs, interaction with key informants, record reviews and observations. A structured tool was developed to collect necessary information, which was supplemented by qualitative tools to interview key informants at different agencies working on different areas of health service delivery and management, Gender Equality and Social Inclusion (GESI), Behavior Change Communication (BCC), Information Technology (IT) in Health and Governance.

1 A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BANKE A team composed of 13 H4L staff was formed for carrying out RA in Banke where there was a good skill mix among the members to cover different areas of the RA Involvement of Central, Regional and District office staff was ensured.

Before carrying out of the RA in Banke, one and a half day orientation on RA objective, methods and tools were organized for H4L staff together with orientation on H4L project in Hotel Siddhartha, Nepalgunj on 23 and 24 day of April. Director and three senior officials from the Mid-western Regional Health Directorate, Surkhet and the Senior Public Health Administrator of Banke DPHO also participated in the RA orientation. They provided inputs in further refining the RA tools. RA in Banke was completed by H4L Staff in six days beginning April 25 to April 30, 2013. Small groups were formed within the team where the members divided their responsibilities, visited DPHO and other stakeholders for establishing relationships, interactions and information collection. At the end of each day all the members gathered for about an hour and shared their experiences. Information collected by the team members was verified on the same day and brief notes were developed for each thematic area. Report was prepared using the template provided by the H4L central office. A brief PowerPoint presentation was also prepared covering the key findings of the RA which was shared with DPHO, DDC on April 30, 2013.

Banke was one of the two-practice sites for RA of the district health systems. Hence, the RA process followed in Banke gave H4L many tips in further strengthening the RA process and the tool.

The interaction processes and the information collection during the RA were confined to district- based offices. The RA team did not make field trips to below district level institutions for information collect because of most information including the sub-district level that the RA required were availability at the district offices. Visiting peripheral health facilities and interaction with HFOMCs and FCHVs would have enriched the RA but this was not done. This can be considered as the major limitation of the RA.

1.4 Organization of the Report

The findings of the RA are presented in nine Chapters. Chapter one presents the purpose of carrying out RA and the methodology followed. Chapter two presents the introduction of Banke district. Chapter three explains the DPHO systems and structures. Fourth and the Fifth chapter present the service statistics and the status of the HFOMCs in Banke district. Sixth and the Seventh chapter present the findings on service delivery/quality of care and logistics management system. Chapter Eight, Nine and Ten report the findings on BCC, AYFS and GESI in Banke district.

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BANKE 2 2. INTRODUCTION OF BANKE DISTRICT

2.1 Geo-Political Situation Banke District is situated in , and in the Mid-Western Development Region of Nepal. Nepalgunj is the district headquarters. Banke covers an area of 2,337 square km. Banke is bordered on the west by on the north and east by Salyan and Dang districts and on the south by of India. Nepalgunj is the district headquarters of Banke district. There are 46 Village Development Committees (VDCs) and one municipality (Neplagunj) in Banke district.

KOHALPUR RAJHENA 36019 26158

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Table 2.1: Population of the District 2.2 Demographic Information Number Percent Table 2.1 presents the Census 2011 data on Total Population 491,313 - total population of Banke district. The total Male 244,255 49.72 population of Banke district is 491,313 where Female 247,058 50.28 the proportion of female is slightly greater than Household number 94,773 - male. The Census also reports 94,773 Source: Census 2011 households in Banke district. Dalit 41746 10.8 Relatively Advantaged 8449 2.1 Janajati The Census 2011 data by caste/ethnicity is not Bramhin/Chhetri 100092 25.9 available yet hence, the RA used caste /ethnicity Disadvantaged Janajati 89627 23.2 data from 2001 Census. The result shows that Other Terai Caste 58926 15.2 Group about one-third of the population of Banke Muslim 81645 21.1 belongs to disadvantaged caste groups (10 Others 5355 1.3 percent are dalits and 23 percent are Source: Census2001 disadvantaged janajatis). It also shows that there is 21.1 % muslim, 15.2% other terai caste group and 25.9 % Bramhin/Chhetri in Banke.

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BANKE 3 3. DPHO STRUCTURE AND SYSTEMS

This chapter presents the findings related to the D/PHO structure and systems collected from the RA. The findings covers following areas: service delivery points, management system, health workforce, monitoring and evaluation system, IT and health information management and disaster management system.

3.1 Service Delivery Points Table 3.1: Number of service delivery points in the District The District Public Health Office, Type of service delivery points Number located in Nepalgunj is the main Government Hospital 1 responsible institution of the MOHP at PHCC 3 Banke to provide preventive, promotive Health Post 13 and curative health services to the Sub-health Post 31 people of Banke. There are a total of 47 Private hospital/Nursing Home 06 peripheral public health facilities (3 Birthing centers 27 PHCCs, 13 HPs and 31 SHPs) and a Functioning birthing centers 27 Zonal Hospital (Bheri Zonal Hospital) SBA Sites 1 in Banke district. There are 27 birthing PHC Out-Reach Clinic 145 centers and all of them were Immunization Clinic 303 FCHVs (VDCs) 704 functioning during the time of RA. FCHVs (Municipality) 85 There are 145 PHC-ORCs and 303 NGO clinics (SBA/BEOC/FP) 07 Immunization Clinics. There are 704 Medical College 01 Female Community Health Volunteers Source: D/PHO Banke, 2013 (FCHVs) in all VDCs and 85 FCHVs in municipality of the district. There are six private hospitals and nursing homes in Banke. In addition, there is one medical college, one regional police hospital, one army hospital and two private dental hospitals in the district.

Table 3.2: Current Status of Program Management Team 3.2 Management Systems DPHO Team Status 1. Sr. Public Health Administrator Filled 3.2.1 Program Management Team 2. Public Health Officer Filled 3. Public Health Nurse vacant 4. Statistics Assistant/Officer Filled Table 3.2 presents the sanctioned 5. FP focal person (FPS) Filled positions at DPHO. There are a total of 6. Malaria focal person Filled 16 technical staff and managers 7. Health Education Tech/ Officer Filled sanctioned at DPHO, Banke, out of that 8. DTLA/Officer Filled the positions of Public Health Nurse is 9. EPI Supervisor/Officer Filled vacant and the remaining positions 10. Cold Chain Assistant/ Officer Filled 11. Computer Operator/Officer Filled were filled-in during the time of RA. At 12. Store Keeper Filled present, DPHO has assigned a staff 13. Child Health focal person Filled nurse of PHCC Bankatuwa to perform 14. Public health inspector Filled the work related to PHN in the district. 15. Lab technician Filled 16. Lab assistant Filled 17. Account officer Filled 18. Admin officer Filled

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BANKE 4 3.2.2 Meetings

D/PHO Banke holds different types of meeting every month, which includes monthly meetings of the Health Facility In-charge at DPHO, Reproductive Health Coordination Committee (RHCC) and the Quality Assurance Working Group meeting. The monthly meeting of the ilaka in charge is organized on 7th of every month at DPHO. RHCC meeting is organizing on quarterly basis (The list of RHCC members is provided in Annex). QAWG has been formed at DPHO Banke, but its meetings have not been organized for a year.

In the same way, there is system of FCHVs monthly meeting in all HFs which is very good forum to disseminate the health massage up to the community level and also for the onsite coaching to the FCHVs on technical issues at one place. Ilaka level staff meeting has been interrupted since last few months due to the budgetary problem and it is essential to continue the meeting because it is very much effective to discuss on monthly HMIS and providing feedback and helpful to discuss about the issues related to quality of health services at one place. In DPHO, GESI technical group also has been formed and conducting meeting regularly and organizing program activities focusing to M/DAG in hard to reach VDCs. DACC meeting is also organizing regularly in the district to solve the HIV/AIDS related problem/issues.

3.3 Health Workforce Table 3.3 presents the status of health workforce in Banke district. Out of the 3 PHCCs, only one has fulfilled the post of Medical Officer (MO) and two has fulfilled the post of Staff Nurse (SN) during the time of RA. The sanctioned positions of (Sr.) ANMs were almost completely filled-in at the time of RA. Thirteen positions of the AHWs who have been promoted from VHWs are vacant. DPHO, Banke has contracted and posted 27 ANMs, two AHWs and one SN to different HFs. It was also reported that some peripheral level health workers have been recruited by National Planning Commission (NPC) and VDCs. However, the number of the health workers recruited by these agencies might have been over or under reported in this RA as health facilities were not visited to verify the information collected at district level.

Table 3.3: Current status of health workforce Type of human resources Number GoN Number supported from Sanctioned Filled- Temp Cont VDC NPC Other in orary ract a. Medical Officer 3 01 0 0 0 0 0 b. Staff Nurse 3 02 0 1* 0 0 0 c. Sr. ANM 18 18 0 0 0 0 0 d. ANM 3 2 0 27** 1 1 0 e. HA/Sr. AHW 17 17 0 0 0 1 0 f. AHW 57 55 0 2* 0 3 0 g. AHW (Previous MCHWs) 47 34 0 0 0 0 0 h. ANM (Previous VHWs) 35 35 0 0 0 0 0 i. Lab Assistant 06 05 0 0 0 0 0 j. Adm. Assistant 05 05 0 0 0 0 0 k. Store Keeper 01 01 0 0 0 0 0 l. Office assistant 54 45 0 0 0 0 0 m. Vaccinator NA 00 0 08** 0 0 0 Source: DPHO, Banke Source: Admin section of DPHO, Banke * From RHD, **From DPHO

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BANKE 5 3.4 Monitoring and Supervision

There is monitoring and supervision system at DPHO Banke. DPHO supervisors’ makes supervision to the peripheral health facilities on monthly basis as per the monitoring and supervision plan developed for each fiscal year. However, there is no such monitoring and supervision plan developed for ilaka level health facilities to monitor SHPs. District supervisors uses the integrated supervision tools during their supervisions. Furthermore, the clinical staff also carries out clinical supervision.

3.5 Information Technology

The RA also explored the existing Information Technology (IT) infrastructure at D/PHO. At present, the D/PHO has 14 desktops, 04 laptops as well as 10 printers with well-established internet facility. Two of the HFs also has computers. Among the district supervisors, 05 of them are skilled on using MS word and Excel.

3.6 Health Information Management

DPHO Banke has a system to enter Health Facility level data in HMIS software. For improving data quality, DPHO has been organizing Data Validation program every year but it has not conducted in this fiscal year because of budgetary problem. Banke is one of the 10 districts where Social Inclusion reporting was piloted in 2009. Since, HFs has been reporting data to districts and the district has been entering data from the HF social inclusion reports into the database (developed in MS Access) and sending it to HMIS section However, it is found that the D/PHO has not been analyzing Social Inclusion data.

3.7 Natural Disaster Response Mechanism

DPHO Banke has a well-functioning Rapid Response Team (RRT) formed at the district and HF level. Along with the DPHO various organizations like District Administration Office (DAO), DDC, care Nepal, Plan Nepal, RRN, GIZ, BNMT; NRCS etc are working with close collaboration to respond to disaster when needed.

3.8 Strength and Opportunities

The major strengths of the DPHO are as following:

 Most of the sanctioned posts are fulfilled  Functioning integrated supervision system with plan in the district  System of written feedback to the HFs after supervision  Having very good IT infrastructure at DPHO  Existence of Web- based HMIS reporting system at DPHO

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BANKE 6 The key opportunities are as following:

 Existing committees (QAWG, RHCC, GESI-TG, DACC) in the district and HFOMC at facility level  Existence of different partner organizations in the district

3.9 Key Issues and Challenges

The major challenges and constraints faced by the D/PHO Banke are as following  No regular QAWG and Ilaka level staff meeting.  Problem to retain staff at HFs, especially in the VDCs separated by Rapti river i.e. Laxmanpur, Katakuiya, Narainapur, Kalaphata and Mataihiya VDCs  Health workers are not regularly providing services in hard to reach VDCs (HFs).  Social Inclusion data is not analyzing and using in the district.

3.10 Possible ways to overcome the problems/issues  To ensure regular meeting by fixing the date  Make a focal person with full authority to arrange, coordinate for the regular meeting.  Encourage capable person to do relevant work.  Could minimize the problem related to staff retention by encouraging them and providing some extra incentive (if possible), prioritizing during training/workshop, managing staff quarter etc  Capacity building of SA for the analyzing and use of social inclusion data in the district

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BANKE 7 4. SERVICE STATISTICS

The RA also sought information on the service statistics of the following programs: Immunization, Child health, Safe Motherhood and Family Planning. HMIS data for the last five years were collected from DPHO and analyzed. The five year trend analysis of the selected indicators is presented in this section. Data for the years 2065/66 to 2068/69 is for one complete year and that for the year 2069/70 is for eight months (Shrawan-Falgun 2069/70).

4.1 Immunization The coverage of BCG, DPT3, measles and TT were analyzed for the last five years (see Table 4.1). Data for the current FY is not complete. Analysis of the immunization data of the first four FYs revealed that the coverage of all vaccines is in increasing trend. The eight months data of the current FY showed that the overages of BCG, DPT3, measles among under one year children and TT2+ among pregnant women are 72 percent, 59 percent, 55 percent and 47 percent respectively. With these current achievements, it is likely that the coverage of measles and TT2+ may decrease in this FY. The graph shows that the coverage of Measles Vaccine in Banke district is in increasing trend. It also shows that the coverage of measles vaccine is higher than National average in F/Y 2068/69, which was lower in F/Y 2066/67 and 2067/68.

4.2 CB-IMCI The proportion of new pneumonia cases treated with antibiotics is in increasing trend. In the same way, proportion of new diarrheal cases treated with ORS + Zinc are also in increasing trend in Banke district which shows the successes of the community based interventions.

The above graphs show that the % of Severe pneumonia case among new ARI cases is slightly higher than the national average whenever the % of severe dehydration cases among new diarrhea cases is slightly lower than the national average. However, there is the increasing trend of severe

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BANKE 8 pneumonia among new ARI cases and severe dehydration among new diarrheal cases within the district in comparison of previous FYs, which indicates the possible gaps of those interventions.

4.3 Safe Motherhood Data on safe motherhood displayed in the Table shows that ANC first visit as percent of expected pregnancy, delivery conducted by SBA (Home and Institution) and PNC first visit as percent of expected live births are all in increasing trend. Dropouts from ANC first to the fourth visit are high in every FY. (See the adjoining bar diagram). ANC four visit is very low in comparison to the ANC first visit in each FY.

4.4 Family Planning The graph shows that the CPR (all modern methods) as percentage of MWRA of Banke district is slightly higher than the national average even it is fluctuating over the time. There are various organizations, I/NGOs providing support to the public sector in providing FP services. Regular reporting of the services provided from the private sector is essential in analyzing the actual CPR of Banke district.

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BANKE 9 Table 4.1: Trend in utilization of services SN Indicators 2065/66 2066/67 2067/68 2068/69 2069/70* 1 BCG coverage 81.3 107.0 113.9 119.5 72.3

2 DPT 3 83.2 82.1 95.3 97.4 59.2

3 Measles vaccination coverage 78.7 84.3 84.2 89.5 54.5

4 TT 2 & TT2+ coverage among pregnant 67.2 76.6 79.3 79.6 47.3 women 5 Proportion of new pneumonia cases 31.5 29.5 42.1 47.7 46.6 treated with antibiotics 6 Percentage of severe pneumonia among 0.9 0.2 0.2 0.4 1.0 new cases 7 Proportion of new diarrheal cases treated 96.6 97. 98.2 99.0 99.0 with ORS + Zinc (under 5 years children) 8 Percentage of severe dehydration among 0.3 0.2 0.1 0.2 0.5 new cases 9 ANC 1st visit as percent of expected 73.8 99.9 93.4 93.5 55.0 pregnancies 10 Four ANC visits among as percent of 38.9 43.6 43.2 44.6 32.0 expected pregnancies 11 Percent of pregnant mothers receiving iron 68.2 94.1 92.8 87.7 49.0 tablets 12 Delivery conducted by SBAs (both home 21.94 69.47 79.05 95.36 31.85 and institutions) as percent of expected live birth pregnancies 13 PNC First visit as percent of live birth 39.23 90.58 93.04 99.70 31.58

14 Percent of postpartum mothers receiving 39.9 75.7 89.3 64.3 39.0 Vitamin A within 6 weeks 15 Contraceptive prevalence rate (all 41.4 53.5 43.9 47.0 41.5 methods) as percentage of MWRA

*Shrawan-Falgun 2069

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BANKE 10 5. HEALTH FACILITY MANAGEMENT COMMITTEE AND LOCAL HEALTH GOVERNANCE

Information on Health Facility Operation and Management Committee (HFOMC) was sought from both DPHO and DDC. Both quantitative and qualitative methods were used for collecting information. Information was collected on the following topics: HFOMC functionality, capacity building, presence of different community-based groups at VDC level and their federations at district level. This chapter presents the major findings of the assessment on HFOMC.

5.1 Functioning HFOMC

In Banke, all the HFs (PHCCs, HPs and SHPs) has handed over to the local committees in F/Y 2062/63. DPHO chief and the program supervisors were asked to give their opinions about the criteria for measuring the functionality of HFOMCs. According to them, the criteria for measuring HFOMCs functioning are: The top five functional HFOMCs: 1. Radhapur, 2. Naubasta, 1. Regularity of HFOMC meeting (as per the guideline) 3. Chisapani, 2. Participation of HFOMC members in the meeting - at least 4. Baijapur and 51% or more 5. . 3. Preparing meeting minutes with plan of action The bottom five HFOMCs 4. Implementation of plan of action prepared or decision 1. Piprahawa, made during meeting. 2. Laxmanpur, 5. Support provided by HFOMC to the HFs (National 3. Matahiya, 4. Holiya and Campaigns, HR management, infrastructure etc.) 5. Udharapur

D/PHO supervisors including HFOMC focal person expressed that it is not possible to do rating for the functional HFOMC of all HFs (VDC wise) at present situation because they do not have adequate information at DPHO for the rating of functionality of HFOMC. They also expressed that a standard format may need to be designed to collect the information and need to visit all HFs. Based on their observation and field experiences, they can only estimate the ratio of functional HFOMCs in the district.

On the basis of random sampling in the interval of 05 HFs and telephone interview with the HF incharges, 03 out of 09 (33%) of HFOMC found functional in term of regularity of Meeting, support providing to the HFs, preparing meeting minute and implementing at local level.

The top five functional HFOMCs as judged by the district supervisors include - Radhapur, Naubasta, Chisapani, Baijapur and Manikapur. DPHO observed that most of the HFOMC of the southern belt of the district are non-functional. The bottom five HFOMCs in terms functionality are Piprahawa, Laxmanpur, Matahiya, Holiya and Udharapur (EPISO) is responsible for the HFOMC program in the district.

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BANKE 11 5.2 Capacity Building of HFOMC The HFOMCs of Banke district has received capacity building training in the F/Y 2062/63. The training was provided by DPHO with the support of NFHP II. In addition, NFHP II has also provided refresher trainings to all HFOMCs of Banke district and visited by project staff to monitor the HFOMC activities and building their capacity.

5.3 Community Groups/Federation/Alliance According to the district supervisors’ different type of community groups exists at VDC level of Banke district. These groups include-Forestry Users Group, Pregnant Mothers’ Group, Drinking Water Users Group, Irrigation Users Group, Road Rural Users Group, Cooperatives and Media. Pregnant Mother’s groups has been formed in all 09 wards of 12 VDCs of Banke district by a local NGO named Geruwa with the support of PLAN Nepal. The VDCs are Piprahwa, Karkando, Indrapur, , Bankatti, Kamdi, Betahani, , Parashpur, Udharapur, and Jaishpur. The members of pregnant mothers group meet monthly for sharing information and experiences. Health education sessions on safe motherhood also have been organizing for the husbands and mother in laws of pregnant mothers at local level so that the pregnant mothers can have more support from their family members. As per the DDC Banke, there are existence of the federation/alliances of Forestry Users Group, Irrigation Users Group, Cooperatives as well as Press and Media at district level.

5.4 Strength and Opportunities HFOMC has formed in all VDCs and all the HFs have handed over to the local committees in F/Y 2062/63. All the HFOMC members have received capacity building training including refresher training with the support of NFHP II. No any HFOMC have reformed completely after formation except minor changes in some of the HFOMC. Different type of community groups exists at VDC level of Banke, which can contribute some efforts for the strengthening of HFOMC and health delivery system at local level. These groups include- Forestry Users Group, Pregnant Mothers’ Group, Drinking Water Users Group, Irrigation Users Group, Road Rural Users Group, Cooperatives and Media.

5.5 Key Issues and Challenges (Based on discussion with D/PHO and DDC personals)  Irregular meeting of HFOMC in most of the VDCs: VDC secretary (Chair person of HFOMC) usually don’t give much time for HFOMC meeting due to high workload, involvement in so many other programs and centralized working practice (District based) because of security problem especially in the southern part of the district. Other HFOMC members thought that in absence of VDC secretaries, the meeting would not be effective since they cannot take any decisions related to finance. Due to less responsibility feeling of HFOMC members towards the HFs, they do not take the HFOMC meeting as priority. They thought that the management of Health facility is the responsibility of Government of Nepal. Since they do not have any incentive for the meeting they do not have much interest to attend the HFOMC meeting regularly (monthly basis). Therefore, they do not come for the meeting and meeting becomes irregular. According to the focal person, the situation can be improved by sensitizing of HFOMC members on their roles and responsibilities through on site coaching.

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BANKE 12  Lack of community ownership towards the HFs: The community people especially from the madheshi community thought that what they will get after meeting and why should they expend their time for the meeting. They usually thought that the management of Health facility is the responsibility of Government of Nepal. They also thought that there is no any financial benefit and do not have any authority to mobilize financial resources. Therefore, they do not come for the meeting in regular basis and not want to take much responsibility towards the HF. So, DHO supervisor expressed that it is necessary to teach them about their roles and responsibility along with the values of HFOMC for the strengthening of health services at local level.

 No meaningful participation of HFOMC members during meeting: As per the HFOMC guideline, at least 51% of members should participate to make the meeting effective. For productive meeting, it is necessary to participate maximum number of HFOMC member in the meeting but it is not in practice in most of the VDCs. Even they participate; they usually don’t come at the same time and don’t take part in the discussion actively. The reasons behind are lack of responsibility feeling toward HFs, irregularity of VDC secretary in the meeting and less involvement in financial management etc. As per the focal person, by encouraging the HFOMC members for active participation in the meeting can improve the situation and also help to minimize the problems/issued related to health services at local level.

 Less monitoring from DPHO/DDC: The non-functionality of HFOMC is also due to the less monitoring form DPHO/DDC. As per the HFOMC focal person, it can be improved if regular monitoring of HFOMC meeting can be done from DPHO/DDC.

5.6 Efforts are required to overcome the problems/constraints  Regular follow up of meeting and action plan from DDC, DPHO  Joint monitoring visit from DCC, D/PHO and other stakeholders  Sensitization of HFOMC on their roles and responsibilities  Encouraging them for regular meeting  Capacity building with HFOMC members through technical assistance and onsite coaching during HFOMC meeting  Better coordination with VDC and other local stakeholders

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BANKE 13 6. SERVICE DELIVERY/QUALITY IMPROVEMENT

This chapter presents the RA findings related to service delivery and quality of health care. Information on the quality of ANM schools, infection prevention practices at HFs, implementation of community-based interventions, and the provision of IUCD and Implants services were collected at district level. The major finding of the assessment is presented hereunder.

6.1 Service Delivery

The RA sought information on the availability of FP Satellite clinics, Comprehensive Emergency Obstetric and Neonatal Care (CEONC), Basic Emergency Obstetric and Neonatal care (BEONC), long acting FP methods, and implementation of community-based interventions such as Community- based Newborn Care Package (CB-NCP), and Matri Surakshya Chakki (MSC).

In Banke three HFs have satellite clinics. CEONC service is providing on regular basis from 04 Hospitals (Government-01, Private-03) and all are located in city area of the district. In the same way, BEONC service is also providing from two peripheral HFs (PHCCs) of the district in regular basis. In Banke, Community-based MSC was implemented by D/PHO in support of NFHP since 2005. Banke is the pilot district for community-based MSC program which is now scaled up in many other districts. CB-NCP has also been implemented in Banke with the Support of Plan Nepal. With regards to providing long acting reversible FP methods, it was reported that IUCD service is being provided from 14 health facilities and Implants from 08 HFs of Banke district (Table 6.1).

Table 6.1: IUCD and Implants Insertion and Removal Sites of Banke IUCD Insertion/removal sites Birthing Center? Implants Insertion/removal sites Birthing Center? Yes/No Yes/No 1. ICTC center Nepalgunj No 1. ICTC center Nepalgunj No 2. Bankatwa PHC Yes 2. Bankatwa PHC Yes 3. Khajura PHC Yes 3. Khajura PHC Yes 4. Laxmanpur PHC Yes 4. Laxmanpur PHC Yes 5. Kachanapur HP Yes 5. Kachanapur HP Yes 6. Baijapur SHP Yes 6. Baijapur SHP Yes 7. Fattepur HP Yes 7. Fattepur HP Yes 8. Gangapur HP Yes 8. HP Yes 9. SHP Yes 10. Samserganj HP Yes 11. Titihiria SHP Yes 12. Saigaun SHP Yes 13. Kamdi SHP Yes 14. Sonapur HP Yes Note: Total no. Birthing sites in the district: 27 Total CEONC sites: 04 Total BEONC Sites: 02 Total no. of IUCD service Sites: 14 Total no. of Implant service sites: 08 Total no. of Satellite clinic: 03

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BANKE 14 6.2 ANM Schools

H4L intends to improve the quality of pre-service ANM trainings. As such basic information on the ANM schools of Banke district were sought from DPHO. In this district, there is only one ANM college- the Sushma Koirala Memorial Trust- CMA and ANM campus. It is located at Nepalgunj. DPHA and PHN also shared that the ANM School has been coordinating regularly with DPHO for practical.

6.3 Infection Prevention and Waste Management Practices at HFs

Few questions related to infection prevention and waste management practices followed at HFs of Banke were also asked to district supervisors during RA. It was found that out of total 27 birthing centers, 17 have placenta pit for the proper disposal of placenta. In the rest of birthing sites, where there is no placenta pit, the visitors used to take placenta with them to dispose but not confirmed how and where the visitors dispose it. IP practice in BZH is satisfactory because they are using placenta pit for placenta disposal, incinerator for other waste materials and also found using Virex (Chlorine) for decontamination and sterilized instruments for surgical procedures in the hospital.

6.4 Strength and Opportunities

There are 27 functional birthing centers and 46 Nursing staff trained in SBA in the district. Out of 27 birthing centers, 17 have placenta pit for the proper disposal of placenta. Out of total 47 HFs, 14 HFs have providing IUCD and 08 HFs have providing Implant service regularly. In addition of that there are 04 CEONC service center ( Bheri Zonal Hospital, Nepalgunj Medical college Kohalpur, Nepalgunj Medical college and Nursing home Nepalgunj and Western Hospital Nepalgunj) and 02 BEONC service centers ( Khajura PHC and Bankatuwa PHC) in the district. Programs like CB-IMCI, CB-NCP and MSC already implemented in the district which is very good opportunity to improve the health status of mother and child of Banke district. In the same way, there is also CMA/ANM technical school which is coordinating with DPHO for Practicum.

FPAN, MSI and PSI are also working in the sector of FP and RH in the district. FPAN is providing ANC/PNC and FP service though 01 static clinic at Nepalgunj and 04 outreach clinics at Bankatuwa, Kohalpur, and VDCs. In the same way MSI and PSI is providing FP service from their static clinics on regular basis and also conduct mobile clinics in coordination with DPHO in the different VDCs of Banke district.

6.5 Key Issues and Challenges

 Problem in the infrastructure of some birthing centers  Problem in staff retention specially in the VDCs separated by Rapti river  Problem in logistic supply (Instruments, equipments)  Untrained HWs and FCHVs on CB-IMCI :- HWs-22 (20 are contract-based staff) and about 200 FCHVs  Delay release of Budget.

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BANKE 15 6.6 The possible ways to overcome the problems/issues

 Provision of budget at local level so that they can manage minor problems at local level  Coordination with DDC/VDC and other INGOs working in the same field to overcome the problems related to infrastructure.  Coordination with DDC/VDC to hire staff on contract basis to overcome the staffing problem and ensure regular and effective health services  Making the logistic system more effective (strengthening of PULL System in the district)  On site coaching and training to the staff and community volunteers on technical areas  Coordination with center for the timely release of budget

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BANKE 16 7. LOGISTICS MANAGEMENT SYSTEM

Logistics management is an important part of district health systems. Efficient logistics management is required to smoothly run all the public health programs at district, sub-district and the VDC levels. The RA also sought information from DPHO on the logistics management system. The major findings of the assessment are presented below.

7.1 Availability of Key Drugs and Commodities

During RA, the store room of the D/PHO was also visited and the store keeper was interviewed. The availability of 11 commodities/some essential drugs (Injectable, Oral Contraceptive, Condom, ORS, Vitamin A, Iron Folate Tablets, Cotrim (Ped.), Zinc, Oxytocin, Gentamycin and MgSO4) in the district store at the time of visit was checked. It was found that all of them were available when checked. The store keeper was also asked whether the 11 drugs/commodities were out of stock anytime in the last 12 months, and it was found that there has not been stock out of these commodities in the last 12 months. The RA team members also checked the expiry dates of the drugs/commodities and not any of them were expired at the time of visit.

Table 7.1: Availability of key drugs/commodities and their expiry dates SN Drugs/Commodities Availability at Stock out in Expired drugs in the time of the last 12 stock at the time of visit months visit 1 Injectable Contraceptive Y N N 2 Oral contraceptive Y N N 3 Condom Y N N 4 ORS Y N N 5 Vitamin A Y N N 6 Iron Folate Tablets Y N N 7 Cotrimoxazole (Ped) Y N N 8 Zinc Y N N 9 Oxytocin Y N N 10 Gentamycin Y N N 11 MgSO4 Y N N

The Store keeper was also asked to list the drugs that have most problems with stock outs in the FY 2069/70 and found that tab Ibuprofen, Metronidazole and Hyosine Bromide were the drugs with the most problems of stock outs in the year. It is also found that MgSO4 and Syrup Metronidazole are the most problems with over stock in the FY 2069/70.

7.2 Cold Chain and FEFO Management

DPHO Banke has seven functioning refrigerators. The available refrigerators are sufficient to DPHO for maintaining cold chain and also have regular power back up system for the cold chain room. The management of five drugs in the store was checked to see whether First Expiry First out (FEFO) was maintained or not. It was found that FEFO system is maintained in the district store at the time of visit.

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BANKE 17 7.3 LMIS reporting

D/PHO is using web-based LMIS to report to center regularly. DPHO has recruited one data entry person for the entering LMIS data.

7.4 Strength and Opportunities

DPHO Banke have well managed district store and cold chain system with regular power back up system including on trained data entry person for the entry of LMIS data. FEFO system is maintained in the district store. PULL system have been implemented in the district for the proper management of drug supply to the HFs.

7.5 Key Issues and Challenges  Congested store room at district level.  Vehicle is not in good condition for the drugs and commodities supply (Old Vehicle)  Difficult to follow the PULL system at all time

7.6 Possible ways to overcome the problems/Issues  Managing one extra room for the store  Keeping Vehicle in condition  Strengthening of PULL system to make it functional

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BANKE 18 8. BEHAVIOR CHANGE COMMUNICATION

H4L aims to understand legal, cultural/religious, and policy dimensions of GESI inequities on health service access and use and design interventions to ensure sustainable, high-quality BCC and IEC approaches that respond to local realities, and include groups not commonly targeted, but crucial to meeting Nepal’s health goals by mobilizing LTAPs.

One of the objectives of the RA was to explore the range of BCC interventions that is being implemented for healthy behaviors. Following are the major findings on BCC:

8.1 Existing D/DPHO Programs on BCC

DPHO Banke has been organizing BCC program activities as per the National Health Education Information and Communication Center (NHEICC) yearly plan such as production and distribution of IEC materials, short massages broadcasting through local FM radio, school health program, orientation to teachers, journalists etc. DPHO do not have any collaboration with other INGO, CBO for the implementation of such program except Medias (FM, Journalist).

8.2 FM Stations/Cable Television Networks

In Banke there are nine FM stations. 1. Bageshwari FM, Hariya Baba 2. Krishnasar FM, 3. Himal FM, Near Audhyogik Chhetra 4. Bheri FM, Bankegaun 5. Radio Bheri Awaaz, Karkado 6. Radio Rubaru, Salyanibag 7. Nepalgunj Express FM, 8. Pratibodh FM, Kohalpur 9. Kohalpur FM, Kohalpur

D/PHO Banke has collaborated with all of the above FM stations for airing radio health programs and Public Service announcements (PSAs) on Safe motherhood (ANC/PNC and Institutional Delivery), Family Planning, Neonatal care, Breast Feeding, Immunization, ARI, Diarrhoea, smoking and communicable diseases called Janasankhya Hamro Sarokar (Every Evening 6.00-6.30 pm). DPHO has been distributing program to these FM on rotation basis. It was also reported that there is one Cable TV networks in Banke but it has not developed and aired any district-based programs related to health.

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BANKE 19 8.3 Organizations working in IEC/BCC activities

RA identified the following organizations working in IEC/BCC in Banke:  WCO:- Orientation to the members of Mahila samuha and Kishori Samuha on RH and FP related issues. . FPAN:- Adolescent awareness on RH and FP related issues through AFHS sites and mobile clinics. . GIZ:- Distribution of BCC materials for Adolescent through AFHS sites. . PLAN in partnership with Geruwa Jagaran Sanstha: support in the broadcasting of RH and CH related massages through local FMs in Nepalgunj . Muslim Samaj, Nepalgunj:- Community awareness activities like street drama and interaction meeting on health issues including RH/FP in coordination with DPHO. . Social Awareness Center (SAC)Nepal: Community awareness activities on HIV and GESI in coordination with DDC. . BNMT:- One shot orientation at community level to increase awareness on TB and HIV. . NRCS:- Awareness raising activities on use of Supanet

All the above-mentioned organizations are working on IEC/BCC activities focusing on their program activities. They are providing IEC/BCC materials related to their specific program activities.

H4L plans to use mobile phones to reach target groups with messages on health in selected district. The RA also explored whether any organization has used mobile phones to communicate health messages to target groups or entire district population together with D/PHO. It was found that DPHO had used mobile phone (one-shot program) to send text messages to the community people to inform about Polio Program during NID in last FY (2068/69) with the support of WHO.

8.4 Counseling Service One area of intervention of H4L is to improve the quality of counseling provided by health workers and community-based health workers to clients. It is therefore essential to find out whether there is pool of resources available at district level to improve counseling services. Hence, RA also collected information on the district health staff who received training on COFP/C in the last three years. Hence, it is known that all the old staff working with DPHO have received COFP/C training but the name list of trained staff could not found during the visit.

8.5 School Health Program Conducting health education classes at schools is one of the activities of D/PHO. In the last Fiscal year 068/069, total 140 session of school health program were organized in 140 school from which total 3451 students benefited. The topics mostly covered during the School Health Education Program includes- HIV/AIDS, RH, GBV, early marriage etc. But in current FY, there are no any activities for school health program planed and conducted.

According to the Health Education Technician Officer (HETO, beside school health education program Peer education among adolescent group will be effective in reaching adolescents with health messages.

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BANKE 20 8.6 Mapping of DAG and Exploring Cultural Practices Affecting Health

During the RA, in-depth information on DAG communities residing in Banke district was also collected from HETO. The major findings of this assessment are as following: Ethnic/Caste Villages that still Villages that were group deprived practice early highly populated Migration pattern from service marriage and Early by DAG utilization Child Bearing  Samsherganj Dalits,  Matehiya, Sex:- Mostly males  Naubasta Muslims,  Narainapur, Caste/Ethnicity:- Mostly people from  Baijapur Yadav,  Kalaphata, Dalits and disadvantaged community  Titihiriya Kurmi of Rapti-Pari  Katkuiya,  Raniyapur VDcs like Matehiya,  Laxmanpur Type of Migration  Holiya Narainapur, Seasonal Migration to India and longer  Gangapur Kalaphata, migration to  Kathkuiya Katkuiya, and Gulf countries Laxmanpur were VDCs with High Migrants  Laxmanpur the deprived castes  Udharapur  Kohalpur group.  Betahani  Rajhena  Naubasta  Bankatti  Chisapani  Bankatuwa  Bageshwari  Sitapur  Radhapur

The reason behind the practice of early marriage and early child bearing is lack of awareness in the community and no special activities or intervention has done to resolve these problems except FCHVs mobilization to increase awareness in the community and conducting few school health education sessions in different schools.

As per the focal person, DPHO Banke has implemented health education campaign on environmental sanitation, Hand washing practice, distributed IEC/BCC materials and organized free heath campaign for M/DAG especially focusing in hard to reach VDCs across Rapti River in last F/Y 2068/69 and in Patharkatta community of Indrapur VDC in current F/Y 2069/70 to increase awareness and access to the health service.

DHO supervisors especially Health education technician officer have suggested that H4L should plan some new program and interventions in school and community especially targeted to the adolescents. The program has to be periodic, instead of just one-time program so that it can be taken forward to ensure continuity but they do not suggest any name, structure or design of program.

8.7 Strength and Opportunities

There are total nine FM stations in Banke district which can be used for the airing of different Health massages through PSA, Radio Drama etc. Different organizations like GIZ, PLAN, Red-Cross, FPAN, Muslim Samaj, Sac and BNMT have been also working on BCC programs in this district which will be very much helpful to improve community awareness on health issues.

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BANKE 21 8.8 Key Issues and Challenges

 It is difficult to increase awareness and provide health services among people who have strong traditional and cultural beliefs, practice of early marriage and early child bearing practice.  Bulk amount of BCC materials supply from center Vs use at local level due to improper distribution at local level.

8.9 Possible ways to overcome the issues and challenges  Timely and proper distribution of BCC materials to the community  Mobilization of Mass Medias for community awareness activities  Conducting special intervention programs in coordination with local I/NGOs to increase community aawaeness

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BANKE 22 9. ADOLESCENTS AND YOUTH FRIENDLY SERVICES

H4L will also work with D/PHOs in selected districts to improve service accessibility of Adolescents under its Objective 6. The RA also explored different aspects of Adolescents and Youth friendly services in the public health facilities of Banke district. Following are the major findings:

9.1 Existing Services for Adolescent

In Banke, there is focused program for Adolescents in 17 sites (GIZ supported 13 & FPAN supported 4 sites) and all are reporting regularly. GIZ is providing support to the government AYFS centers where FPAN is providing service through their own out-reach clinic. WCO is providing support to the adolescent girls of 12 VDCs through “KISHORI SAMUHA” in which RH related information shared and life skill training provided. WCO have also providing services to the adolescents through four counseling centers of Belber, Bageshwari, Mahadevpuri and Saigaun VDCs in which FP counseling service provided and referred the interested clients to the nearest HFs for commodities. NRCS providing support to the adolescents through youth red-cross circle and junior red-cross circle to all over the district. The following are the AFS site of Banke district:

GIZ supported AYFS Sites: 1. Institutionalized Clinic Training center (ICTC) Nepalgunj 2. Laxmanpur PHC 3. Khajura PHC 4. Bankatuwa PHC 5. Sonapur HP 6. Kachnapur HP 7. Samshergunj HP 8. Fattepur HP 9. Titihiriya SHP 10. Sitapur SHP 11. Kamdi SHP 12. Bashudev SHP 13. Baijapur SHP

FPAN supported Sites (Adolescent focused program through their own outreach clinic):- 1. Ganapur VDC 2. Bankatuwa VDC 3. Mahadevpuri VDC 4. Kohalpur VDC

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BANKE 23 9.2 Organization working for Adolescent

In Banke, GIZ, WCO, NRCS and FPAN are actively working for adolescent’s health.

GIZ is providing support to the 13 AFS sites in the different HFs. GIZ have provided furniture, equipments etc. on need basis to the AFS sites including BCC materials (Booklets). As per GIZ, School could be the best place to provide the information for adolescents however, providing health service through HF as regular service will be much better rather than establishing the especial clinics for them. After implementing AYFS, it is noticed that the use of temporary family planning methods like Condom, Pills has increased among unmarried adolescents unfortunately, medical abortion (MA) is also increasing as they are taking MA as a Family Planning means. They also expressed that, BCC program has been successful however, service delivery targeting to the adolescents through establishing the separate corner is not effective as much as they expect . FPAN is providing adolescent focused service through their own our reach clinics in 04 VDCs of Banke. They also noticed that the use of temporary family planning methods like Condom, Pills has increased among unmarried adolescents.

NRCS providing support to the adolescents through youth red-cross circle and junior red-cross circle to all over the district.

WCO is providing support to the adolescent girls of 12 VDCs through “KISHORI SAMUHA” in which RH related information shared and life skills training provided. WCO have also providing services to the adolescents through four counseling centers of Belber, Bageshwari, Mahadevpuri and Saigaun VDCs in which FP counseling service provided and referred the interested clients to the nearest HFs for commodities. They also provide knowledge on lively-hood skills and sharing and support on future planning of life called “Jeevan Upayogi sip talim” which is very effective to changed their behavior so this training is under plan to expand to other districts

The following are the list of VDCs having “KISHORI SAMUHA” supported by WCO: 1. 2. Baijapur 3. Mahadevpuri 4. Samsherganj 5. Khajurapur 6. Hirminiya 7. Parashpur 8. Jaishpur 9. 10. Ganapur 11. Bilvar 12. Bitani

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BANKE 24 9.3 Strength and Opportunities There is GIZ supported 13 health facilities & FPAN supported 4 VDCs (Sites) have Adolescent & Youth Friendly Services (AFS) in Banke. DPHO has conducted Peer Review training to 10 schools in the current FY. WCO is providing support to the adolescent girls of 12 VDCs through “KISHORI SAMUHA” in which RH related information shared and life skills training provided and NRCS providing support to the adolescents through youth red-cross circle and junior red-cross circle to all over the district. H4L can coordinate and collaborate with those groups while working with adolescents at community level.

9.4 Key Issues and Challenges  Limited government programs and resources to expand peer review learning in to schools, which is not sufficient.  Government provides fund to implement programs only in 10 schools, which is not sufficient  Lack of awareness on RH and FP issues in the adolescents especially in Rapti-Pari VDCs

9.5 Possible ways to overcome the issues and challenges  The additional program has to be focused especially for the adolescents in the district in coordination with I/NGOs  Special intervention need to done to increase awareness on RH and FP issues especially in hard to reach VDCs

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BANKE 25 10. GENDER EQUALITY AND SOCIAL INCLUSION

H4L is designed to support the Government of Nepal’s stated commitment and responsibility to ensure that quality health services are accessible to all citizens. As such, it is critically important that sound, ongoing GESI-sensitive analysis and gender integration underpin H4L program interventions. H4L’s GESI Objectives are designed to re-address gender and social inequities, and dove-tail with the objectives set forth in the MOHP’s 2009 Health Sector Gender Equality and Social Inclusion Strategy as follows:  Objective 1: Support existing MOHP policies, strategies, plans and programs that create a

favorable environment for integrating GESI in Nepal’s health sector;  Objective 2: Support MOHP’s efforts to enhance the capacity of service providers and ensure equitable access and use of health services by the poor, vulnerable and marginalized castes and ethnic groups; and  Objective 3: Improve health-seeking behavior of the poor, vulnerable and marginalized castes and ethnic groups in collaboration with local government partners, community-based organizations (CBOs) and other stakeholders.

The first objective is related to policy while the latter two are directly related to D/PHO systems. The RA also included assessment and analysis of the health programs of the D/PHO Banke from GESI perspective. The major findings were as following:

10.1 Formation and Functionality of GESI Committee

In Banke, is given the responsibility of GESI focal person. GESI committee as formed on 04 Jestha 2069. The committee has 15 Members (Male-9, Female-6). The committee received partial orientation from GESI focal person. A social service unit has been established in BZH on 4th June 2013 to provide free health service to poor, dalit, disadvantaged, disabled, old aged people from the Hospital based on standard protocol prepared by GoN.

After formation of the GESI committee, only one meeting has conducted on 23rd Chaitra 2069 although it is decided to organize meeting on quarterly basis. The reason behind not organizing meeting regularly is lack of budget for the meeting especially for refreshment. As per the decision of the last meeting, free health camp has been organized at Patherkatti of Indrapur VDC and VDC to address the health issues of excluded community. After organizing free health camp in those communities, people became very happy for having health service easily and most of the female and adolescents have visited to the camp for the health services. Lack of awareness for health seeking behavior is noticed as a major problem in the community.

One-Stop Crisis center: Not established at Banke

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BANKE 26 10.2 Organizations working on GESI

Three organizations (DDC, WCO, GIZ and SAC) working on GESI in Banke district were also visited during RA. Interaction with the staff working on the project revealed that DDC has formed a GESI committee under the chairmanship of LDO on 2068/02/19. After formation of GESI committee, orientation provided to Committee members and chief of the district offices, VDC secretary and social mobilizers in technical collaboration with SAC Nepal (A local NGO).

GIZ and WDO have no any direct or separate activity on GESI but it has been going on as cross cutting issues through AFS centers (GIZ) and “KISHORI SAMUHA” (WDO) along with other activities especially during program implementation at community level, provision of services and selection of participants for training/orientation/meeting etc. Social Awareness center (SAC) is a local NGO have worked on GESI with the support of DDC especially to provide technical support in the orientation on GESI to DDC staff, VDC secretaries and VDC level social mobilizers.

10. 3 Opportunities  The GESI concept well known among district government (WCO, DHO and DDC) stakeholders  The focal person has comprehensive knowledgeable on GESI concept  The technical group has been formed  The GESI concept is incorporating in all government services

10. 4 Major problem/constraints:

 Muslim, Madhesi communities do not usually give same preference to men and women  There are many hard to reach areas in Banke, which are unreachable in normal circumstances.  Many people are not aware of health services provided through health facilities, which continue to deprive them of health services  Resources constraints to implement GESI related activities  GESI related activities are limited up to district level rather than health facilities level

10.5 Possible ways to overcome the problems:

 Providing information on health services offered by health facilities  Raising awareness and providing health education to communities  Media can play important role in raising awareness among people in DAG and “hard to reach” areas  Members of HFOMCs, FCHVs can be sensitized on GESI to have it integrated in each health programs.

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A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BANKE 27 Annex 1

Table: Contact information of D/PHO Staff, Banke Years of Years of service Name Position Cell Phone no. service in district Public Health Administrator 29 02 9841557095 Public Health Officer 25 06 months 9848046384 Statistics Assistant/Officer 33 09 9848036276 FP Supervisor 03 01 9848041327 Malaria focal person 26 08 9848030970 Health Education Tech/ Officer 33 2.5 9848074476 DTLA/Officer 25 1 9748008803 EPI Supervisor/Officer 19 16 9848023260 Cold Chain Assistant/ Officer 10 02 9848022082 Computer Operator/Officer 19 16 9848025407 Store Keeper 16 3 9848018846 Child Health focal person 13 9 9858020849 Ac. PHN/FCHV Focal Person 10 6 9848033915 N/A Medical Recorder Malaria Inspector Officer 9 8 9848024154 Malaria Inspector Officer 10 4 9848044383 EPI Officer 3 9848047802 Adm. Officer/Na. Su. 5 3 9848120579 Adm (Na. Su.) 13 9 9848020511 Account Officer 19 1 9858020677 Public Health Inspector 25 10 9858021172 Stat. assistant 13 4 9858020008 Lab Technician 8 1 9848145501 Lab. Assistant 9 6 9848035767 Lab. Assistant 18 10 9848027367 Lab. Assistant 3 2 9848021468 Cold Chain Assistant 9 4 9848020472

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BANKE 28 Annex 2

List of RHCC members

 Chairman:- DPHA  Members:- Representative of District Development Committee District Education Office Women and Child Office Bheri Zonal Hospital, Nepalgunj Institutionalize Clinic and Training Center (ICTC), Nepalgunj Family Planning Association of Nepal (FPAN) Nepal Red Cross Society (NRCS) Mery Stopes International (MSI) PLAN GIZ Population Service International (PSI) Contraceptive Retail services (CRS) Geruwa Gramin Jagaran Sanstha SAC Nepal UNESCO Health Care and Research Center (HCRC) Nepalgunj Medical College Private Hospitals (United Hospital, Mi-Western poly clinic, Western Hospital, Nepalgunj)  Member Secretary:- RH focal person of DPHO

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BANKE 29 Annex 3 List of Organizations and Individuals visited/contacted during RA SN Name of Organization Individuals Visited Designation 1 Sr. DPHA 2 PHO 3 PHI 4 PHI 5 Stat Officer 6 HETO DPHO, Banke 7 Ac. PHN 8 Store Keeper 9 EPI Supervisor 10 Stat Assistant 11 Na.Su. 12 Ta. Na.Su. 13 Program Officer 14 DDC Banke GESI Focal person) Social Mobilizer Officer 15 WCO 16 WCO, Banke Information Officer 17 Supervisor 18 GIZ, Banke Program officer 19 FPAN, Banke Sr. Branch Manager 20 NRCS, Banke Supervisor 21 PLAN Nepal, Banke PME Coordinator

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BANKE 30 HEALTH FOR LIFE

REPORT ON RAPID ASSESSMENT

OF DISTRICT HEALTH SYSTEMS 2013 BARDIYA

1 A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BARDIYA A R EPORT ON RAPID A SSESSMENT

OF DISTRICT HEALTH SYSTEMS

2013 BARDIYA

MAY 2013

TEAM MEMBERS

TABLE OF CONTENTS

Abbreviations ...... I Key Findings from Rapid Assessment of District Health Systems: ...... II

1. RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS ...... 1 1.1 Health for Life ...... 1 1.2 Rapid Assessment And its Objectives ...... 1 1.3 Methodology ...... 1 1.4 Organization of the Report ...... 2

2. INTRODUCTION OF BARDIYA DISTRICT ...... 3 2.1 Geo-Political Situation ...... 3 2.2Demographic Information ...... 3

3. DPHO STRUCTURE AND SYSTEMS ...... 4 3.1 Service Delivery Points ...... 4 3.2 Management Systems ...... 4 3.3 Health Workforce ...... 5 3.4 Monitoring and Supervision ...... 5 3.5 Information Technology ...... 6 3.6 Health Information Management ...... 6 3.7 Natural Disaster Response Mechanism ...... 6 3.8 Strength and Opportunities ...... 6 3.9 Key Issues and Challenges ...... 6 3.10 Possible ways to overcome the challenges ...... 7

4. SERVICE STATISTICS ...... 8 4.1 Immunization ...... 8 4.2 CB-IMCI ...... 8 4.3 Safe Motherhood ...... 9 4.4 Family Planning ...... 9

5. HEALTH FACILITY MANAGEMENT COMMITTEE AND LOCAL HEALTH GOVERNANCE ...... 11 5.1 Functioning HFOMC ...... 11 5.2 Capacity Building of HFOMC ...... 11 5.3 Community Groups/Federation/ALLIANCE ...... 11 5.4 Strength and Opportunities ...... 12 5.5 Key Issues and Challenges (Based on discussion with D/PHO and DDC personals) ...... 12 5.6 Efforts are required to overcome the problems/constraints ...... 12

6. SERVICE DELIVERY/QUALITY IMPROVEMENT ...... 13 6.1Service Delivery ...... 13 6.2 ANM Schools ...... 13 6.3Infection Prevention and Waste Management Practices at HFs ...... 14 6.4 Strength and Opportunities ...... 14 6.5 Key Issues and Challenges ...... 14

i 6.6 Possible ways to overcome the challenges ...... 14

7. LOGISTICS MANAGEMENT SYSTEM ...... 15 7.1 Availability of Key Drugs and Commodities ...... 15 7.2 Cold Chain and FEFO Management ...... 15 7.3 LMIS reporting ...... 16 7.4 Strength and Opportunities ...... 16 7.5 Key Issues and Challenges ...... 16 7.6 Possible ways to overcome the issues and challenges ...... 16

8. BEHAVIOR CHANGE COMMUNICATION ...... 17 8.1 Existing D/DPHO Programs on BCC ...... 17 8.2 FM Stations/Cable Television Networks ...... 17 8.3 Organizations working in IEC/BCC activities ...... 17 8.4 Counseling service...... 18 8.5 School Health Program ...... 18 8.6 Mapping of DAG and Exploring Cultural Practices Affecting Health ...... 18 8.7 Strength and Opportunities ...... 19 8.8 Key Issues and Challenges ...... 19 8.9 Possible ways to overcome the issues and challenges ...... 19

9.ADOLESCENTS AND YOUTH FRIENDLY SERVICES ...... 20 9.1 Existing Services for Adolescent...... 20 9.2 Organization working for Adolescent ...... 20 9.3 Strength and Opportunities ...... 21 9.4 Key Issues and Challenges ...... 21 9.5 Possible ways to overcome the problems ...... 21

10. GENDER EQUALITY AND SOCIAL INCLUSION ...... 22 10.1 Formation and Functionality of GESI Committee ...... 22 10.2 One-Stop Crisis Management center ...... 22 10.3 Organizations working on GESI ...... 23 10.4 Opportunities ...... 23 10.5 Challenges ...... 23 10.6 Possible ways to overcome the problems: ...... 23

Annex 1: Contact Details of DHO program focal persons ...... 24 Annex 2: List of RHCC members ...... 25 Annex 3: List of Organizations and Individuals visited/contacted during RA ...... 26 ABBREVIATIONS

AHW Auxiliary Health Worker AIDS Acquired Immunodeficiency Syndrome ANC Antenatal Care ANM Auxiliary Nurse Mid-wife AYFS Adolescent youth friendly service BC Birthing centre BCC Behavior Change Communication BEONC Basic Emergency Obstetric and Newborn Care BNMT Britain Nepal Medical Trust CAC Compressive Abortion Care CB-IMCI Community-Based Integrated Management of Childhood Illness CB-NCP Community-Based Newborn Care Package CEONC Comprehensive Emergency Obstetric and Neonatal Care CH Child Health CPR Contraceptive Prevalence Rate DAG Disadvantaged Group DDC District Development Committee DPHO District Public Health Office DOHS Department of Health Service FCHV Female Community Health Volunteer FEFO First expiry first out FM Frequency Modulation FMC Facility Management Committee FP Family Planning FY Fiscal Year GBV Gender Based Violence GESI Gender Equality and Social Inclusion HA Health Assistant H4L Health for Life HF Health Facility HP Health Post HFOMC Health Facility Operation and Management Committee HIV Human Immunodeficiency Virus HMIS Health Management Information System ICTC Institutionalized Clinic and Training Center IUCD Intra Uterine Contraceptive Device I/NGO International/Non-Governmental Organization IT Information Technology IUCD Intra Uterine Contraceptive Device LDO Local Development Officer LMIS Logistics Management Information System LTAP Local technical Assistant Partner M/DAG Marginalized/Disadvantaged group MO Medical Officer MOHP Ministry of Health and Population MNCHN Maternal Neonatal Child Health and Nutrition

i MgSO4 Magnesium Sulphate MSC Matri Surakshya Chakki M&S Monitoring and Supervision MWDR Mid-western Development Region N Number NFHP II Nepal Family Health Program II NGO Non-Governmental Organization NPC National Planning Commission NRCS Nepal Red Cross Society PAC Post Abortion Care PHCC Primary Health Care Center PHC/ORC Primary Health Care / Out-Reach Clinic PHN Public Health Nurse PNC Postnatal Care PSA Public Service Announcement QI Quality Improvement QAWG Quality Assurance Working Group RA Rapid assessment RH Reproductive Health RHCC Reproductive Health Coordination Committee RHD Regional Health Directorate SAC Social Awareness Centre SBA Skilled Birth Attendance SHP Sub Health Post SN Staff Nurse TMUK Tharu Mahila Utthan Kendra USAID Unites States Agency for International Development VDC Village Development Committee WCO Women and Children Office WDR Western Development Region

ii KEY FINDINGS FROM RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS:

TOTAL POPULATION 426,576 NUMBER OF VDCS 31 MUNICIPALITY 01 () DPHO STRUCTURE AND Public Health facilities: SYSTEMS  District Hospital-1, PHCCs-3, HPs -12 and SHPs-18 and District Ayurved Hospital-1 Private Health facilities:  Private hospitals and nursing homes-1,  SOS Health Centre-1  Thakurdwara Community Health Unit-1 Meetings:  Ilaka Incharge Monthly at District- 8th of every month  QAWG- No meeting held in the last one year  RHCC- Meets quarterly Health Workforce:  All technical positions at DHO filled-in except Doctors and PHN.  Unfilled positions at HFs–MO, ANM, AHW and Lab assistant.  25 ANM and few Vaccinators and SN hired on contract basis. Few health workers hired from NPC and VDC Monitoring and Supervision:  M&S system exists at district level only. Integrated supervision tools are not in use. IT infrastructure at D/PHO:  Desktops-15, Laptops-6, Printers-9  Well established internet facility in HMIS section.  Three HFs have computers.  Supervisors skilled in using MS Word and Excel-6.  Health Facility wise data entry in HMIS software. Rapid Response Team:  Functioning well at the district and HF level SERVICE STATISTICS  The coverage of BCG and Measles vaccine seems fluctuating in last five FY (from FY 2065/66 to 2069/70). The coverage of both vaccines in FY 2067/68 and 2068/69 was less than 70%.  Percentage of severe pneumonia and severe diarrhea cases are less than 1%. More children with pneumonia are being treated with antibiotics.  ANC first visit and four ANC visit is in decreasing trend and four ANC visit is very low in comparison of ANC first visit. As per the eight month data of FY 2069/70, ANC 1st visit is 42.5% and four ANC visit is 32.6%. In the same way, SBA delivery (Both Home and Institute) is in increasing trend i.e. 14.1 % in FY 2065/66 to 37.1 % in FY 2069/70(Eight months data).  Contraceptive Prevalence Rate is also in increasing trend i.e. 48.7 % in FY 2065/66 to 56.5% in current FY 2069/70 (As per eight months data). HEALTH FACILITY  All HFs handed over to local HFOMC. MANAGEMENT COMMITTEE  All HFOMCs received capacity building trainings with the support of Save AND LOCAL HEALTH the Children and most of them are nonfunctional. GOVERNANCE  At community level, groups such as -Forestry Users Group, Mothers’ Group, Cooperatives, Media group and Pregnant Mother group are functioning. SERVICE  No CEONC service is available in the district. iii DELIVERY/QUALITY  BEOC services are provided through 4 sites including district hospital IMPROVEMENT  Community-based service delivery-CMAM was piloted in Bardiya in December 2008 and is still running. CB-NCP was implemented in 2008.  Satellite FP clinics-3, but functioning only one.  IUCD services are available in eight health facilities and Implants in 7 HFs including district FP/MCH clinic.  Birthing centers-17 including district hospital.  Placenta pits-9 including district hospital.  One-step Crisis Management Centre established and functioning in the district hospital of Bardiya. LOGISTICS MANAGEMENT  All tracer drugs and commodities available on the day of visit. SYSTEM  Drugs with most problems of stock outs in the year- Tab Cotrim-Ped, and Iron, Primaquine and FP commodities like implant and IUCD.  Drugs with most problems of over stock in the last year- Tab. Metochlorpropamide, MgSO4, Tetracycline eye ointment and Cotrim DT (240 mg).  Functioning refrigerators-11, sufficient for maintaining cold chain, and have regular power back up system for the cold chain room.  First Expiry First out (FEFO)- maintained well .  Existence of web-based LMIS reporting system. Data entry person recruited. BEHAVIOR CHANGE  FM stations-3 COMMUNICATION  Few I/NGOs engaged in their program specific BCC activities with minimum involvement and technical support of DHO in terms of coordination but no special activities in community.  In the FY 2068/069, D/PHO organized school health program on HIV/AIDS, RH, GBV, early marriage etc in different schools  Villages that are highly populated by DAG- Pashupatinagar, , , , Sanoshree and Suryapatuwa.  Ethnic/Caste group deprived from service utilization- Dalits, Muslims, Yadav, Kurmi of southern belt of Gulariya Municipality and some VDCs like Daulatpur, Gola, Bhimapur, Patabhar, Badalpur and Baniyabhar were the deprived castes group.  Villages that still practice early marriage and Early Child Bearing- Mainapokhar, , Dhadhawar, , Motipur and .  High Migrants VDCs- , Sanoshree, Rajapur, Jamuni and . ADOLESCENTS AND YOUTH  AFS sites- GIZ supported 13 sites in the HFs and FPAN supported 5 sites in FRIENDLY SERVICES the schools.  WCO have female adolescent youth group “KISHORI SAMUHA” to enhance life-skill trainings and give information on RH issues in 5 VDCs. GENDER EQUALITY AND  GESI Committee was formed in DHO on 2069/02/31 as per the guideline SOCIAL INCLUSION and a focal person has been assigned for GESI program. All members have received orientation but no meeting conducted after its formation.  DDC, WCO, TMUK and GIZ have GESI related activities in Bardiya.  At DDC, GESI committee under the chairmanship of LDO is also formed but meeting is not regular due to budgetary constraint.

iv 1. RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS

1.1 Health for Life

Health for Life (H4L) is a five-year bilateral agreement between the Ministry of Health and Population (MoHP) and the Unites States Agency for International Development (USAID) which focuses on Systems Strengthening and improving the Maternal Neonatal Child Health and Nutrition/Family Planning (MNCHN/FP) service delivery at district and sub-district levels in 14 districts. 12 of the 14 districts are in the Mid-western Development Region (MWDR) –Brdiya, Banke, Dang, Surkhet, Salyan, Pyuthan, Dailekh, Kalikot, Jumla, Rukum, Jajarkot and Rolpa and two are in the Western development Region (WDR) of Nepal- Arghakhanchi and Kapilvastu. The project will be implemented between 2012 and 2017.

1.2 Rapid Assessment And its Objectives

Rapid assessment (RA) is a method of analyzing situation of a district where issues are not well defined and where there is not sufficient time or other resources for in-depth quantitative research. RA uses intensive team interaction in both the collection and analysis of data instead of prolonged field work and iterative data analysis and additional data collection to quickly develop a preliminary understanding of a situation from the insider’s perspective. The main purpose of carrying out the Rapid Assessment was to understand the current situation of the health service delivery system of the Bardiya district so as to help in planning activities at district level.

Specifically, the objectives of the RA included the following:  Understanding the demographic profile of the district  Understanding the existing health care delivery system of the district  Knowing the functionality of the Health Facility Operation and Management Committees  Understanding the status of health indicators  Analyzing the strengths and weakness of the DHO systems  Identification of potential Local Technical Assistance Partners (LTAPs)  Exploring feasibility for the implementation of specific programs for adolescents and youth  Exploring feasibility of using Information Technology in information management

1.3 Methodology

A mix of both qualitative and quantitative methods was used to execute Rapid Assessment in Bardiya district. These includes visit to DHO, District Development Committee (DDC), WCDO, and I/NGOs, interaction with key informants, record reviews and observations. A structured tool was developed to collect necessary information which was supplemented by qualitative tools to interview key informants at different agencies working on different areas of health service delivery and management, Gender Equality and Social Inclusion (GESI), Behavior Change Communication (BCC), Information Technology (IT) in Health and Governance.

1 A team composed of 12 H4L staff was formed for carrying out RA in Bardiya where there was a good skill mix among the members to cover different areas of the RA Involvement of Central, Regional and District office staff was ensured.

Before carrying out of the RA in Bardiya, one and a half day orientation on RA objective, methods and tools were organized for H4L staff together with orientation on H4L project in Hotel Siddhartha, Nepalgunj on 23 and 24 day of April. Director and three senior officials from the Mid- western Regional Health Directorate, Surkhet and the Senior Public Health Administrator of Banke DPHO also participated in the RA orientation. They provided inputs in further refining the RA tools. RA in Bardiya was completed by H4L Staff in six days beginning April 25 to April 30, 2013. Small groups were formed within the team where the members divided their responsibilities and visited DHO and other stakeholders for establishing relationships, interactions and information collection. At the end of each day all the members gathered for about an hour and shared their experiences. Information collected by the team members was verified on the same day and brief notes were developed for each thematic area. Report was prepared using the template provided by the H4L central office. A brief PowerPoint presentation was also prepared covering the key findings of the RA which was shared with DPHO, DDC on April 29th, 2013.

Bardiya was one of the two practice site for RA of the district health systems. Hence, the RA process followed in Bardiya gave H4L many tips in further strengthening the RA process and the tool.

The interaction processes and the information collection during the RA were confined to district- based offices. The RA team did not make field trips to below district level institutions for information collection because of most information including the sub-district level that the RA required were available at the district offices. Visiting peripheral health facilities and interaction with HFOMCs and FCHVs would have enriched the RA but this was not done. This can be considered as the major limitation of the RA.

1.4 Organization of the Report

The findings of the RA are presented in ten Chapters. Chapter one presents the purpose of carrying out RA and the methodology followed. Chapter two presents the introduction of Bardiya district. Chapter three explains the DHO systems and structures. Fourth and the Fifth chapter present the service statistics and the status of the HFOMCs in Bardiya district. Sixth and the Seventh chapter present the findings on service delivery/quality of care and logistics management system. Chapter Eight, Nine and Ten reports findings on BCC, AYFS and GESI in Bardiya district.

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BARDIYA 2 2. INTRODUCTION OF BARDIYA DISTRICT

2.1 Geo-Political Situation Bardiya District is situated in Bheri zone, of the Mid-Western Development Region of Nepal. Gulariya is the districts headquarter of Bardiya and it covers an area of 2,025 km². Bardiya is bordered on the west by north by , east by Banke District and the south by Uttar Pradesh of India. There are 31 Village Development Committees (VDCs) with 279 wards and one municipality - Gulariya with 14 wards in Bardiya district. Among 31 VDCs, 11 are across the Karnali river.

BANIVABHAR SANOSHREE

MAGARAGADI DEUDAKALA GULARIYA MUNICIPALITY MOTIPUR DHADHAWAR

Table 2.1: Population of the District 2.2Demographic Information Number Percent Table 2.1 presents the Census 2011 data on Total Population 4,26,576 - total population of Bardiya district. The total Male 2,05,080 48.07 population of Bardiya district is 4, 26,576 where Female 2,21,496 51.92 the proportion of female is slightly greater than Household number 83147 - Source: Census 2011 male. The Census also reports 83,147 Dalit 34086 8.9 households in Bardiya district. Relatively Advantaged 5503 1.4 The Census 2011 data by caste/ethnicity is not Bramhin/Chhetri 94951 24.8 available yet hence, the RA used caste /ethnicity Disadvantaged Janajati 216064 56.4 data from 2001 Census. The result shows that Other Terai 19789 5.1 more than 50 percent of the population of Caste Group Bardiya belongs to disadvantaged caste groups Muslim 11569 3.0 Others (56.4 percent are Disadvantaged janajatis and 687 0.1 Source: Census2001 8.9 percent are dalits). It also shows that there is 3.0 % muslim, 5.1 % other terai caste group and 24.8 % Bramhin/Chhetri in Bardiya.

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BARDIYA 3 3. DPHO STRUCTURE AND SYSTEMS

This chapter presents the findings related to the D/PHO structure and systems collected from the RA. The findings covers following areas: service delivery points, management system, health workforce, monitoring and evaluation system, IT and health information management and disaster management system.

3.1 Service Delivery Points Table 3.1: Number of service delivery points Type of service delivery points Number The District Health Office, located in Government district Hospital 1 Gulariya is the main responsible institution PHCC 3 of the MOHP at Bardiya to provide Health Post 12 preventive, promotive and curative health Sub-health Post 18 services to the people of Bardiya. There Private hospital/Nursing Home 01 are a total of 33 peripheral public health Birthing centers 17 facilities (3 PHCCs, 12 HPs and 18 SHPs) Functioning birthing centers 17 and a district Hospital in Bardiya district. SBA Sites 17 There are 17 birthing centers and all of PHC Out-Reach Clinic 155 them were reported as being functioning Immunization Clinic 190 FCHVs (VDCs) 754 by DHO officials during the time of RA. FCHVs (Municipality) 87 There are 155 PHC-ORCs and 190 NGO clinics (SBA/BEOC/FP) 1 Immunization Clinics. There are 841 SOS health centre 1 Female Community Health Volunteers Source: D/PHO Bardiya, 2013 (including municipality) of the district. There is one private hospital in Rajapur VDC. In addition, there is one SOS health centre, one district Ayurvedic hospital and one Thakurdwara Community Health Unit in the district.

3.2 Management Systems Table 3.2: Current Status of Program Management Team 3.2.1 Program Management Team DHO Team Status 1. Sr. Public Health Administrator Filled 2. Public Health Officer Filled Table 3.2 presents the sanctioned 3. Public Health Nurse vacant positions at DHO. There is a total of 13 4. Statistics Assistant/Officer Filled technical staff at DHO, Bardiya. In 5. FP focal person (FPSO) filled Bardiya, the post of Public Health Nurse 6. Malaria focal person Filled (PHN) is vacant and the remaining 7. Health Education Tech/ Officer Filled positions were filled-in during the time of 8. DTLA/Officer Filled RA. 9. EPI Supervisor/Officer Filled 10. Cold Chain Assistant/ Officer Filled 11. Computer Operator/Officer Filled 12. Store Keeper Filled 13. Public health inspector Filled 14. Child Health focal person Filled 15. Account officer Filled 16. Admin officer Filled

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BARDIYA 4 3.2.2 Meetings DHO Bardiya holds different types of meeting every month which includes monthly meetings of the Health Facility In-charge at DHO, Reproductive Health Coordination Committee (RHCC), Quality Assurance Working Group meeting, District AIDS coordination Committee meeting and GESI technical group meeting. The monthly meeting of the ilaka in-charges is organized on 8th of every month at DHO. RHCC meeting are conducted on quarterly basis (The list of RHCC members is provided in Annex 2). QWAG is formed at the district level but its meeting is not regular. QI committees at HF level also have been formed and orientation provided with the support of GIZ but the committees do not meet on regular basis because of budgetary problem. GESI technical group in the district also not functional due to budgetary constrain.

3.3 Health Workforce Table 3.3 presents the current status of health workforce in Bardiya district. Out of the 3 PHCCs, only one has Medical Officer (MO) position filled-in and all positions of staff nurse are fulfilled during the time of RA. Ten positions of the AHWs who have been promoted from VHWs are vacant. DHO Bardiya has contracted and posted 25 ANMs to different HFs. It was also reported that some peripheral level health workers have been recruited by National Planning Commission (NPC) and VDC. Table 3.3: Current status of health workforce Type of human resources Number GoN Number supported from Sanction Filled- Temp Cont VDC NPC Other ed in orary ract a. Medical Officer 6 1 0 0 0 0 0 b. Staff Nurse 7 7 0 0 0 0 1 c. Sr. ANM 3 3 0 0 0 0 0 d. ANM Including Padnam ANM 42 31 0 25 10 0 0 e. HA/Sr. AHW 18 14 0 2 * 0 0 0 f. AHW Including Padnam AHW 81 71 0 0 0 0 2 g. Lab Assistant 06 04 0 0 0 0 10 h. Adm. Assistant 04 04 0 0 0 0 0 i. Store Keeper 02 02 0 0 0 0 0 j. Office assistant 60 60 0 0 0 0 0 k. Vaccinator NA 00 0 08** 0 0 0 Source: DPHO, Bardiya * From RHD, **From DPHO

3.4 Monitoring and Supervision There is monitoring and supervision system at DHO Bardiya but it has not developed any supervision plan for the FY 2069/70. Supervisors of DHO Bardiya is doing program specific supervision and monitoring to the HFs as needed but they don’t provide written feedback in regular basis to the HFs after monitoring and supervision. Sometimes the district supervisors do program specific joint supervision and monitoring visit to the HFs with Save the children and Max-pro staff. There is no system of supervision and monitoring from ilaka HFs to SHP.

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BARDIYA 5 3.5 Information Technology The RA also explored the existing IT infrastructure at DHO. There is internet facility in DHO. Among the district supervisors currently 6 personnel are skilled on Computer application in MS-Word and Excel and are working on it. There are 15 desktop, six laptops and nine printers - functioning at DHO Bardiya. Similarly there are three computers in the peripheral HFs ( HP, Rajapur PHC and Sanoshree HP).

3.6 Health Information Management

DHO Bardiya has a system to enter Health Facility level data in HMIS software. Recently the Statistics Officer received four days training on web-based HMIS reporting. For improving data quality, DHO is organizing an event of Data validation program every year but it has not been conducted in this fiscal year due to transfer of budgets to other programs.

3.7 Natural Disaster Response Mechanism

DHO Bardiya has well functioning RRT at district level as well as at HF level (cluster-wise). Along with the DHO, various organizations like DAO, DDC, WCO, DEO, RRN, GIZ, NRCS, FPAN and Tharu Mahila Utthan Kendra etc are also working to respond to natural disasters in close collaboration with each other.

3.8 Strength and Opportunities The major strengths of the DPHO are as following:  Almost all sanctioned posts are fulfilled except PHN  Web- based HMIS reporting system existing in DHO  Meetings, Workshop and orientations are generally carried out prior or after the office time  All HWs received QI orientation from GIZ.

Likewise, the key opportunities are as following:  Existing committees (RHCC, QAWG, GESI-TG and DACC) at district and HFQI committee at Health facility level through which most of the problem can be solved to improve the quality of health services.  Working different partner organizations in the sector of Health like Save the Childern, PLAN through local NGO GERUWA, GIZ, FPAN, MSI, NRCS and Max-pro. H4L can do collaboration with the organizations that have the same type of program objectives.  Ilakas’ monthly meeting is conducted in monthly basis due to budgetary problem

3.9 Key Issues and Challenges The major challenges and constraints faced by the DHO Bardiya are as following:  No regular QAWG meeting at district level and no regular HFQI meeting at HF level.  Doctors are not available as per the sanctioned post and staff retention problem persists.  Problem in staff retention especially in Karnali-Pari VDCs.  Irregularity of HWs in Hard to reach VDCs especially in Karnali-Pari VDcs.

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BARDIYA 6 3.10 Possible ways to overcome the challenges  Make a focal person with full authority to arrange, coordinate for the regular meeting (Fixing of meeting date).  Coordination with higher authority to fulfill the vacant post (PHN and doctors)  Could minimize the problem by encouraging them by providing some extra incentive (if possible), prioritizing during training/workshop etc

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BARDIYA 7 4. SERVICE STATISTICS

The RA also sought information on the service statistics of the following programs: Immunization, Child health, Safe Motherhood and Family Planning. HMIS data for the last five years were analyzed. The five year trend analysis of the selected indicators is presented in this section. Data for the years 2065/66 to 2068/69 is for one complete year and data for the FY 2069/70 is from Shrawan to Falgun (08 months) only.

4.1 Immunization The Diagram shows that the coverage of measles vaccine in Bardiya district is in decreasing trend and it is also than less than the national average. The coverage of both vaccines (BCG and Measles) in FY 2067/68 and 2068/69 is less than 70%. If the coverage trend of both vaccines remains same in the current FY 2069/70, it seems that the coverage of BCG will remain below 85 % and the coverage of measles vaccine will remain below 75%. So, DHO Bardiya may need to have some special attention to improve the immunization coverage of the district. The coverage of TT2 & TT2+ among pregnant women is 58.18%, 64.05%, 51.1% and 50.98 % respectively in FY 2065/66 to 2068/69 and 42.2 % in 2069/70 (Shrawan to Falgun).

4.2 CB-IMCI The graphs show that the trend of severe pneumonia among new ARI cases and severe dehydration among new diarrhoeal cases is less than 1% and also not exceed the national average. Rapid assessment also shows that the proportion of new pneumonia cases treated with antibiotics and new diarrheal cases treated with ORS + Zinc is in increasing trend.

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BARDIYA 8 4.3 Safe Motherhood The graphs show that the ANC first visit and four ANC visit is in decreasing trend and four ANC visit is very low in comparison to ANC first visit. It also shows that, delivery conducted by SBA (Home and Institution) is in increasing trend, but PNC first visit as percent of expected live births is decreasing.

4.4 Family Planning The diagram shows that the CPR (all modern methods) as percentage of MWRA of Bardiya district is in increasing trend. As per the eight month data of Current FY 2069/70 the CPR of Bardiya is 56.47 % which is greater than national average (43%). FPAN and Marie stops center is also working in the district on FP and providing support to DHO Bardiya.

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BARDIYA 9 Table 4.1: Trend in utilization of services SN Indicators 2065/66 2066/67 2067/68 2068/69 2069/70*

1 BCG coverage 70.49 73.32 67.71 66.05 56.49 Table 4.1: Trend in utilization of services 2 DPT 3 73.13 67.11 76.87 69.39 50.9

3 Measles vaccination coverage 71.28 75.11 68.33 65.76 47.1

4 TT 2 & TT2+ coverage among pregnant 58.18 64.05 51.1 50.98 42.2 women 5 Proportion of new pneumonia cases treated 24.74 24.45 34.62 36.34 33.14 with antibiotics 6 Percentage of severe pneumonia among new 0.29 0.41 0.39 0.4 0.25 cases 7 Proportion of new diarrheal cases treated 74.22 51.46 99.32 99.55 97.71 with ORS + Zinc (under 5 years children) 8 Percentage of severe dehydration among 0.17 0.06 0.06 0.11 0.02 new cases 9 ANC 1st visit as percent of expected 78.64 80.68 68.85 66.85 42.49 pregnancies 10 Four ANC visits among as percent of 48.31 50.48 44.72 44.48 32.6 expected pregnancies 11 Percent of pregnant mothers receiving iron 84.18 87.59 76.59 68.35 45.57 tablets 12 Delivery conducted by SBAs (both home and 14.11 32.57 39.92 41.20 37.06 institutions) as percent of expected live birth pregnancies 13 PNC First visit as percent of live birth 44.60 57.64 48.87 44.91 37.96

14 Percent of postpartum mothers receiving 50.88 64.38 56.13 55.16 42.95 Vitamin A within 6 weeks 15 Contraceptive prevalence rate (all methods) 48.75 48.78 51.54 52.48 56.47 as percentage of MWRA

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BARDIYA 10 5. HEALTH FACILITY MANAGEMENT COMMITTEE AND LOCAL HEALTH GOVERNANCE

Information on Health Facility Operation and Management Committee was sought from both DHO and DDC. Both quantitative and qualitative methods were used for collecting information. Information was collected on the following topics: HFOMC functionality, capacity building, presence of different community-based groups at VDC level and their federations at district level. This chapter presents the major findings of the assessment on HFOMC.

5.1 Functioning HFOMC Top Five functional HFOMC  Sanoshree In Bardiya, all HFs (PHCCs, HPs and SHPs) has been handed over to  Bagnaha the local bodies in F/Y 2062/63. District supervisors were also  Thakurdwara asked some questions on criteria for measuring HFOMC  Baniyabhar functioning. According to them, the criteria for measuring  Rajapur HFOMCs functioning are: The bottom of Five HFOMC  Regularity of HFOMC meeting (as per the guideline).  Pasupatinagar  Suryapatuwa  Support provided by HFOMC to the HFs (HR management, infrastructure and National Campaigns etc.)  Mathurahardwar  Preparing of meeting minute and status of it’s implementation  Beluwa  Daulatpur  Social auditing at local level.  Local resource mobilization for health.

The DHO supervisors also expressed that 40% of the total HFOMCs of the district are functional. The top five functional HFOMCs as reported by the district supervisors Mr. Sanat Kumar Sharma (HFOMC Focal Person) are: Sanoshree, Bagnaha, Thakurdwara, Baniyabhar and Rajapur. Similarly, the bottom five HFOMCs in terms of functionality are Pasupatinagar, Surayapatuwa, Mathurahardwar, Beluwa and Daulatpur.

5.2 Capacity Building of HFOMC According the HFOMC focal person Mr. Sanat Kumar Sharma (Health Education Technician officer), the entire HFOMCs of Bardiya district have received capacity building training. The training was organized by DHO with the support from Save the Children and GIZ.

5.3 Community Groups/Federation/ALLIANCE

According to the district supervisors’ different type of community groups exists at VDC level of Bardiya district. These groups include-Forestry Users Group, Mothers’ Group, Drinking Water Users Group, Cooperatives and Media group. Pregnant Mother’s group has also been formed in all 09 wards of 05 VDCs of Bardiya district (across the Karnali River) by a local NGO named Geruwa in support of PLAN Nepal. The VDCs are Bhimapur, Dhadhawar, Mahamadpur, Baniyabhar and Suryapatawa. The members of pregnant mother group meet monthly for sharing information and experiences. As per the DDC Bardiya, there is existence of the federation/alliances of Forestry Users Group, Drinking water users group, Cooperatives as well as Press and Media federation at district level.

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BARDIYA 11 5.4 Strength and Opportunities  HFOMC have been formed in all VDCs in F/Y 2062/63.  All the HFs has been handed over to the local committees in the same F/Y.  All the HFOMC members have received capacity building training and refresher training.  Pregnant Mother’s group has also been formed in 05 VDCs of Bardiya across the Karnali River by a local NGO named Geruwa in support of PLAN Nepal. They meet monthly for

sharing information and experiences and discussed in BPP flip chart.  Different type of community groups exists at VDC level. These are Forestry Users Group, Pregnant Mothers’ Group, Drinking Water Users Group, Cooperatives and Media group.

5.5 Key Issues and Challenges (Based on discussion with D/PHO and DDC personals)  Irregular meeting of HFOMC in most of the VDCs. Due to less responsibility feeling of HFOMC members towards the HFs, they don’t take the HFOMC meeting as priority. They thought that the management of Health facility is the responsibility of Government of Nepal. Since they don’t have any incentive for the meeting they don’t have much interest to attend the HFOMC meeting regularly (monthly basis) but they used to come for meeting on need basis especially when they are called for special programs like NID, NVAP and other special evidence. According to the focal person, the situation can be improved by sensitizing of HFOMC members on their roles and responsibilities through on site coaching.  Lack of community ownership towards the HFs The community people especially from the madheshi community thought that what they will get after meeting and why should they expend their time for the meeting. They usually thought that the management of Health facility is the responsibility of Government of Nepal. They also thought that there is no any financial benefit and also don’t have any authority to mobilize financial resources. So they don’t come for the meeting in regular basis and also

not want to take much responsibility towards the HF.  No meaningful participation of HFOMC members during meeting. In practice, the HFOMC members in most of the VDCs don’t come for meeting in time and also not in regular basis because they think that it is not their job and they don’t get any incentive for the meeting. Even they participate; they usually don’t come at the same time and don’t take part in the discussion actively. The reasons behind are lack of responsibility feeling toward HFs and less involvement in financial management etc. As per the focal person, by encouraging the HFOMC members for active participation in the meeting can improve the situation and also help to minimize the problems/issued related to health services at local level.  Less monitoring from DPHO/DDC. The non functionality of HFOMC is also due to the less monitoring form DPHO/DDC. As per the HFOMC focal person, it can be improved if regular monitoring of HFOMC meeting can be done from DPHO/DDC. 5.6 Efforts are required to overcome the problems/constraints  Regular follow up by doing joint visit to HFOMC meeting  Sensitization of HFOMC on their roles and responsibilities.  Encouraging them for regular meeting.  Technical assistant and on site coaching to HFOMC members during meeting.

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BARDIYA 12 6. SERVICE DELIVERY/QUALITY IMPROVEMENT

This chapter presents the RA findings related to service delivery and quality of care. Information on the quality of ANM schools, infection prevention practices at HFs, implementation of community- based interventions, and the provision of IUCD and Implants services were collected at district level. The major findings of the assessment are presented here under.

6.1Service Delivery

The RA sought information on the availability of Satellite clinics, CEONC, long acting FP methods, implementation of community-based interventions such as CB-NCP, MSC, Calcium, and Nutrition service integration.

In Bardiya, DHO has planned to conduct satellite clinic in 3 sites, but only one site is functional at the time of RA. CEONC service is not available in the district because of unavailability of doctor in the district. BEOC service is providing through 3 PHCCs and 01 district hospital.

In Bardiya, MSC program is not implemented. CB-NCP is implemented with the Support of Save the Children. CMAM and IYCF with Baalvita community promotion program have been implemented with the support of UNICEF and Maxpro respectively. With regards to providing long acting FP methods, IUCD is being provided from 8 HFs including district clinic and Implants from 7 HFs. FPAN is also providing the long acting Family Planning service from 4 VDCs and district static clinic. Detail information of birthing sites and SBA trained HWs is provided in Annex 1.

Table 6.1: IUCD and Implants Insertion and Removal Sites of Bardiya IUCD Insertion/removal sites Birthing Center? Implants Insertion/removal sites Birthing Center? Y/N Y/N 1. Sorahawa PHC Y 1. Sorahawa PHC Y 2. Mangragadhi PHC Y 2. Mangragadhi PHC Y 3. Rajapur PHC Y 3. Rajapur PHC Y 4. Sanoshree HP Y 4. Sanoshree HP Y 5. Bagnaha HP Y 5. Dhadawar SHP Y 6. Khairichandanpur HP Y 6. Bagnaha HP Y 7. Nayagau HP Y 7. District FP/MCH clinic N 8. District FP/MCH clinic N Note: Total no. Birthing sites in the district: 17 Total CEONC sites: 00 Total BEONC Sites: 04 Total no. of IUCD service Sites: 08 Total no. of Implant service sites: 07

6.2 ANM Schools

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BARDIYA 13 H4L intends to improve the quality of pre-service ANM trainings. In case of Bardiya, there is no ANM school but ANMs from different institute of other districts (especially from CMA/ANM Institute, Nepalgunj) often comes for practicum. The institutes coordinate with DHO and come for practicum only after receiving consent of DHO, Gulariya.

6.3Infection Prevention and Waste Management Practices at HFs

Few questions related to infection prevention and waste management practices followed at HFs were also asked to district supervisors during RA. It was found that different HFs practice different type of infection prevention and waste disposal practices. Out of the 17 birthing sites, only nine have placenta pit. In the rest of birthing sites, where there is no placenta pit, the visitors used to take placenta with them to dispose but not confirmed how and where the visitors dispose it. In the district hospital the IP practice is not satisfactory due to the shortage of manpower (Sweeper) for waste disposal and cleaning purpose even there is existence of placenta pit and incinerator.

6.4 Strength and Opportunities

There are 17 functional birthing centers and 51 Nursing staff are trained in SBA in the district. Out of 17 birthing centers, 9 have placenta pit for the proper disposal of placenta. Programs like CB- IMCI, CB-NCP, CMAM and IYCF with Bal-vita Promotion program have been implemented in the district which is very good opportunity to improve the health status of mother and child of Bardiya district.

6.5 Key Issues and Challenges

 Problem in the infrastructure of some birthing centers especially in Khairichandanpur HP and Deudhakala HP (Under Construction)  Problem in logistic supply (Instruments, equipments) like Suction machine, Vacuum set etc.  Untrained HWs and FCHVs on CB-IMCI (60 HWs including contract staff. and about 100 FCHVs)  Delay release of Budget so difficulty to conduct quality activities.

6.6 Possible ways to overcome the challenges

 Co-ordination with DDC and VDC for local resource mobilization (infrastructure, staff hiring etc.).  HFOMC Re-activation for health needs analysis and linkage with DDC/VDC.  Making the logistic system more effective (strengthening of PULL System in the district)  On site coaching to the staff and community volunteers on technical areas

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BARDIYA 14 7. LOGISTICS MANAGEMENT SYSTEM

Logistics management is an important part of district health systems. Efficient logistics management is required to smoothly run all the public health programs at district, sub-district and the VDC levels. The RA also sought information from DHO on the logistics management system. The major findings of the assessment are presented below.

7.1 Availability of Key Drugs and Commodities

During RA, the store room of the DHO was also visited and the store keeper was interviewed. The availability of 11 commodities/some essential drugs (Injectable, Oral Contraceptive, Condom, ORS, Vitamin A, Iron Folate Tablets, Cotrim (Ped), Zinc, Oxytocin, Gentamycin and MgSO4) in the district store at the time of visit was checked. It was found that all of them were available when checked. The store keeper was also asked whether the 11 drugs/commodities were out of stock anytime in the last 12 months, and it was found that 2 commodities (Iron folate and Cotrim-pd) had been out of stock in the last 12 months. The RA team members also checked the expiry dates of the drugs/commodities and it is found that Magnesium Sulphate was expired at the time of visit.

Table 7.1: Availability of key drugs/commodities and their expiry dates SN Drugs/Commodities Availability at Stock out in the Expired drugs in the time of visit last 12 months stock at the time of visit 1 Injectable Contraceptive Y N N 2 Oral contraceptive Y N N 3 Condom Y N N 4 ORS Y N N 5 Vitamin A Y N N 6 Iron Folate Tablets Y Y N 7 Cotrimoxazole (Ped) Y Y N 8 Zinc Y N N 9 Oxytoxin Y N N 10 Gentamycin Y N N 11 MgSO4 Y N Y

The Store keeper was also asked to list the drugs that have most problems with stock outs in the FY 2069/70 and found that Cotrim-Pd. Iron, Primaquine, IUCD and Implant were the drugs with the most problems of stock outs in the year. It is also found that MgSO4, Metochlorpropamide tab, tetracycline ointment Cotrim DT (240 mg) are the drugs with most problems of over stock in the FY 2069/70.

7.2 Cold Chain and FEFO Management

DHO Bardiya has fifteen refrigerator among them eleven are functioning. The available refrigerators are sufficient to DHO for maintaining cold chain and also have regular power back up system for the cold chain room. The management of five drugs in the store was checked to see whether First Expiry First out (FEFO) was maintained.

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BARDIYA 15 7.3 LMIS reporting

DHO is using web-based LMIS to report to center regularly. DHO has recruited one data entry person for the entering LMIS data.

7.4 Strength and Opportunities

DHO Bardiya have well managed district store and cold chain system with regular power back up system including on trained data entry person for the entry of LMIS data. FEFO system is maintained in the district store. PULL system have been implemented in the district for the proper management of drug supply to the HFs.

7.5 Key Issues and Challenges

 Vehicle is not in good condition for the drug supply (Old Vehicle)  Difficult to follow the PULL system at all time.  Delay dispatch of HMIS forms from the centre.  Supply of unrequested medicine from the centre.  Less supply of Iron and folate to the district as per the target expected pregnancy.

7.6 Possible ways to overcome the issues and challenges

 Maintainance of vehicle in good condition  Strengthening of PULL system  Coordination with LMD for timely and sufficient supply of HMIS tools an commodities to the district.

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BARDIYA 16 8. BEHAVIOR CHANGE COMMUNICATION

H4L aims to understand legal, cultural/religious, and policy dimensions of GESI inequities on health service access and use and design interventions to ensure sustainable, high-quality BCC and IEC approaches that respond to local realities, and include groups not commonly targeted, but crucial to meeting Nepal’s health goals by mobilizing LTAPs.

One of the objectives of the RA was to explore the range of BCC interventions that is being implemented for healthy behaviors in Bardiya district. Following are the major findings on BCC:

8.1 Existing D/DPHO Programs on BCC

DHO Bardiya has been organizing BCC program activities as per the National Health Education Information and Communication Center (NHEICC) yearly plan such as production and distribution of IEC materials, short massages broadcasting through local FM/radio, school health program, orientation to teachers, journalists etc. DHO do not have any collaboration with other INGO, CBO for the implementation of such program except Medias (FM, Journalist).

8.2 FM Stations/Cable Television Networks

In Bardiya there are three FM stations. Name Address: Fulbari FM Gulariya and Bhurigaon Babai FM Gulariya Rurubaba FM Basgadhi

DHO Bardiya has partnership with all of the above mentioned FM stations for airing radio health programs and Public Service Announcements (PSAs) on FP, RH, Immunization, ARI, Diarrhoea, Neonatal care, Institutional Delivery and communicable diseases on prime time. DHO has been distributing program to these FM on rotation basis. It was also reported that there is one Cable TV networks in Bardiya but it has not developed and aired any district-based programs related to health.

8.3 Organizations working in IEC/BCC activities

RA identified the following organizations working in IEC/BCC in Bardiya  Save the children: Community awareness raising activities through FCHVs and local FMs on child health issues especially on CB-NCP and HRH  FPAN: Adolescent awareness on FP, RH related issues through AFHS sites and mobile clinics.  GIZ: Distribution of BCC materials for Adolescent through AFHS sites.  PLAN-Nepal: support in the broadcasting of RH and CH related health massages through local FMs in Nepalgunj  Dalit Sewa Sangha : Community awareness raising activities on RH, Education, Nutrition

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BARDIYA 17 All the above mentioned organizations have program specific BCC activities. They are doing BCC activities based on their own program activities in the district.

H4L plans to use mobile phones to reach target groups with messages on health in selected district. The RA also explored whether any organization has used mobile phones to communicate health messages to target groups or entire district population together with DHO. None of the EDPs have supported in communication through mobile phone and messaging but government’s CHD section have planned to launch mobile messaging on National Immunization Program.

8.4 Counseling service One area of intervention of H4L is to improve the quality of counseling provided by health workers and community-based health workers to clients. It is therefore essential to find out whether there is pool of resources available at district level to improve counseling services. Hence, RA also collected information on the district health staff who received training on COFP/C in the last three years. During RA no record were found on COFP counseling trainees, neither with health education technician officer nor with the family planning focal person and other supervisors.

8.5 School Health Program Conducting health education classes at schools is one of the activities of DHO. In the last Fiscal year 068/069, total 72 session of school health program were organized in 72 schools from which total about 1800 students benefited. The topics mostly covered during the School Health Education Program includes-HIV/AIDS, RH, GBV, early marriage etc in different schools but in current FY2069/70, no any activities for school health program have planed and conducted.

According to the Health Education Technician Officer (HETO), beside school health education program, Peer Education among adolescent group will be more effective in reaching adolescents with health messages.

8.6 Mapping of DAG and Exploring Cultural Practices Affecting Health During the RA, in-depth information on DAG communities residing in Bardiya district was also collected from HETO. The major findings of this assessment are as following: Ethnic/Caste Villages that still Villages that were group deprived practice early highly populated Migration pattern from service marriage and Early by DAG utilization Child Bearing  Pashupatinagar  Dalits,  Mainapokhar,  Sex:- Mostly male (married)  Patabhar  Muslims,  Deudakala  Caste/Ethnicity:- Mostly people from  Baniyabhar  Yadav,  Dhadhawar Dalits and disadvantaged community  Dhadhawar  Kurmi  Jamuni  Type of Migration  Sanoshree  Motipur  Seasonal Migration to India and longer  Suryapatuwa.  Neulapur migration to Gulf countries  VDCs with High Migrants  Taratal  Sanoshree  Rajapur  Jamuni  Belawa

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BARDIYA 18 The reason behind the practice of early marriage and early child bearing is lack of awareness in the community and no special activities or intervention has been done to resolve these problems except FCHVs mobilization to increase awareness in the community and conducting school health education sessions in different schools..

DHO Bardiya has implemented health education campaign on Hand washing practice, environmental sanitation and also distributed IEC/BCC materials and organized free heath campaign for M/DAG especially focusing in hard to reach VDCs across Karnali River in last F/Y 2068/69 to increase awareness and to increase access to service.

DHO supervisors especially Health education technician officer have suggested that H4L should plan some new program and interventions in school and community especially targeted to the adolescents and it should be long term instead of one shot program and it must be in local language and culturally acceptable but they don’t suggest any name, structure or design of program.

8.7 Strength and Opportunities There are total 3 FM stations in Bardiya district which can be used for the airing of different Health massages through PSA, Radio Drama etc. Different organizations like GIZ, Save the Children, PLAN, FPAN and Dalit Sewa Sangha have been engaged on BCC programs in this district which will be very much helpful to improve community awareness on health issues.

8.8 Key Issues and Challenges  None of the EDPs have M/DAG focused BCC program in the community.  Bulk amount of BCC materials supply from center vs use at local level due to improper distribution at local level.  It is difficult to increase awareness and provide health services among people who have strong traditional and cultural beliefs, practice of early marriage and early child bearing practice.

8.9 Possible ways to overcome the issues and challenges  Timely and proper distribution of BCC materials to the community.  Mobilization of Mass Medias for community awareness activities  Conducting special intervention programs in coordination with local I/NGOs to increase community aawaeness

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BARDIYA 19 9. ADOLESCENTS AND YOUTH FRIENDLY SERVICES

H4L will also work with DHOs in selected districts to improve service accessibility of Adolescents and youths under its Objective 6. The RA also explored different aspects of Adolescents and Youth friendly services in the public health facilities of Bardiya district. Following are the major findings:

9.1 Existing Services for Adolescent

In Bardiya, there are some focused programs for Adolescents; among them most effective and regular is Adolescent Friendly Health Services (AFHS). It’s implemented from 13 centers including District FP/MCH clinic and Khairapur HP of Gulariya municipality and others are below the district (In Peripheral HFs). It’s been operating and providing services to youths since April (Baishakh) 2012, and reporting regularly every month. The following are the AFS site of Bardiya district. 1. Mangaragadhi HP 2. Patabher HP 3. Rajapur HP 4. Khairichandanpur HP 5. Neulapur HP 6. Sanoshree HP 7. Deudhakala HP 8. Sohara PHC 9. Nayagaun HP 10. Khairapur HP 11. HP 12. Shivapur HP 13. District Hospital

Besides these, other adolescents and youth friendly services are implemented from DHO with the support of Population Division like Dautari Sikshya and Saathi Sikshya, and it is still continue in the district.

9.2 Organization working for Adolescent

In Bardiya, GIZ, WCO, NRCS and FPAN are working for adolescent’s health. GIZ is providing support to the 13 AFS sites in the different HFs. It has been providing furniture, equipments on need basis to the AFS sites including BCC materials (Booklets). Family Planning Association of Nepal (FPAN) is implementing Population, Health and Environment (PHE) project funded by WWF. It has established five youth information centers and one school information center reaching 1,086 youths of the district. Special cooperative approach, “Laghu Bitta” program for reaching to Disadvantage Groups (DAG) is also implemented by FPAN. They have noticed that the use of temporary family planning methods like Condom, Pills has increased among unmarried adolescents after implementation of such programs in the district. As per FPAN, BCC program among adolescent seems more effective through school rather than FCHVs because

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BARDIYA 20 sometimes the adolescents do not expose/share their problems/issues with FCHVs in the community. So, they recommend to conduct school health program more effectively. WCO is also working with Adolescents in 5 VDCs through “KiSHORI SAMUHA” (Sorahawa, Sanoshree, Taratal, Thakurdwara and Suryapatuwa). They are providing RH related information along with life skill training to the adolescent girls. NRCS providing support to the adolescents through youth red-cross circle and junior red-cross circle to all over the district.

9.3 Strength and Opportunities

There are 13 AFS centers in Bardiya to provide services to the adolescents. WCO is also working with Adolescents in 5 VDCs (Sorahawa, Sanoshree, Taratal, Thakurdwara and Suryapatuwa) through “KISHORI SAMUHA”. It has established good networking of youths through youth corners, significant achievement in reducing early marriage problem, and also decreased the dropout rate of adolescents from the schools. It has also increased confidence in the youths to talk about sexual and reproductive health. FPAN has established five youth information centers and one school information center reaching 1,086 youths of the district. NRCS is also working in youth group through junior red-cross circle and youth red-cross circle in all over the district. H4L can coordinate and collaborate with these groups while working with adolescents at community level.

9.4 Key Issues and Challenges

 There is no separate place for the service to the adolescents.  Lack of resources for extra incentive and human resource  Lack of awareness among adolescent girls: Maintenance of hygiene during menstruation is seen a key problem to adolescents’ girls, which resulted in dropout from schools or irregularity.

9.5 Possible ways to overcome the problems

 The additional program has to be focused especially for the adolescents in the district  Coordination with higher authority for extra efforts

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BARDIYA 21 10. GENDER EQUALITY AND SOCIAL INCLUSION

H4L is designed to support the Government of Nepal’s stated commitment and responsibility to ensure that quality health services are accessible to all citizens. As such, it is critically important that sound, ongoing GESI-sensitive analysis and gender integration underpin H4L program interventions. H4L’s GESI Objectives are designed to redress gender and social inequities, and dove-tail with the objectives set forth in the MOHP’s 2009 Health Sector Gender Equality and Social Inclusion Strategy as follows:  Objective 1: Support existing MOHP policies, strategies, plans and programs that create a favorable environment for integrating GESI in Nepal’s health sector;  Objective 2: Support MOHP’s efforts to enhance the capacity of service providers and ensure equitable access and use of health services by the poor, vulnerable and marginalized castes and ethnic groups; and  Objective 3: Improve health-seeking behavior of the poor, vulnerable and marginalized castes and ethnic groups in collaboration with local government partners, community-based organizations (CBOs) and other stakeholders.

The first objective is related to policy while the latter two are directly related to DHO systems.

The RA also included assessment and analysis of the health programs of the DHO Bardiya from GESI perspective. The major findings were as following:

10.1 Formation and Functionality of GESI Committee In Bardiya, is assigned as GESI focal person. GESI committee was formed on 2069/02/29 and the committee has 26 Members (Male-20, Female 6). The committee received orientation from RHD representative.

Even though GESI committee has been formed in the district, no any meeting have organized after the formation because no budget has been allocated for the meeting and activities for the program also not defined. DHO supervisors are found well oriented on GESI but its reflection has not seen fully at community level interventions such as in the service utilization process, distribution of resource and presence of M/DAG group in decision making process. At one occasion during RA, D/PHO explained that they have been focusing and trying to reach to the hard to reach people through health services. But in the absence of GESI specific indicators they are not being able to track and measure the achievements. He also commented that the plan sent from center for district also lack GESI perspective.

10.2 One-Stop Crisis Management center One stop crisis center was established 2068/08/18 in Bardiya Hospital which has been providing 24 hour service in Bardiya. Four members working committee is also formed (Medical officer of district Hospital, Government lawyer, Staff Nurse, Female police) for the smooth functioning of OCMC. Currently MO is not available in the hospital and staff nurse is taking the responsibilities for the OCMC. According to OCMC in-charge Ms. Alina Khadka, the centre provides the services such as counseling, treatment, laboratory test and referral. Since its establishment to till Chaitra 2069, there were altogether 63 cases registered in the district. Among them 95 percent victims (cases) were female. The focal person reported that most of the cases are related to rape. Beside rape, other cases were related to GBV, physical assaults, poisoning and burns. Most of the cases come

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BARDIYA 22 through Police and their relatives. During the record review, it was found that around 47 percent cases were 20 and below 20 years. Most of the cases were registered from Mainapokhar, Jamuni, Dhadhawar and Deudhakala VDCs. Even though there is well working environment and infrastructure in the OCMC, the service has been hampered sometimes due to frequent transfer of staff and lack of essential equipments and budget.

10.3 Organizations working on GESI Three organizations: DDC, WCO and Tharu Mahila Utthan Kendra (TMUK) working on GESI were also visited during RA.

DDC has formed a GESI committee under the chairmanship of LDO and provided orientation to Committee members, staff of DDC and VDC secretaries. It was also identified that they do not have GESI specific programs, but they are integrating GESI perspective in their regular program where appropriate.

WCO and Tharu Mahila Uthan Kendra (TMUK) have no direct or separate activity on GESI, but it has been going on as a cross cutting issues along with other activities while implementing the program activities in the community, providing services at local level and selecting participants for orientation/training/meeting etc.

10.4 Opportunities  The GESI concept well known among district government (WCO, DHO and DDC) stakeholders  The focal person has comprehensive knowledgeable on GESI concept  The technical group has been formed  The GESI concept is incorporating in all government services  OCMC has been functioning well as district Hospital.

10.5 Challenges  There are many hard to reach areas in Bardiya, which are unreachable in normal circumstances.  Lack of community awareness and high traditional belief.  Irregular meeting even though the committee has formed  Difficult to measure GESI indicators in district setup  Resources constraints to implement GESI related activities  GESI related activities are limited up to district level rather than health facilities level

10.6 Possible ways to overcome the problems:  Raising awareness and providing health education to communities through mass media.  Sensitization of HFOMC members, FCHVs on GESI to have it integrated in each health programs.  Regularization of GESI TG group meeting in the district.

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A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BARDIYA 23 Annex 1: Contact Details of DHO program focal persons Years of Years of service Cell Phone Name Position service in no. district DPHA 34 2 9851039335 PHO 23 19 9848024719 Statistics Assistant/Officer 3.5 3 9804539236 FP focal person 10 2.5 9848070518 Malaria focal person 18 18 9858022068 Health Education Tech/ 33 14 9748004696 Officer DTLA/Officer 18 7/12 9858025564 EPI Supervisor/Officer 23 6 9858025325 Cold Chain Assistant/ Officer 18 8 9748019138 Computer Operator/Officer 1/2 1/2 9844820326 Store Keeper 13 5 9748012820 Child Health focal person 24 3 9848023659 Medical Recorder 19 17 9848025144 Nutrition Focal Person 25 3 9858027046

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BARDIYA 24 Annex 2: List of RHCC members

Chairman: DPHA (DHO Bardiya) Members: Representatives of • District Development Committee (DDC) • Women Child Office (WCO) • District Education Office (DEO) • Family Planning Association of Nepal (FPAN) • Nepal Red Cross Society (NRCS) • Dalit Welfare Association (DWA) • Mari stops Center • Geruwa Rural Awarness Association • Helping Hands Nepal. • RRN Member Secretary: RH Focal Person of DHO

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BARDIYA 25 Annex 3: List of Organizations and Individuals visited/contacted during RA

DHO, Bardiya 1. (DPHA) 2. (PHO) 3. (PHI-CH focal person) 4. (HETO) 5. FPO) 6. (Nutrition Focal Persion) 7. EPI Officer) 8. (Storekeeper) 9. Medical Recorder) 10. SN) OCMC centre, District Hospital Bardiya DDC, Bardiya 11. (LDO) 12. (Planning officer) WCO, Bardiya 13. (WCO) I/NGOs working in Bardiya 14. FPAN 15. Save the Children 16. Tharu Mahila Utthan Kendra, Bardiya (TMUK)

A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, BARDIYA 26 HEALTH FOR LIFE REPORT ON RAPID ASSESSMENT

OF DISTRICT HEALTH SYSTEMS

2013 DAILEKH

CHAMUNDA

HHHh

i A REPORT ON RAPID ASSESSMENT

OF DISTRICT HEALTH SYSTEMS 2013

DAILEKH

MAY 2013

TEAM MEMBERS

HEALTH FOR LIFE

HALL 401, OASIS COMPLEX

PATANDHOKA

ii TABLE OF CONTENTS

ABBREVIATIONS IV KEY FINDINGS FROM RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS V 1. RAPID ASSESSMENT 1 2. INTRODUCTION OF SURKHET DISTRICT 3 3. DPHO STRUCTURE AND SYSTEMS 4 4. SERVICE STATISTICS 8 5. HEALTH FACILITY MANAGEMENT COMMITTEE AND LOCAL HEALTH GOVERNANCE 11 6. SERVICE DELIVERY/QUALITY IMPROVEMENT 13 7. LOGISTICS MANAGEMENT SYSTEM 15 8. BEHAVIOR CHANGE COMMUNICATION 17 9. ADOLESCENTS AND YOUTH FRIENDLY SERVICES 21 10. GENDER EQUALITY AND SOCIAL INCLUSION 32

Annexes -----1 34

Annexes------2 33

Annexes------3 33

iii ABBREVIATION

AYFS Adolescents and Youth Friendly Services AHW Auxiliary Health Worker ANM Auxiliary Nurse Mid-wife BEONC Basic Emergency Obstetric and Neonatal Care PHN Public Health Nurse BCC Behavior Change Communication CB-IMCI Community-Based Integrated Management of Childhood Illness CB-NCP Community-Based Newborn Care Package CC Child Club FECOFUN Federation of Community Forestry Users Nepal CEONC Comprehensive Emergency Essential Obstetric and Neonatal Care FMC Facility Management Committee FP Family Planning GESI Gender Equality and Social Inclusion HA Health Assistant H4L Health for Life HF Health Facility HP Health Post HMIS Health Management Information System IT Information Technology LMIS Logistics Management Committee MO Medical Officer MNCHN Maternal Neonatal Child Health and Nutrition MWDR Mid-western Development Region PHCC Primary Health Care Center QI Quality Improvement QAWG Quality Assurance Working Group RA Rapid assessment RHCC Reproductive Health Coordination Committee SHP Sub Health Post N Number USAID Unites States Agency for International Development VDC Village Development Committee WDR Western Development Region BNMT Britain Nepal Medical Trust NHSSP Nepal Health Sector Support Program NRS Nepal Red Cross Society FEDO Feminist Dalit Organization MSC Matri Surakshya Chakki M&S Monitoring and Supervision MWDR Mid-western Development Region N Number NFHP II Nepal Family Health Program II VDC Village Development Committee WCO Women and Children Office WDR Western Development Region

iv KEY FINDINGS FROM RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS- DAILEKH

TOTAL POPULATION 2,61,770 NUMBER OF VDCS 55 MUNICIPALITY Narayan DHO STRUCTURE AND Public Health facilities: SYSTEMS  District Hospital-1, PHCCs-3, HPs -11 and SHPs-45  District Ayurved ausadhalay-1  Ayurved Ausadhalay -2 Private Health facilities:  NA Meetings:  District level monthly meeting with Ilaka Health Post In-charge has been conducted regularly on the 7th of every month  Ilaka level meeting is being conducted regularly for that they have fixed date for different Ilaka.  Reproductive Health Coordination Committee meets quarterly-last meeting –chaitra2069  Quality Assurance Working Group (QAWG) has been formed but meeting has not been conducted. It meets only need basis

Health Workforce:  Out of 5 medical officer only 3 position were filled at a time of RA, out of 6 staff nurse 5 position were filled, like wise out of 23 ANM only 19 position was field, Like wise out of 17 HA/Sr. AHW only 7 AHW was filled in the district, out of 64 padnam AHW only 54 filled, out of 56 padnam ANM only 40 were filled and out of 5 lab assistant only 3 were filled in the district during RA  Most of technical positions at DHO filled in except FP focal person district level  In district hospital Unfilled positions at Hospital and HFs–MO, SN, ANM, AHW and Lab assistant.  To conduct regular services in the district 2 Medical Officer, 3 Staff Nurse, 7 ANM and 11 HA/(Sr)AHW hired in a contract  .  42 ANM, 2 AHW, 2 Lab assistant, 3 AHW (padnam) and few and 25 support staff have hired from VDC  4 staff has hired from NPC Monitoring and Supervision:  M&S system and plan exists at district and Ilaka level. Integrated supervision tools are in use. IT infrastructure at DHO:  Desktops-8, Laptops-4, Printers-6  Most District Supervisors are skilled in using MS World and Excel.  Enter service statistics by HFs in HMIS database  Well established internet facility.  Uses Web-based HMIS for data entry and reporting.  District do not Social Inclusion reporting

Rapid Response Team: Formed at the district but not functioning as desired SERVICE STATISTICS  BCG and Measles coverage above 100 percent in the last three years  Severe pneumonia and severe dehydration cases have declined in the first

v three year period but has increased in the FY 2068/69. Severe cases are below one percent.  Drop out from ANC first to ANC fourth visits is high and in the FY 068/69 it was 97 percent and 56 percent respectively.  SBA deliveries are in increasing trend (64 percentage in 068/069 which is 7 percentage more than 067/068 )  Contraceptive Prevalence Rate is in increasing trend and was 35 percent in 2 068/069) HEALTH FACILITY  None of the HFs is handed over to VDCs. MANAGEMENT COMMITTEE  All HFOMCs received capacity building trainings, refreshers and technical AND LOCAL HEALTH support visit from NFHP II. GOVERNANCE  About 25-50 percent of HFOMCs are said to be functioning  At community level groups such as -Forestry Users Group, Mothers’ Group, Drinking Water Users Group, Irrigation Users Group, Road Rural Users Group, Cooperatives, Media and Pregnant Mother group are functioning. SERVICE DELIVERY/QUALITY  Regular CEONC services provided at district. IMPROVEMENT  Satellite FP clinics-1  CB-NCP, MSC, Calcium programs implemented  Birthing centers-52. All has placenta pit  There are 52/52 functional birthing centers which better opportunity to provide other HEI those clients who came to get services.  32 Birthing centers have placenta pits.  Out of 50 health facilities, 8 provide long term FP methods which are one of way to provide long term family planning services to community people which helps to increases no of long term family planning users.  One CEONC service center is functioning– District hospital  Programs like CB-NCP CB-IMCI and MSC have been already implemented. And district have also one nutrition rehabilitation center  Less monitoring and supervision  Need CB-IMCI training for newly joined FCHVs and health workers (health workers 30 and FCHVs 180) BEHAVIOR CHANGE  FM stations-2 COMMUNICATION  Some I/NGOs engaged in BCC activities  In the FY 2068/069, total 130 session of school health program on HIV/AIDS, RH, GBV, early marriage etc were organized in 130 schools (3,900 students benefited). In current FY, no activities were planed and conducted for school health program.  Villages/VDCs that were highly populated by M/DAG- Naulekatwal, Belaspur, Badalamji, Lakandra, Basi, Salleri, Khadkabada, Sattala, Singaudi, and Layanti etc.  Villages that still practice early marriage and Early Child Bearing- Pipalkot, Lakandra, Bisalla, , Chamunda, , Salleri, , Baluwatar and Narayan Municipality.  Ethnic/Caste group deprived from service utilization- Dalits, Magar, etc. from Bisalla(Dharmakot), Baluwatar (wrd6,7,8,9), Belaspur(wrd1), Salleri (wrd8,9), Awalprajul (Marke), Goganpani, Dadaprajul(Satsalli) and Lakandra (Ramghat) etc.  High Migrants VDCs- Kushapni, Bhairikalikathum, Rawatkot, Badlamji, , Paduka, Nepa, Naulekatwal, Chhiudipusakot, Layanti, Jambukandh,

Chamunda, Bisalla, Lakandra, Tolijaisi, Sattala, Tilepata, Singaudi, Singhasain, Pipalkot, , Kalbhairab, Gauri and Mmalika. ADOLESCENTS AND YOUTH  AYFS- 13HFs supported by GIZ and 4 by FPAN FRIENDLY SERVICES  DHO conducted Peer Review training to 10 schools in the current FY.

vi GENDER EQUALITY AND  GESI committee formed on Jestha 2069 by NHSSP/RHD, SOCIAL INCLUSION  GESI committee is not aware of its scope of work and is not functioning. LOGISTICS MANAGEMENT  All drugs and commodities available except Iron and Cotrim (P) on the day SYSTEM of visit but Iron, Zinc and Cotrim (P) had stock out in the last 12 months.  Drugs with most problems of stock outs in the year Iron, Cotrim pd. and Tab. Antacid.  Drugs with most problems of over stock in the last year- Cap. Tetracycline and Cipro. Ointment.  Functioning refrigerators-8, sufficient for maintaining cold chain, and have regular power back up system for the cold chain room.  First Expiry First out (FEFO)- maintained well  Web-based LMIS reporting system. Data entry person recruited.

vii 1. RAPID ASSESSMENT

1.1 HEALTH FOR LIFE

Health for Life (H4L) is a five-year bilateral agreement between the Ministry of Health and Population (MoHP) and the Unites States Agency for International Development (USAID) which focuses on Systems Strengthening and improving the Maternal Neonatal Child Health and Nutrition/Family Planning (MNCHN/FP) service delivery at district and sub-district levels in 14 districts. 12 of the 14 districts are in the Mid-western Development Region (MWDR) –Banke, Bardiya, Dang, Surkhet, Salyan, Pyuthan, Dailekh, Kalikot, Jumla, Rukum, Jajarkot and Rolpa and two are in the Western Development Region (WDR) of Nepal- Argakhanchi and Kapilbastu. The project will be implemented between 2012 and 2017.

1.2 RAPID ASSESSMENT AND ITS OBJECTIVES

Rapid assessment (RA) is a method of analyzing situation of a district where issues are not well defined and where there is not sufficient time or other resources for in-depth quantitative research. RA uses intensive team interaction in both the collection and analysis of data instead of prolonged field work and iterative data analysis and additional data collection to quickly develop a preliminary understanding of a situation from the insider’s perspective. The main purpose of carrying out the current Rapid Assessment is to understand and to explore the currentexisting situation of the health service delivery system and other associated systems of theSurkhet district and stake holders which helps to implement H4L planning activities at district level as well as peripheral level.

Objectives of the RA includes following area which are given below.  Understandingthe demographic profile of the district  Understanding the existing health care delivery system of the district  Knowing the functionality of the Facility Management Committees  Understanding the status of health indicators  Analyze strengths and weakness of the DHO systems  Exploring feasibility for the implementation of specific programs for adolescents and youth  Exploring feasibility of using Information Technology in information management

1.3 METHODOLOGY

A mix of both qualitative and quantitative methods was used to carry out Rapid Assessment in which mainly contains following matters which is given below.

 Visit to District Health Offices (DHO)  Visit to DDC  Interaction and interview of key staff of government stakeholders as well as non-health organization.  Observation of DHO

1 A structuredslandered tool was developed to accumulatebasic information which was supplemented by qualitative tools to interview key informants at District Development Committee and Local Development Office (LDO), International/Non-Governmental Organizations (I/NGOs) working on different areas of health, Gender Equality and Social Inclusion (GESI), Behavior Change Communication (BCC), Information Technology (IT) in Health, Service delivery, and Governance.

A team composed for carrying out RA which included H4L staff and Government counterpart staff. Skill mix was ensured while forming team where the staff was skilled and knowledgeable on the following- Governance, service delivery, monitoring and evaluation, GESI and BCC. Involvement of Project Center, regional and district office was ensured.

Before carrying out of the RA, one day orientation on RA objective, methods and tools were organized for H4L staff together with orientation on H4L at Dailekh. RA in Dailekh was completed by H4L 4 Staffs in 9 days May9-17, 2013. Collected information was verified in the meantime by doing discussion with team member according to collected information and summary notes were developed on each thematic area for sharing with DHO and other stakeholderswhich helps to preparing RA report. After completing the RA the team finalized the presentation for RA finding sharing with DHO and other stakeholders. At the end of day, RA findings were shared and collected the feedback for final report. .

1.4 ORGANIZATION OF THE REPORT

The findings of the RA are presented in nine Chapters. Chapter one presents the purpose of carrying out RA and the methodology. Chapter two presents the introduction of Dailekh district. Chapter three explains the DHO systems and structures. Fourth and the Fifth chapter present the service statistics and the status of the HFOMCs in Dailekh district. Sixth and the Seventh chapter present the findings in service delivery/quality of care and logistics management system like wise Chapter Eight, Nine and ten report's findings on BCC, AYFS and GESI in Dailekh districts district.

2 2. INTRODUCTION OF DAILEKH DISTRICT

2.1 GEO-POLITICAL SITUATION

Dailekh district is situated in Bheri Zone in the Mid-Western CHAMUNDA Development Region of Nepal. NARAYAN Dailekh is a Hilly district Dailekh MUNICIPALITY district covers 1,505km² of Nepal’s Mid-Western Region. Its distance from the ground ranges from 544 to 4,168 meters above sea level. Administratively, Dailekh comprises 55 Village Development Committees (VDCs), one Municipality, 11 Ilaka, and 2 electoral constituencies. Its District headquarters (DHQ) is Dailekh Bazaar (Narayan municipality), and the district borders Jajarkot to the East, Achham to the West, Kalikot to the North and Surkhet to the South.

2.2DEMOGRAPHIC INFORMATION Table 2.1: Population of Dailekh District Table 2.1 shows the population of Dailekh Number Percent district. Total population of Dailekh district Total Population 2,61,770 - is 261770 among them male population Male 126,990 49 number is 126990 and female population Female 134,780 51 is 134780 which shows female population Household number 48,919 - is slightly garter than male population. Source: Census 2011 Similarly total no of house hold of Surkhet district is 48919 according census reports 2011.

Caste-wise data from 2011 Census is not available yet. According to census report 2001, 63 percent population is Brahmins/Chhetri, 25 percent is Dalits, 10 percent is Disadvantaged Janajati and two percent is relatively advantaged Janajatis. Source census report 2001

3 2. DPHO STRUCTURE AND SYSTEMS

This chapter presents the findings related to the DHO structure and systems collected from the RA. The findings cover following areas: service delivery points, management system, health workforce, monitoring and evaluation system, IT and health information management and disaster management system.

3.1 SERVICE DELIVERY POINTS Table 3.1: Number of service delivery points Type of service delivery points Number The District Public Health Office, located Government Hospital 1 in Dailekh Bazar is the main responsible PHCC 3 institution of the MOHP at Dailekh to Health Post 11 provide preventive, promotive and Sub-health Post 45 District Ayurvedic Ausadhalay 1 curative health services to the people of Ayurvedic Ausadhalay 2 Dailekh. Table no 3.1 shows number of Private hospital/Nursing Home 0 health services delivery points in Dailekh Birthing centers 52 district. There are a total of total 60 Functioning birthing centers 52 public health facilities, among them 59 SBA Sites 0 are peripheral public health facilities (3 PHC Out-Reach Clinic 310 PHC, 11 HPs and 45 SHPs) and one is Immunization Clinic 249 District Hospital. There is one District FCHVs 810 Aurvedic Ausadhalay in Dailekh district. NGO clinics (FP) 4 Source: DHO Dailekh There are 52 birthing centers and all are functioning. There are 310 PHC/ORCs and 249 Immunization Clinics running in the public sector. There are four FP clinics run by NGO. There are 810 Female Community Health Volunteers (FCHVs) in the Dailekh district.

3.2 MANAGEMENT SYSTEMS

3.2.1 MEETINGS Table 3.2: DHO team The DHO Dailekh organizes different meetings at DPHO Team Status district and sub-district levels. It includes the monthly 1. District Health Officer Filled meetings of the ilaka in-charge at district, the 2. Public Health Officer Filled Reproductive Health Coordination Committee (RHCC) 3. Public Health Nurse Filled and the Quality Assurance Working Group (QAWG) 4. Statistics Assistant/Officer Filled meetings and monthly meeting of SHP in-charge at the 5. FP focal person (FPSO) Vacant Ilaka level. The Ilaka monthly meeting is organized on 6. Health Education Tech/ Filled the 3rd of every month. The district meeting of ilaka Officer 7. DTLA/Officer Filled incharge is organized on the 7th of every month. RHCC, 8. EPI Supervisor/Officer Filled QAWG and HFs In charge meeting at district level are 9. Cold Chain Assistant/ Officer Filled organized on need basis. FCHVs monthly meetings are 10. Computer Operator/Officer Filled also conducted in all HFs . 11. Store Keeper Filled 12. Child Health focal person Filled 13. FCHV Focal Person Filled 3.2.2 PROGRAM MANAGEMENT TEAM 14. Medical Recorder Filled Table 3.2 presents the sanctioned positions at DHO. 15. Lab Technician/ assistant Filled During the time of RA, all the positions at DHO except 16. Account officer Filled FP supervisor were filled-in. Refer to Table 3.2. 17. Admin officer Filled

4 Table 3.3 HEALTH WORKFORCE

Table 3.3 presents the current status of health workforce in Dailekh district, covering those who are permanent government staff and those who are in contract or are hired temporarily. According to Nayab Subba of Out of 5 medical officer only 3 position were filled at a time of RA, out of 6 staff nurse 5 position were filled, like wise out of 23 ANM only 19 position was field, Like wise out of 17 HA/Sr. AHW only 7 AHW was filled in the district, out of 64 padnam AHW only 54 filled, out of 56 padnam ANM only 40 were filled and out of 5 lab assistant only 3 were filled in the district during RA.

Most of technical positions at DHO filled in except FP focal person district level. In district hospital unfilled positions at Hospital and HFs–MO, SN, ANM, AHW and Lab assistant. To conduct regular services in the district 2 Medical Officer, 3 Staff Nurse, 7 ANM and 11 HA/(Sr)AHW hired in a contract 42 ANM, 2 AHW, 2 Lab assistant, 3 AHW (padnam) and few and 25 support staff have hired from VDC 4 staff has hired from NPC This makes in some instance easy to perform task in the district and peripheral level health facility but it need s to recruit more medical person according to population based which makes to easy to deliver health services in sound environment in a some extent.

Table 3.3: Current status of health workforce Type of human resources Number Gov Number supported from Sanctioned Filled-in Temp Cont VDC NPC Other orary ract a) Medical Officer 5 3 2 1 0 0 0 b) Staff Nurse 6 5 3 0 0 0 0 c) Sr. ANM 0 0 0 0 0 0 0 d) ANM 23 19 7 0 42 0 0 e) HA/Sr. AHW 17 7 4 0 0 0 0 f) AHW 64 54 7 3 2 0 0 g) AHW (Previous VHW) 56 29 0 0 3 3 0 h) ANM (Previous MCHW) 49 40 0 0 0 0 0 i) Lab Assistant 05 03 0 0 2 1 0 j) Adm. Assistant 03 03 0 0 0 0 0 k) Store Keeper 1 1 0 1 0 0 0 l) Office assistant 19 19 0 0 25 0 0 m) Vaccinator NA 0 0 0 0 0 0 TOTAL 248 183(74%) 23 5 74 4 0 Source: DHO, Dailekh

3.4 MONITORING AND SUPERVISION

DHO Dailekh has its own Monitoring and Supervision System. Even though DHO have annual Supervision plan of the FY 2069/70, it is not strictly followed and the district supervisors makes need-based supervisions to HFs. No monitoring and supervision plan is developed for Ilaka level HFs to monitor SHPs. It is reported that district supervisors uses the integrated supervision tools during their supervisions. This has helped the DHO in some way as it but has not been effective because of lack of proper usage. It was learnt that DHO is in process to maintain feedback mechanism in writing. In addition, it is also promoting clinical supervision in peripheral HFs.

5 3.5 INFORMATION TECHNOLOGY

The RA tools also explored the existing IT infrastructure system at DHO. At present the DHO has 8 desktop computers, four laptops, and six printers. Most of the supervisors are familiar with MS Office package. It was reported by the DHO staff that the computers and printers are not enough for all district supervisors. There is internet facility available in the DHO. Most of DHO supervisor are familiar with IT even though they could not segregate peripheral HF data in an electronically even if lower level health facility provide them by segregating and compiling all data in hard copy. .

3.6 HEALTH INFORMATION MANAGEMENT DHO Dailekh has a system to enter HF level data in HMIS software. For improving data quality, DHO has been organizing Data Validation program every year but it has not been conducted in this fiscal year because the activity was not mention in Redbook. HMIS data by HFs are available for the last 3 years. Recently, the Statistics Officer received training on web-based HMIS reporting.

3.7 NATURAL DISASTER RESPONSE MECHANISM DHO Dailekh has a Rapid Response Team (RRT) formed at the district and Ilaka level. Along with the DHO, other stakeholders and organizations like District Administration Office (DAO), DDC, Nepal Army, Nepal Police, and NRCS etc are involved in the team and are working in close collaboration to respond to disaster. Despite having a RRT at district, the team has not fully functioned due to lack of budget, difficult geographical terrain, lack of physical facility and lack of proper human resources..

3.8 STRENGTH AND OPPORTUNITIES The major strengths of the DHO as observed during the RA are as following:  All HFOMCs are formed according to guidelines and have received training too.  RHCC and QAWG are also formed according to guideline. There is regular conduction of District and Ilaka level meetings, and FCHVs monthly meetings conducted at HFs.  There is annual monitoring/ supervision plan from DHO-Ilaka-HP/SHP. Functioning integrated supervision system with using checklist.  42 ANMs recruited from VDCs for Birthing Centers which is very encouraging.  Web- based HMIS and LMIS reporting system existing in DPHO.  Sufficient IT infrastructure at District level including Personal Computers. Supervisors are skilled on MS Office package. There is Internet Facility available in DHO.  Regular conduct of Ilaka In-charge’s monthly meeting at District.

The key opportunities in DHO are as following:  Different committees represented by different agencies are formed at district level which adds synergy in program efforts are reduces duplication of resources.

3.9KEY ISSUES AND CHALLENGES The major challenges and constraints faced by the DHO are as following:  Irregularities of assigned staff in hard to reach VDCs (HFs)  Lack of transparency of budget and to follow the code and conduct.

6  Covering the whole district by mobilizing few staff.  Coordination between relevant stakeholders within committees, and between committees is a significant challenge.  No regularization of QAWG meeting  No review of FCHV’s report by HWs and no feedback provided to FCHVs.  No clear job responsibility and accountability as well as authority of staff

7 4. SERVICE STATISTICS

The RA also explores the information on the service statistics of the following programs: Immunization, Child health, Safe Motherhood and Family Planning. For that HMIS data for the last five years (2065/66 to 2069/70) were analyzed. Here, data for four year period has been analyzed. Data for the FY 2069/70 has not been analyzed as the FY is still running and the complete data is not available with comparison with previous years.

Figure 4.1: Measles coverage 4.1 IMMUNIZATION

Trend analysis of the BCG, DPT 3 and Measles coverage in Dailekh in the last three years is above 100 (Table 4.1). Figure 4.1 compares the Measles coverage of Dailekh and that of Nepal’s aggregate. The achievements of Dailekh have been higher than that of Nepal’s aggregate in all four years.

4.2CB-IMCI

The proportion of new pneumonia cases treated with antibiotics in Dailekh has been around 20 percent in all four years of comparison. Figure 4.2 shows that the severe pneumonia cases have been declining in Dailekh and have always been lower than Nepal’s average data. Identification of ARI cases at early stage is important in Dailekh.

The proportion of diarrhoeal cases treated with ORS has increased remarkably in the four year period which is 90 percent in the most recent year. The proportion of severe diarrhoeal cases was in decreasing trend in the first three years but increased slightly in the last year. However, the severe cases in Dailekh have been always lower than that in Nepal and are below one percent.

Figure 4.2: Percent of severe pneumonia cases Figure 4.3: Percent of severe dehydration treated with antibiotics among new cases

8 4.3 SAFE MOTHERHOOD

Figure 4.4: First ANC and Four ANC as percent of expected pregnancy Service statistics of last 4 years in the Dailekh districts shows that average of ANC first visit as persentatge of expected pregnancy has decreses in FY 2067/68 and 2068/69 in the comparsion of FY year 2066/67. At list four antenatal check-up according to government protocol. Figure also shows that there s vast different between 1st ANC check up NA 4th ANC check up table shows that pregnant women attending at list 4th ANC check up. In fiscal year 2065/66 made four antenatal visits signifying that about 45.32% mother did not complete the optional fourth ANC visit. Likewise in year 2066/67 about 44.09 % mother did not complete the recommended fourth ANC check up, similarly in FY 2067/68 about 34.77 did not complete the elective recommended fourth ANC check up and FY 2068/69 about 30.61 % of women did not take 4 ANC services. If we can meet the all ANC visit in the district we can detect early complication cases and manage them in early our. Not only that we can also circulate different kind of health tips like provide health education , danger sine during pregnancy, immediate new born care , birth preparedness, BCC and IEC for FP which helps to cover long term family planning services utilization.

4.4 FAMILY PLANNING

Figure 4.5 compares the CPR of Dailekh and Nepal’s Figure 4.5: CPR as percent of MWRA aggregate. The CPR of Dailekh district is lower than that of Nepal’s aggregate in all four years. It also shows that the CPR of Dailekh has slowly increased over the four year period and was 35 percent in the most recent year.

In Dailekh, FPAN is also providing FP services in four different sites (Dullu PHCC, Belpata SHP, Badakhola SHP and Narayan Municipality). It also conducts community clinic and mobile clinic in 12 other VDCs of the district. Unless the reports of FPAN is included in HMIS, the actual CPR of Dailekh cannot be calculated.

9 Table 4.1: Trend in utilization of services SN Indicators 2065/66 2066/67 2067/68 2068/69 2069/70* 1 BCG coverage 93.8 119 115.2 111.5 73.5

2 DPT 3 93.3 105 125,3 109 64

3 Measles vaccination coverage 89.8 112 110.4 106.2 55.8

4 TT 2& TT2+ coverage among pregnant 76.9 86.2 83.4 81.3 45.1 women 5 Proportion of new pneumonia cases 48.3 25.3 18.1 21.5 20 treated with antibiotics 6 Percentage of severe pneumonia among 0.45 0.37 0.26 0.31 0.49 new cases 7 Proportion of new diarrheal cases 42.34 56 83.1 90 93.8 treated with ORS + Zinc (under 5 years children) 8 Percentage of severe dehydration 0.2 0,13 0.11 0.14 1.o4 among new cases 9 ANC 1st visit as percent of expected 100.9 96.41 97.3 58.4 pregnancies 84.8

10 Four ANC visits among as percent of 43.6 58 57.4 56.3 37.9 expected pregnancies 11 Percent of pregnant mothers receiving 85.7 1o2.5 96.6 93.7 56.3 iron tablets 12 Delivery conducted by SBAs (both home 23.4.2 52.1 57.2 63.6 and institutions) as percent of expected 46.3 live birth pregnancies 13 PNC First visit as percent of live birth 35.1 59.9 67.6 60.3 43

14 Percent of postpartum mothers 60.4 75.6 81.2 81 56.1 receiving Vitamin A within 6 weeks 15 Contraceptive prevalence rate (all 28.1 31.2 33.7 34.6 26.1 methods) as percentage of MWRA

10 5. HEALTH FACILITY MANAGEMENT COMMITTEE AND LOCAL HEALTH GOVERNANCE

Information on Health Facility Operation and Management Committee was sought from both DHO and DDC.Both quantitative and qualitative methods were used for collecting information. Information was collected on the following topics: HFOMC functionality, capacity building, the presence of different community-based groups at the VDC level and their federations at district level. This chapter presents the major findings of the assessment on HFOMC.

5.1 FUNCTIONING HFOMC

In Dailekh, none of the HFs are handed over to the local bodies. District supervisors were also asked about criteria for measuring the functionality of HFOMCs. According to HFOMC focal person at DHO, following criteria are essential for measuring functionality of HFOMCs:  meeting regularly and minuting decisions,  implementing the activities planned in meetings,  monitoring mother’s group meetings, and  Availability of human resources in HFs. The top five functional HFOMCs:  Resource (HR and budget) mmobilization 1. SHP  Regular service provision from HF 2. Belpata SHP  Regular performance review of staff. 3. Triveni HP The DHO supervisors expressed that only about 25-50 4. SHP percent of the HFOMCs of the district are functional. The top 5. SHP five functional HFOMCs as judged by the program focal The bottom five HFOMCs person and other district supervisors include-Lakuri SHP, 1. Kalika SHP Belpata SHP, Triveni HP, Gamaudi SHP and Piladir SHP. DHO 2. SHP has observed that most of the HFOMCs of the southern belt of 3. Lalikada SHP the district are non-functional. The bottom five HFOMCs in 4. Naumule PHCC and terms functionality are Kalika SHP, Chauratha SHP, Lalikada 5. Paduka SHP SHP, Naumule PHCC and Paduka SHP.

5.2 CAPACITY BUILDING OF HFOMC

The HFOMCs of Dailekh district have received capacity building training in the last four/five year period. The training was provided by DHO in support of NFHP II. In addition, NFHP II has also provided refresher trainings to all HFOMCs of Dailekh district as well as were visited by project staff to monitor the HFOMC activities and building their capacity.

It was also found out that about a year ago, national NGO- Safe Motherhood Network Federation Nepal in partnership with ADRA Nepal has provided 3 days Leadership Development Training to six HFOMCs (Toli, , Kharigaira, Rawotkot, Bhairikalikathum and Chamunda) of Dailekh district.

11 5.2 COMMUNITY GROUPS/FEDERATION

According to the district supervisors’ different type of community groups exists at the VDC level of Dailekh district. These groups include- Aama Samuha (Health Mothers Group), Drinking water users group, Ban Samuh and Youth Club. Similarly, at the district level, there is Media Federation and Safe Motherhood Network Federation Nepal which comprises 15 local NGOs.

5.3 STRENGTH AND OPPORTUNITIES

 All HFOMC are formed as per guideline  HFOMC members have received capacity building training including refresher training.  HFOMC/VDC ssupported HF in infrastructure, recruited health workers  LDO is providing human resource support in 40 VDCs.  All HFOMCs received capacity building trainings, refreshers and technical support visit from NFHP II.  There are different kind of community level groups such as -Forestry Users Group, Mothers’ Group, Drinking Water Users Group, Irrigation Users Group, Road Rural Users Group, Cooperatives, Media and Pregnant Mother group are functioning by coordinating with them we can disseminate our massage up to hard to reach community group.  Regular supervision and monitoring by coordinating with stakeholders  Coordination is needed with LDO or other responsive person.  Prepare work plan to full fill the gaps of HFs  Health needs assessment practice by HFOMCs which helps to gap identification as well as work on same.

5.4 KEY ISSUES AND CHALLENGES  Despite the interest of LDO and CDO in strengthening HFOMC and are ready to work closely with DHO on this, they were concerned on ways for motivating HFOMC.  HFOMCs are not meeting regularly though they are trained.  Lack of community ownership towards the HFs  HFOMC members selection process is not fair  Less monitoring from DHO/DDC 1. No any HFs handed over to DDC/VDCs at all. 2. Need to regularize the meeting in HFs and update status. 3. Need to improve coordination between stakeholders and local level CBOs and users groups. 4. VDC secretaries are given responsibilities to more one VDC (over load ) 5. Irregular meeting of HFOMC due to Lack of supervision and monitoring to conduct regularize the meeting in HFs and sensitize role and responsibilities of existing members.

12 6. SERVICE DELIVERY/QUALITY IMPROVEMENT

6.1 INFECTION PREVENTION AND WASTE MANAGEMENT PRACTICES AT HFS

RA also asked few questions to district supervisors on infection prevention and waste management practices followed at HFs. It was found that different HFs practice different types of infection prevention and waste disposal practices. There are 52 birthing centers in Dailekh and all have placenta pits for disposing placenta. In Dailekh there is no proper mechanism of throwing away and disposing hospital wastes. Proper management of placenta pit is also a major challenge at the district hospital.

6.3SERVICE DELIVERY

The RA explore information on the availability of Satellite clinics, CEONCs, long acting FP methods, implementation of community- based interventions such as CB-NCP CB-IMCI, MSC and service integration in Dailekh district.

It was reported that the district provides CEONC services on a regular basis. For this purpose, there is one MDGP recruited in the district.

Satellite clinic was conducted once in one site (Kalika) in this FY due to budget constraints. With respect to providing long acting reversible FP methods, it was reported that IUCD is provided from seven HFs and from district and Implants are also provided from seven HFs and from district. Refer to Table 6. Dailekh district has 52 birthing center. One BEONC site is functioning in the district. 28 ANM in Dailekh have received SBA Training.

Table 6.1: IUCD and Implants Insertion and Removal Sites of Dailekh IUCD Birthing Center? Implants Birthing Center? Y/N Y/N 1. Dullu PHC Y 1. Bhawani SHP Y 2. Dadaparajul HP Y 2. Kharigera SHP Y 3. Lakandra PHC Y 3. Lakandra PHC Y 4. Naumule PHC Y 4. Mairikalikathum SHP Y 5. Pagnathn HP Y 5. Naumule PHC Y 6. Santalla HP Y 6. Toli SHP Y 7. Narayan Municipality Y 7. Narayan Municipality Y hospital Hospital 8. Padukasthan SHP Y 8. Dullu PHC Y

 In Dailekh Matri Surkashya Chakki (MSC) was implemented by DHO in support of USAID/NFHP-II. But there have been problems with supply of MSC from Central level. Because of this HFs are facing problem in MSC distribution at community level. CB-NCP program is also implemented in the District with support from NFHP II in 2011-12. Dailekh is the district where Calcium intervention for the prevention of eclampsia was piloted. Integrated Management of Acute Malnutrition (IMAM) and Infant and Young Child Feeding (IYCF) services also provided in the district for that nutrition rehabilitation center has

13 established in this district In Dailekh, 30 health workers and about 180 FCHVs needs CB-IMCI Training.

6.4 STRENGTH AND OPPORTUNITIES

 Programs such as MSC, CB-NCP, Calcium, program are implemented in this district.  There is 52 Birthing Centers and only 32 birthing center have placenta pit. There are 28 ANM who have received SBA Training.  There are 52/52 functional birthing centers which better opportunity to provide other HEI those clients who came to get services.  32 Birthing centers have placenta pits.  Out of 50 health facilities, 8 provide long term FP methods which are one of way to provide long term family planning services to community people which helps to increases no of long term family planning users.  One CEONC service center is functioning– District hospital  Less monitoring and supervision  Need CB-IMCI training for newly joined FCHVs and health workers (health workers 30 and FCHVs 180)

6.4KEY ISSUES AND CHALLENGES

 Problem in the infrastructure of some birthing centers.  Problem in logistic supply (Instruments, equipment, MSC).  30 HWs and about 180 FCHVs need CB-IMCI Training.  Difficult to implement district programs due to delay release of Budget.  IUCD and Implant sites are limited.  Lack of clinical supervision.

14 7. LOGISTICS MANAGEMENT SYSTEM

Logistics management is an important part of district health systems. Efficient logistics management is required to smoothly run all the public health programs at district, sub-district and the VDC levels. The RA also sought information from DHO on the logistics management system. The major findings of the assessment are presented below.

7.1 AVAILABILITY OF KEY DRUGS AND COMMODITIES

During RA, the store room of the DHO was also visited and the store keeper was interviewed. The availability of 11 commodities/some essential drugs (Injectable, Oral Contraceptive, Condom, ORS, Vitamin A, Iron Folate Tablets, Cotrim (Ped.), Zinc, Oxytocin, Gentamycin and MgSO4) in the district store at the time of visit was checked. It was found that except Iron folate tablets and Cotrimoxazole (P), all other items were available when checked. The store keeper was also asked whether the 11 drugs/commodities were out of stock anytime in the last 12 months, and it was found that Zinc and Cotrimoxazole (P) has not been stock out in the last 12 months as well. The RA team members also checked the expiry dates of the drugs/commodities and not any of them were expired at the time of visit. Refer to Table 7.1.

Table 7.1: Availability of key drugs/commodities and their expiry dates SN Drugs/Commodities Availability at Stock out in Expired drugs in the time of the last 12 stock at the time of visit months visit 1 Injectable Contraceptive Y N N 2 Oral contraceptive Y N N 3 Condom Y N N 4 ORS Y N N 5 Vitamin A Y N N 6 Iron Folate Tablets N Y N 7 Cotrimoxazole (Ped) N Y N 8 Zinc Y Y N 9 Oxytocin Y N N 10 Gentamycin Y N N 11 MgSO4 Y N N

When asked about the drugs that had most problem with stock outs in the last year, it was reported that Iron, Cotrim (P) and Tab. Antacid were mostly stocked out in the last FY. Drugs with most problems of over stock in the last year was Cap. Tetracycline and Cipro. Ointment.

7.2 COLD CHAIN AND FEFO MANAGEMENT

DPHO Dailekh has eight functioning refrigerators. The available refrigerators are sufficient to DHO for maintaining cold chain. Power back up system is also regular in the cold chain room.

7.3 LMIS REPORTING

DHO is using web-based LMIS to report to center regularly.

15 7.4 STRENGTH AND OPPORTUNITIES

DHO Dailekh has well managed district store and cold chain system with regular power back up system. It has a trained data entry person for the entry of LMIS data. FEFO system is maintained in the district store. PULL system have been implemented in the district for the proper management of drug supply to the HF. All drugs and commodities available except Iron and Cotrim (P) during the time of visit. DHO has eight functioning refrigerators, which is sufficient for maintaining cold chain, and have regular power back up system for the cold chain room. First Expiry First out maintained well in Dailekh.

All drugs and commodities available except Iron and Cotrim pd. on the day of visit. . 7.5 KEY ISSUES AND CHALLENGES

 Congested store room at district level.  Vehicle is not in condition for the drug supply (Old Vehicle)  On the day of visit but Iron, Zinc and Cotrim pd. had stock out in the last 12 months.  Drugs with most problems of stock outs in the last FY were Iron, Cotrim pd. and Tab. Antacid.  Drugs with most problems of over stock in the last year were Cap. Tetracycline and Cipro. Ointment.  Difficult to follow the PULL system while working in the DHO. The pull inventory control system begins with a HF order. With this strategy, we can only make to fulfill HF orders. One advantage to the system is that there will be no excess of inventory that needs to be stored, thus reducing inventory levels and the cost of carrying and storing goods.

16 8. BEHAVIOR CHANGE COMMUNICATION

H4L aims to understand legal, cultural/religious, and policy dimensions of GESI inequities on health service access and use and design interventions to ensure sustainable, high-quality BCC and IEC approaches that respond to local realities, and include groups not commonly targeted, but crucial to meeting Nepal’s health goals..

One of the objectives of the RA was to explore the range of BCC interventions that is being implemented for healthy behaviors. Following are the major findings on BCC:

8.1 EXISTING DHO PROGRAMS ON BCC

DHO Dailekh has been organizing BCC program activities as per the DHO’s yearly plan provided from the National Health Education Information and Communication Center (NHEICC) such as production and distribution of IEC materials, Public Service Announcement airing through local FM radio, school health program, orientation to teachers, journalists etc. All the IEC/BCC related information has been collected from (HE focal person) and (FP focal person).

8.2 FM STATIONS/CABLE TELEVISION NETWORKS

There are two FM stations in Dailekh.

1. Radio Dhruba Tara FM, Narayan Municipality, Dailekh 2. Radio PanchaKoshi, Khada Chakra, Narayan Municipality, Dailekh

DHO Dailekh has partnered with all of the above FM stations for airing of PSA and Radio Jingles. It was also reported that there is one Cable TV networks in Dailekh but it has not developed and broadcasted any district-based programs related to health.

8.3ORGANIZATIONS WORKING IN IEC/BCC ACTIVITIES

RA identified the following organizations working in IEC/BCC, community mobilization in Dailekh:  Nepal Public Health Foundation (NPHF): working in research.  WCO  Family Planning Association of Nepal (FPAN): working in reproductive health.  GIZ  Feminist Dalit Organization (FEDO): working in increasing access to health services  Women empowerment forum  Social Service Center (SOSEC) Nepal  CAED/WRRP working area women reproductive health and Life skill training and advocacy.

H4L plans to use mobile phones to reach target groups with messages on health in selected district but there is no such intervention implemented in the district.

17 8.4 COUNSELING TRAINING

One area of intervention of H4L is to improve the quality of counseling provided by health workers and community-based health workers to clients. It is therefore essential to find out whether there is pool of resources available at district level to improve counseling services. Hence, RA also collected information on the district health staff who received training on COFP/C in the last three years.

8.5 SCHOOL HEALTH PROGRAM

Conducting health education classes at schools is one of the major activities of DHO. In the last FY (2068/2069), altogether 130 session of school health program were organized in 130 schools of 60 VDCs in which 3,900 students were benefited. The most commonly covered topics in School Health Education Program includes- HIV/AIDS, Reproductive Health, Gender-based Violence, early marriage etc. But in current FY, no activities were planed and conducted for school health program due to lack of program in red book.

Beside School Health Program, DHO could not implement any IEC/BCC activities for M/DAG to increase access to service. The reason for not organizing such events was lack of budget.

According to the Health Education focal person, beside school health education program Peer Education among adolescent group (school going or out-of-school adolescents), Health Exhibition, Adolescent focused BCC Corner in school will be effective in reaching adolescents with health messages.

8.6MAPPING OF DAG AND EXPLORING CULTURAL PRACTICES AFFECTING HEALTH

During the RA, in-depth information on DAG communities residing in Dailekh district was also collected from HE focal person and other DHO Team. The major findings of this assessment are as following:

Villages that are highly populated by DAG: 1. Naulekatwal 5. Bansi 9. Singaudi 2. Belaspur 6. Salleri 10. Tilepata 3. Badlamji 7. Khadkabada 11. Layanti 4. Lakandra 8. Sattala 1 Ethnic/Caste group deprived from service utilization: 2 Bisalla- Dharmakot, Baluwatar ward # 6,7,8 , 9, Belaspur ward 1, Saller ward 8 and 9, Awalparaju 3 (Marke), Goganpani, Dadaprajul, Satalla, Lakandra VDC’s have people belonging to Dalit, Magar 4 and Thakuri caste groups. These groups are deprived from health service utilization due to 5 geographic, economic and other barriers. 6 7 Villages that still practice early marriage and early child bearing: 8 The marginalized communities living in the 9 VDCs (Pipalkot, Lakandra, Bisalla, Kushapani, 9 Chamunda, Naulekatwal, Salleri, Belpata and Baluwatar) and Narayan Municipality’s still 10 practices early marriage and early child bearing practices. The girls stay in separate places during 11 menstruation period, and are unsuccessful in studies. Life skill training, house hold visits, school 12 health program and radio program has been effective medium to educate the girls and their 13 families.

18 14 15 Migration pattern: 16 60 percent youth and other people, majority of Male from Dalit, Chhetri, Magar and Thakuri from 17 24 VDCs (Election area no. 2) migrate to India. Migration is mostly seasonal and is high during the 18 period of Kartik to Phalgun and Baishakh to Bhadra. About two percent people migrate to gulf 19 countries. Youth from the following VDCs mostly migrate: 1. Kushpani, 9. Chhiudipusakot, 17. Tilepata, 2. Bhairikalikathum, 10. Layanti, 18. Singaudi, 3. Rawatkot, 11. Jambukandh, 19. Singhasain, 4. Badalamji, 12. Chamunda, 20. Pipalkot, 5. Dullu, 13. Bisalla, 21. Rakam, 6. Paduka, 14. Lakandra, 22. Kalbhairab, 7. Nepa, 15. Tolijaisi, 23. Gauri and 8. Naulekatwal, 16. Sattala, 24. Malika etc.

H4L can use following communication approaches in Dailekh:  Media person interaction program related on GESI  District stakeholder interaction program on BBC and service utilization  People awareness program regarding health service  Networking and advocacy with stakeholders. Likewise, networking and advocacy activities need to be coordinated to avoid unnecessary duplication or confusion.  RH interaction program with adolescent.

8.7 STRENGTH AND OPPORTUNITIES

 DHO has partnership with both the local FMs for PSA airing for year round.  There are organizations like FEDO, FPAN, GIZ, SOSEC, NPHF, WCO and women empowerment forum that are working in BCC and community mobilization activities.  Adequate availability of IEC/BCC materials in the district.

8.8 KEY ISSUES AND CHALLENGES

It is difficult to increase awareness and provide health services among people who have strong traditional and cultural beliefs, practice of early marriage and early child bearing practice.  Bulk amount of BCC materials supply from center vs use at local level due to improper distribution at local level.  Continuation of School health program.  Strong coordination between NGOs and DHO for BCC and community mobilizations activities.  High seasonal migration from near about 50% VDCs, mostly to India.  It is difficult to increase awareness and provide health services among people who have strong traditional and cultural beliefs, practice of early marriage and early child bearing practice. 9. ADOLESCENTS AND YOUTH FRIENDLY SERVICES

H4L will also work with DHOs in selected districts to improve service accessibility of Adolescents and youths under its Objective 6. The RA also explored different aspects of Adolescents and Youth friendly services in the public health facilities of . Following are the major findings:

9.1 EXISTING SERVICES FOR ADOLESCENT

In Dailekh district, there are not many NGOs working on adolescents and youth. DHO has Adolescents and Youth Friendly Health Services (AYFS) program in 13 VDC with the support of GIZ. DHO is also conducting Saathi Sikchya (Peer Education) program in 10 schools in this fiscal year. The Peer Educator program has been providing services to adolescents and youth on different issues like reproductive health, menstruation, sexual health and hygiene and sanitation. DHO has been supporting capacity building of school teachers on adolescents related health issues. Teachers selects peer group and the group transfer the messages and practices to other students and peer groups in the schools. In-terms of reporting mechanism, the Health Facilities (HFs) has been sending report on monthly basis. But the system for monitoring and providing feedback are not in place and also not followed by responsible person. Beside HFs there are few other local organizations actively involved in educating adolescents and youth on the issues related with delay marriage, sexual reproductive health, and women empowerment.

Name of AYFS VDCs in Dailekh are given below:

1. Baraha , 6. Lakuri, 10. Rakamkarnali, 2. Dadaparajul, 7. Narayan 11. Raniban, 3. Dullu, Municipality, 12. Santalla, 4. Gamaudi, 8. Namaule, 13. Raniban and 5. Lakendra, 9. ,

9.2 ORGANIZATION WORKING FOR ADOLESCENT & YOUTH

During the assessment RA team visited few of the organizations in the district that were working on adolescents’ health. Following are the name list of visited organization and their key working areas:

a. FEDO (Feminist Dalit Organization (FEDO) b. WEAF ( Women Empowerment Association Forum) c. SOSCE ( Social Service Center) d. Women group of Marginalized people (WAM) e. Women and Children Federation f. FPAN (Family Planning Association Nepal)

In Dailekh, only few NGOs are working for youth and adolescents health service. Family Planning Association (FPAN) provides overall family planning services and contraceptive distributions in 13 VDCs. The RA team visited FPAN office unfortunately the key person was not available in the district. In the district level they work with a structure of one branch in municipality and three community clinics. In community health clinic they have formed ‘Out of school’ and ‘In school’ groups. In this group, school teachers also supports in organizing different activities for students enrolled in 5 to 10 grade. FPAN is also prioritizing gender equality and social inclusion issues by focusing on socially excluded groups in their community health clinic. Here are some key points:

 Safe abortion with proper counseling that provides FP options and voluntary decision.  Family health clinic: immunization, safe delivery, contraceptive distribution.  Youth information center is available.  Weekly Outreach Clinic for family planning in 13 VDC.  Adolescents program mainly focused on family planning and contraceptives.

Some of the visited organizations were interested to join H4L work so they just mentioned that they are working on youth and adolescents but in reality there were no such program focused at the moment.

9.3 STRENGTH AND OPPORTUNITIES

The district received health education and services related program from numbers of local organizations and associations. The local organization also tried to build capacity of health worker and FCHV. DHO has been running youth friendly services and FPAN is also working for youth and adolescents. Meanwhile WDO is also working for adolescents focused program in the district. Following are some of the key strength and opportunities of DHO:

1. Receiving AFHS monthly report regularly from 13 VDC but the reviewing and feedback system is not in place. 2. Child Network, social inclusion group, women group and informal youth club formed in VDC and Municipality by FDO, FPAN and local organization. 3. Focused program on delay marriage, sexual reproductive health, FP, HIV, hygiene & sanitation. 4. Provided material support to HFs like equipment for family planning service, IEC/BCC

materials and other technical support by NGOs.

9.4 KEY ISSUES AND CHALLENGES

 Health worker who works in AYFS are not updated about the knowledge and counseling skills on adolescents related issues/problems  Regular feedback sharing mechanism is not in place.  Coordination of DHO staffs with other NGOs and CBOs is also lacking.  AFHS expansion to additional hard to reach VDCs is identified according to DHO and focal person.  Need to follow up and update the data and check the service quality in AYFS site.  Need to organize advocacy program to raise awareness about AYFS.  Regular monitoring and supervision plan and feedback and sharing mechanismis needed.  Quality monitoring mechanism should be introduced.  Need to have separate place to maintain privacy for counseling and other regular checkup in service sites.  Need to regularly follow-up and encourage health workers who work in AYFS sites. 10. GENDER EQUALITY AND SOCIAL INCLUSION

H4L is designed to support the Government of Nepal’s stated commitment and responsibility to ensure that quality health services are accessible to all citizens. As such, it is critically important that sound, ongoing GESI-sensitive analysis and gender integration underpin H4L program interventions. H4L’s GESI Objectives are designed to redress gender and social inequities, and dove-tail with the objectives set forth in the MOHP’s 2009 Health Sector Gender Equality and Social Inclusion Strategy as follows:

 Objective 1: Support existing MOHP policies, strategies, plans and programs that create a favorable environment for integrating GESI in Nepal’s health sector;  Objective 2: Support MOHP’s efforts to enhance the capacity of service providers and ensure equitable access and use of health services by the poor, vulnerable and marginalized castes and ethnic groups; and  Objective 3: Improve health-seeking behavior of the poor, vulnerable and marginalized castes and ethnic groups in collaboration with local government partners, community-based organizations (CBOs) and other stakeholders.

The first objective is related to policy while the latter two are directly related to D/PHO systems.

The RA also included assessment and analysis of the health programs of the DHO Dailekh from GESI perspective. The major findings are as following:

10. 1 EXISTING SCENARIO ON GESI

In Dailekh, GESI is totally unknown component for DHO staffs. GESI committee was formed in Jestha 2069 with the initiation of NHSSP/RHD. RA team also reviewed GESI committee formation minute but the focal person is unknown and task just handed over to him as a new focal person. It seems like they have not received clear direction/orientation the activities. Motivation part was much lacking with the staffs. They keep asking about the training and support but not ready to do perform something from their own.

The focal person and DHO assumed that GESI concept is integrated in DHO annual plan, and monitoring and supervision plan but no data and evidence was identified during the assessment. RA team also visited to Local development office (LDO) and District Administration Office. It seems they are very aware about the need to provide health service in hard to reach area. In fact LDO have been supporting to provide human resource in such HFs.

10.2 FORMATION AND FUNCTIONALITY OF GESI COMMITTEE

After formation of the GESI committee, DHO has not call for any GESI meeting or Technical Working Group members’ meeting. Only one meeting had held during GESI committee formation. RA team reviewed meeting minutes and most of local NGOs/ CBOs were participated in the committee but nobody is aware about its activities and modality in health system and service. There were 20 members involved including NGOs/CBOs in the committee. The GESI committee has not focused to include M/DAG people from hard to reach community. Following are the gaps in GESI:  No coordination with DHO staffs, LDO, CDO and other staffs about the GESI and its importance from NHSSP/RHD.  Not clear understanding on the guideline and integrating approach in DHO system and health services.  No regular coordination with LDO, CDO and other I/NGOs, CBOs  No coordination with HFs (VDC and Ilaka level) in terms of GESI.  No program to address early marriage, Gender-based violence.  Assumption that GESI doesn't come in health service and system.

10.3 ORGANIZATIONS WORKING ON GESI

There are only few organizations working on GESI in Dailekh district. Following are the names of some organization working on GESI: a. WEAF (Women Empowerment Association Forum): b. FEDO (Feminist Dalit Organization) c. WDO (Women and Children Development Forum) d. Sustainable Development and Environment Conservation Center (SUDECC)

Women and Children Development Office (WDO)

The RA team visited WDO staffs but the responsible person was not available during the visit. The district women and children development committee is working on some of the H4L interest areas. WDO have exclusive Girls Adolescents Group (Kishoria Shamuha) in some of VDCs in Dailekh. They have tried to reach in socially excluded community.

Feminist Dalit Organization (FEDO)

The Organization is formed by Dalit community to serve socially excluded people. Currently, they are working on equal access of Dalit women to health services funded by The European Union. They have been working to promote Dalit rights and eliminate cast and gender discrimination and improving the access to health services in Dailekh district. They had been working in 9 VDCs of Dailkeh district and municipality. They work to ensure a better future for vulnerable Dalit women by empowering their access to health services. FEDO do have a partnership with Center for Technical Education and Vocational Training-CTEVT for providing ANM training to Dalit women/girl and after received AMN training she serve in Dalit community as community health volunteer. Volunteer in the sense that she doesn't get salary but receives some facility/opportunity provided from HFs like training and other supports.

The major activities of the organization are: o Dalit women health worker training o Training of Community Medical Assistant o Safe motherhood and child health care training o Sanitation awareness training o Primary health care and adolescents training o Family planning training

FEDO is working in the following VDCs of Dailekh: Badalamaji, Bisalla, Chamunda, Jambukandh, Khadkawada, Lakandra, Lytibbindraseni, Padukasthan, and . 10.5 KEY ISSUES AND CHALLENGES

 GESI need to be sensitized among the DHO staffs. They need orientation on it.  Clear understanding of MOHP GESI strategy, guideline, and other key information in essential.  Coordination with LDO, CDO is lacking  Motivation part is also lacking among DHO staffs.  GESI Approaches and concepts are not clear in DHO and are not practiced  More concern about training and orientation and depending with project/donor.  LDO is providing human resource support in 40 HFs in hard to reach HFs.  Stakeholders are very aware about the need to reach remote VDC/HFs and ready to work together with DHO.  Joint monitoring and supervision by LDO, CDO and DHO might be helpful.

***************** Annex 1

Table: Contact information of DHO Staff, Dailekh Added Years of Years of Cell Phone DHO Team (current) Name Responsibii service in service no. ty district District Health Officer 6 m 9841378425 Public Health Officer 3 m 3 m 9813202156 Public Health Nurse 3 9845048445 Statistics 3 3 9848820808 Assistant/Officer FP focal person A/Y, 17 3 9848043843 (Act.) GESI,MNH Malaria focal person NA Health Education Tech/ Disaster 25 2 9844808019 Officer DTLA/Officer 18 10 9848050163 EPI Supervisor/Officer HFOMC 25 18 9848049452 Cold Chain Assistant/ 26 22 9741045147 Officer Computer Store 2 2 9848078609 Operator/Officer Store Keeper 16 4 9848062872

Child Health focal Nutrition 25 2 9848141022 person FCHV Focal Person Medical Recorder 26 2 9848042249

Annex 2: List of Organizations and Individuals visited/contacted during RA SN Name of Organization Name post DHO 1 PHO 2 NASU 3 EPI officer 4 Section officer 5 Computer operator 6 DHO DAILEKH Kharidar 7 SN 8 DTLO 9 Stat. Assistant 10 HA 11 FO 12 Sr. AHW 14 DDC LDO/ DDC 15 WEAF Dailekh 18 GIZ, Dailekh 19 FPAN, Dailekh 20 NRCS, Dailekh 21 FEDO PC 22 WCO Annex -3 List of RHCC members in Dailekh DHO SN Name Post & Organization 1 LDO/ DDC 2 DHO 3 DEO 4 PHO/DHO 5 WCO 6 FPAN 7 FEDO 8 WEAF 9 SMNF 10 SOSEC 11 FP Focal person/DHO HEALTH FOR LIFE

REPORT ON RAPID ASSESSMENT

OF DISTRICT HEALTH

SYSTEMS 2013 DANG

1 A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013 DANG

MAY 28, 2013

TEAM MEMBERS

2 TABLE OF CONTENTS

ABBREVATIONS iii KEY FINDINGS FROM RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS v

1 RAPID ASSESSMENT 1 1.1 Health for Life 1 1.2 Rapid Assessment and its Objectives 1 1.3 Methodology 1 1.4 Organization of Report 2

2 INTRODUCTION OF DANG DISTRICT 3 2.1 Geo-Political Situation 3 2.2 Demographic Information 3

3 DPHO STRUCTURE AND SYSTEMS 4 3.1 Service Delivery Points 4 3.2 Management Systems 5 3.3 Health Workforce 6 3.4 Monitoring and Supervision 7 3.5 Information Technology 7 3.6 Health Information Management 7 3.7 Natural Disaster Response Mechanism 8 3.8 Strength and Opportunities 8 3.9 Key Issues and Challenges 9

4 SERVICE STATISTICS 10 4.1 Immunization 10 4.2 CB-IMCI 10 4.3 Safe Motherhood 11 4.4 Family Planning 11

5 HEALTH FACILITY OPERATION MANAGEMENT COMMITTEE AND LOCAL HEALTH GOVERNANCE 13 5.1 Functioning HFOMC 13 5.2 Capacity Building of HFOMC 13 5.3 Community Groups/Federation/Alliance 14 5.4 Strength and Opportunities 15 5.5 Key Issues and Challenges 15 5.6 Efforts Required to Overcome Problems/Constraints 16

6 SERVICE DELIVERY/QUALITY IMPROVEMENT 17 6.1 ANM Schools 17 6.2 Infection Prevention and Waste Management Practices at HFs 17 6.3 Service Delivery 17 6.4 Strength and Opportunities 19 6.5 Key Issues and Challenges 19

7 LOGISTICS MANAGEMENT SYSTEM 21 7.1 Availability of Key Drugs and Commodities 21 7.2 Cold Chain and FEFO Management 21 7.3 LMIS reporting 21 7.4 Strength and Opportunities 22 i 7.5 Key Issues and Challenges 22

8 BEHAVIOR CHANGE COMMUNICATION 23 8.1 Existing DPHO programs on BCC 23 8.2 FM Stations/Cable Television Networks 23 8.3 Organizations working in IEC/BCC activities 24 8.4 School Health Program 24 8.5 Mapping of DAG and Exploring Cultural Practices affecting Health 25 8.6 Strength and Opportunities 26 8.7 Key Issues and Challenges 26 8.8 H4L Intervention on BCC 27

9 ADOLESCENTS AND YOUTH FRIENDLY SERVICES 28 9.1 Existing Services for Adolescents and Youths 28 9.2 Organization working for Adolescent 28 9.3 Strength and Opportunities 29 9.4 Key Issues and Challenges 30

10 GENDER EQUALITY AND SOCIAL INCLUSION 31 10.1 Formation and Functionality of GESI Committee 31 10.2 Activities on GESI and Information on Disaggregated Data 32 10.3 Organizations working on GESI 32 10.4 Areas of Synergy and Collaboration in GESI 33 10.5 One Stop Crisis Management Center (OSCMC) 33

ANNEXES Annex 1: Contact information of DPHO Staff, Dang 35 Annex 2: List of RHCC member organizations, DPHO/Dang 36 Annex 3: List of Individuals/Organizations visited during RA/Dang 36

ii ABBREVIATIONS

AFS Adolescents Friendly Service AYFA Adolescents and Youth Friendly Service AHW Auxiliary Health Worker ANM Auxiliary Nurse Mid-wife BC Birthing centre BCC Behavior Change Communication BEONC Basic Emergency Obstetric and Newborn Care BNMT Britain Nepal Medical Trust CB-IMCI Community-Based Integrated Management of Childhood Illness CB-NCP Community-Based Newborn Care Package CEONC Comprehensive Emergency Obstetric and Neonatal Care CRRT Community Rapid Response Team DAG Disadvantaged Group DDC District Development Committee DPHO District Public Health Office DRR Disaster Risk Reduction FCHV Female Community Health Volunteer FECOFUN Federation of Community Forestry Users of Nepal FEFO First expiry first out FP Family Planning FPAN Family Planning Association of Nepal FY Fiscal Year GESI Gender Equality and Social Inclusion HA Health Assistant H4L Health for Life HF Health Facility HP Health Post HFOMC Health Facility Operation and Management Committee HMIS Health Management Information System I/NGO International/Non-Governmental Organization IT Information Technology INF International Nepal Fellowship IUCD Intra Uterine Contraceptive Device IFPSC Institutionalized Family Planning Service Center LDO Local Development Office LGCDP Local Governance and Community Development Program LMIS Logistics Management Information System MO Medical Officer MNCHN Maternal Neonatal Child Health and Nutrition MgSO4 Magnesium Sulphate MSC MatriSurakshyaChakki MSI Marie Stopes International MWDR Mid-western Development Region M/DAG Marginalized/Disadvantaged Groups No. Number NFHP Nepal Family Health Program NHSSP National Health Sector Support Program NPC National Planning Commission NPR Nepalese Rupees PHCC Primary Health Care Center QI Quality Improvement QAWG Quality Assurance Working Group iii RA Rapid assessment RH Reproductive Health RHCC Reproductive Health Coordination Committee RHD Regional Health Directorate RRT Rapid Response Team SHP Sub Health Post SN Staff Nurse UNFPA United Nations Population Fund USAID Unites States Agency for International Development VDC Village Development Committee WCO Women and Children Office WOREC Women Rehabilitation Center WDR Western Development Region

iv KEY FINDINGS FROM RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS

TOTAL POPULATION 552,583 (Census 2011)—53% Female and 47% Male NUMBER OF VDCS 39 MUNICIPALITY 2 (GhorahiandTulsipur) DPHO STRUCTURE AND Public health facilities& outreach service points SYSTEMS  2 Government Hospitals; 3 PHCCs; 15 HPs and 21 SHPs  31functional Birthing Centers (including Rapti Sub Regional Hospital, Rapti Zonal Hospital and Regional Ayuvedic Hospital)  125 PHC/ORC; 195 Immunization Clinic  1 CEONC Site; 4 BEONC Site; 2 Satellite Clinics  926 FCHVs Ayurvedic health facilities  2 Ayurvedic Hospitals (Regional, Zonal) Private health facilities/community hospitals/nursing homes  7 Private Hospitals and Nursing Home  1 Community Hospital  3 NGO Clinics  2 Urban clinics run by municipalities Meetings:  RHCC and DACC—functional and meetings conducted regularly  QAWG—non functional  GESI- only formed, no follow ups then after  RRT and CRRT functional—based on need  IlakaMonthly Meeting- 3rd of Nepali month—meeting discontinued  District Level IlakaIncharge Meeting 7th of Nepali month— functional  FCHV Monthly meeting—29th of Nepali month—functional  FCHV District level meeting- 14th of Nepali month-functional Health Workforce:  197 is fulfilled position out of 200 sanctioned positions  1 Medical Officer in temporary position,  24 ANM and 1 AHW in contract.  National Planning Commission supported 5 ANM and 3 AHW  VDC supported 22 ANMS Monitoring and Supervision:  DPHO has annual monitoring and supervision plan, but is not effectively practiced  Monitoring and supervision from ilaka level health facilities to SHPs is also very limited.  Use of verbal feedback than written with very few follow ups. IT infrastructure at D/PHO:  Desktops-12, Laptops-4, Printers-12  Good internet facility.  6 HFs have computers  Supervisors skilled enough to perform their daily responsibilities  Web-based HMIS and LMIS system reporting system in place and is up-to-date. v  Five year service data easily available from FY 2065/66 to 2069/70 (until Chaitra 2069).  No social inclusion reporting so far.  No use of mobile phone, tablets or other devices for recording and reporting purpose.  No data validation program in FY 2069/70 due to budget constraint, which was in place last FY. Rapid Response Team:  Formed at district and functional  CRRT formed in 4 health facilities—3 PHCCs and 1 HP  Buffer stock maintained in these 4 health facilities SERVICE STATISTICS  BCG, DPT3 and Measles coverage is more than 90% in the last three years.  Severe pneumonia case and dehydration case is in decreasing trend which is less than 1%. More children are being treated with antibiotics and ORS/Zinc  Drop out from ANC 1st to ANC 4th visits is high which is 77% and 43% respectively in 2068/69.  PNC 1st visit as percent of expected live births is 54% in 2068/69.  SBA deliveries (both home and institution) in increasing trend (22% in 2065/66 to 48% in 2068/69  Contraceptive Prevalence Rate 46% in FY 2068/69 HEALTH FACILITY  Out of 39 health facilities, 26 SHPs were handed over to MANAGEMENT DDC/VDCs COMMITTEE AND LOCAL  About 85% of the health facilities have active HFOMCs as rated by HEALTH GOVERNANCE DPHO staff.  HFOMCs have received capacity building training during NFHP II, which provided orientation and refresher training, and helped with review meetings in close collaboration with DPHO  FCHV District Network, NGO Federation, NGO Coordination Committee, Journalist Federation, Federation of Community Forestry Users Nepal (FECOFUN), and district level cooperative network in district SERVICE  1 ANM school in Dang- Rapti Health Institute, DELIVERY/QUALITY  31 birthing centers—all functional and have placenta pit IMPROVEMENT  Sub-regional and Zonal hospitals also have delivery facilities  62 SBAs in 25 sites (includes SBAs from Rapti Sub Regional Hospital, Rapti Zonal Hospital and Regional Ayuvedic Hospital)  2 health facilities in Gadhwa and Sisihaniya have satellite clinics  1 CEONC site at sub-regional hospital in Ghorahi  4 BEONC sites in all three PHCCs in Lamahi, and Shrigaun and one zonal hospital.  IUCD services provided through 15 services sites including FPAN and Marie Stopes International.  Implant services provided through 6 sites including FPAN and Marie Stopes International.  Around 20 health workers and 40 FCHVs from 39 HFs have not received CB-IMCI training.  Likewise, 20 health workers and 118 FCHVs from and vi Tribhuwannagar municipalities have not received the same training LOGISTICS MANAGEMENT  All tracer drugs and commodities available on the day of visit. SYSTEM  Drugs with most problems of stock outs in the year- Cotrim (P) and Zinc  Drugs with most problems of over stock in the last year- Metronidazole Syrup, Cotrim (P) 480 mg, Vitamin B  Functioning refrigerators-8, sufficient for maintaining cold chain, and have regular power back up system for the cold chain room.  First Expiry First Out (FEFO) maintained in store  Web-based LMIS reporting system—data entered and updated by Store keeper BEHAVIOR CHANGE  FM stations – 12; DPHO BCC programs through 4 FM stations COMMUNICATION  DPHO has been involved in awareness raising and interaction programs among people of disadvantaged communities and regions.  Most of the DPHO staffs have received COFP counseling training except for some 20 new staffs.  No Peer Education Program/DPHO this year due to budget constraints  5 different organizations working in IEC/BCC activities: WCO,

FPAN, Dang Plus, INF, Red Cross  Madeshi communities (mostly Yadav living in Dang), Dalit &Janajatiand Economically poor communities practice early marriage and early child bearing ADOLESCENTS AND  Programs like peer education, adolescent and youth friendly YOUTH FRIENDLY services, youth friendly service centers, and adolescent girl’s SERVICES information and counseling center are currently running in Dang.  Organizations like GIZ, UNFPA, WCO, FPAN, MSI, INF and Youth Network working with adolescents  GIZ/DPHO working on adolescent and youth friendly services in 13 HFs of Dang  UNFPA/FPAN has been providing youth friendly service centers from 4 community clinics. It also has 25-30 Peer Learning Groups in Dang with 10 people in each group  WCO has Information and Counseling Center for adolescent girls in 5 VDCs. GENDER EQUALITY AND  GESI working committee formed but no follow up meetings held SOCIAL INCLUSION thenafter  GESI focal person and other district supervisors not aware of its importance—the main problem integrating GESI in DPHO programs  No disaggregated data by age, caste, ethnicity, wealth quintile and region  No DAG mapping done recently

vii 1. RAPID ASSESSMENT

1.1 HEALTH FOR LIFE

Health for Life (H4L) is a five-year bilateral agreement between the Ministry of Health and Population (MoHP) and the Unites States Agency for International Development (USAID) which focuses on systems strengthening and improving the Maternal Neonatal Child Health and Nutrition/Family Planning (MNCHN/FP) service delivery at district and sub-district levels in 14 districts. Two of the 14 districts are in Western Development Region (WDR) of Nepal— Arghakhanchi and Kapilbastu, and the remainings are in Mid-Western Development Region (MWDR) — Dang, Salyan, Pyuthan, Rolpa, Rukum, Banke, Bardiya, Surkhet, Dailekh, Jajarkot, Jumla and Kalikot. The project will be implemented between 2012 and 2017.

1.2 RAPID ASSESSMENT AND ITS OBJECTIVES

Rapid Assessment (RA) is a method of analyzing situation of a district where issues are not well defined or where there is no sufficient time or other resources to conduct in-depth quantitative research. RA uses intensive team interaction in the collection and analysis of data, instead of a prolonged field work, iterative data analysis and additional data collection, to quickly develop a preliminary understanding of situation from an insider’s perspective. The main purpose of carrying out the current Rapid Assessment is to understand the current situation of health service delivery system and other associated systems of Dang district so as to help in planning activities at district level.

Specifically, the objectives of the RA includes  Understanding the demographic profile of the district  Understanding the existing health care delivery system of the district  Knowing the functionality of Health Facility Operation and Management Committees (HFOMC)  Understanding the status of health indicators  Analyzing strengths and weakness of the D/PHO systems  Identification of potential Local Technical Assistance Partners (LTAPs)  Exploring feasibility for the implementation of specific programs for adolescents and youth  Exploring feasibility for using Information Technology in information management

1.3 METHODOLOGY

A mix of both qualitative and quantitative methods was used to execute Rapid Assessment in Dang district which includes:  Visits to District Public Health Office (DPHO)  Interviews and interactions with key staffs  Observation at DPHO

A structured tool was developed to collect necessary information, which was supplemented by qualitative tools to interview key informants at District Development Committee (DDC) and Local Development Office (LDO), International/Non-Governmental Organizations (I/NGOs) working on

1 different areas of health, Gender Equality and Social Inclusion (GESI), Behavior Change Communication (BCC), Information Technology (IT) in Health, Service delivery, and Governance.

A team was composed for carrying out RA which included H4L staffs and Government counterpart staff. Skill mix was ensured while forming team where staffs were skilled and knowledgeable on the aspects of governance, service delivery, monitoring and evaluation, GESI and BCC. During RA, the involvement of project center, regional and district offices was ensured.

Before carrying out of the RA, one day orientation on its objective, methods and tools was organized for H4L staff, along with other orientation on H4L project in Hotel Siddhartha, Nepalgunj. RA in Dang was completed by gour members of H4L team— from Regional Health Directorate (RHD), Surkhet from May 1-10, 2013. The information collected was verified on the same day and brief notes were developed for each thematic area for sharing with DPHO and other line agencies and also for preparing report. After the completion of RA, a two-hour sharing program was organized at DPHO among district supervisors and members of DPHO.

1.4 ORGANIZATION OF REPORT

The findings of RA are presented in altogether tenchapters. Chapter 1 presents the purpose of carrying out RA and the methodology; chapter 2 presents the introduction of Dang along with its demographic information; chapter 3 talks about the structure and systems of DPHO, and provides detail information on service delivery points, management systems, status of health workforce, the practice of monitoring and supervision, status of information technology and information management as well as mechanism of natural disaster response. Chapter 4 presents the service statistics of district; chapter 5 presents information on health facility operation and management committee (HFOMC) and local health governance. Likewise, chapter 6 discusses on what has been done for quality improvement of health service delivery; chapter 7 presents information on logistics management system of DPHO; chapter 8 discusses several windows of IEC/BCC activities conducted by DPHO; chapter 9 explains the status of adolescent and youth friendly services in district, and chapter 10 presents information on gender equality and social inclusion (GESI), and whether or not the committees have been formed and are functional. Each chapter discusses the strength and opportunities based on the data collected through RA and explains key issues and challenges to fulfill them.

2 2 INTRODUCTION OF DANG DISTRICT

2.1 GEO-POLITICAL SITUATION

Dang district is situated in of Mid- Western Development Region of Nepal. It covers an area of 2,955 km² and borders with India and six other districts of Nepal. Uttar Pradesh of India lies on south of Dang, Arghakhanchi and Kapilbastu on South-East, Pyuthan on East, Rolpa and Salyan towards north and Banke towards west. Administratively, Dang has 39 VDCs and 2 Municipalities- Ghorahi and Tulsipur, and is headquartered at Ghorahi. Out of 39 VDCs, five lie in hilly areas while other lie in plains. There are altogether 13 ilakas and five constitutional divisions in Dang.

EMOGRAPHIC NFORMATION 2.2 D I Table 2.1: Population of Dang District The total population of Dang as per the Population Distribution Number Percent Census of 2011 is 552,583 out of which Total Population 552,583 - Male 261,059 47 53 percent is female and 47 percent is Female 291,524 53 male population. Source: Census 2011 Caste/Ethnicity distribution The proportion of Brahmin and Chhetri, Brahmin/Chhetri/Thakuri/Sanyasi 170,539 37 including Thakuri and Sanyasi in Dang is Tharu 147,328 32 highest (37 percent) followed by Tharu Disadvantaged Janajati (Magar, Kumal) 62,385 13 Dalit 44,921 10 (32 percent). The district has 13 percent Others 21,714 5 of disadvantaged Janajati mainly Kumal Tarai Caste Group (Yadav) 6,762 1 and Magar, followed by 10 percent of Muslim 4,637 1 Dalit. Other categories account to 5 Relatively Advantaged (Newar) 4,094 1 percent of population. About one Source: Census 2001 percent each belongs to Tarai caste group, Muslim and relatively advantaged caste, which is mainly Newar. 3 3 DPHO STRUCTURE AND SYSTEMS

This chapter presents the findings related to the DPHO structure and systems of Dang collected from RA. The findings cover the areas of service delivery points, management system, health workforce, monitoring and evaluation system, IT and health information management and disaster management system.

3.1 SERVICE DELIVERY POINTS

The District Public Health Office, located in Table 3.1: Number of service delivery points Ghjorahi is the main responsible institution of Type of service delivery points Number the MOHP at Dang to provide preventive, Government Hospital 2 promotive and curative health services to its PHCC 3 people.There are a total of 39 public health Health Post 15 facilities in Dang, which includes 3 PHCCs, 15 Sub-health Post 21 HPs and 21 SHPs. Dang also has Rapti Sub- Private hospital/Nursing Home 7 Regional Hospital in Ghorahi, Rapti Zonal Ayurvedic Hospital 2 Hospital in Tulsipur, and a Regional Ayurvedic Community Hospital 1 Birthing centers (All functional) 31 Hospital and a Zonal Ayurvedic Hospital. At SBA Sites 25 present, there are 3 PHCCs in Lamahi, Syuja and PHC Out-Reach Clinic 125 Shrigaun, 15 Health Posts and 21 Sub Health Immunization Clinic 195 Posts. There are 31 functioning Birthing CEONC Site 1 Centers in Dang which also includes Sub- BEONC Site 4 Regional Hospital, Zonal Hospital and Regional Satellite Clinic 2 Ayurvedic Hospital. There are a total of 125 FCHVs 926 PHC/ORC and 195 Immunization Clinics. One NGO Clinics 3 CEONC site is located in Rapti Sub-Regional Urban Clinics 2 Hospital, and 4 BEONC sites are located in Rapti Source: DPHO, Dang Zonal Hospital and 3 PHCCs. Similarly, two Satellite Clinics are located in HP and Sisihaniya HP. There are altogether 926 Female Community Health Volunteers (FCHVs) in Dang, which form an integral part of health service delivery in the country. There are seven private hospitals and nursing homes, and one community hospital in Lamahi. Likewise, NGO clinics are run by Family Planning Association of Nepal (FPAN), Marie Stopes International (MSI) and International Nepal Fellowship (INF) with major focus on RH/FP.

3.2 MANAGEMENT SYSTEMS

3.2.1 Committees and Meetings

There are several committees formed at DPHO to support health activities and deliver quality health services. Some of the meetings are held regularly or on a fixed date while others are held on need basis.

Reproductive Health Coordination Committee (RHCC) is one of those committees formed as a coordinating body among different stakeholders working in reproductive health, the meeting of which is held at DPHO regularly and based on need. The last meeting was held on Jan 25, 2013

4 (Magh 12, 2069) where discussions on (a) formation of working committee in response to unsafe abortion; (b) adolescent and youth friendly services; (c) expansion of IUCD services; (d) Uterine prolapse camp; and e) the planning for the next meeting were held.

Likewise, Quality Assurance Working Group (QAWG) was formed at DPHO and the last meeting was held during April/May 2012. Although all health facility workers have received orientation on quality improvement, neither Quality Improvement Committees isreformed at health facility level, nor is the QAWG meeting at district functional. As per the information gathered during RA, the status of QAWG and its minutes register remain unknown after the expiryof its focal person, who could not handover his duties and responsibilities to any others at DPHO.This is the reason why the details of QAWG (members and their number, exact meeting date,etc) could not be found. One reason for the stagnation of QAWG is lack of budget allocation under this heading this year.

Gender Equality and Social Inclusion (GESI) is another committee formed at DPHO to mainstream GESI sensitivity into health systems and in all health activities. GESI working committee was formed on Dec 4, 2012 (Mangsir 19, 2069) and a partial orientation was given to DPHO staffs.As per DPHO staffs, they are not aware of the importance of GESI nor do they have MOHP GESI Strategy and Operational guidelines, which is one of the reasons why no follow-up meetings have been held since then.

Similarly, Rapid Response Team (RRT) is another committee formed at DPHO in order to respond to the disasters that might happen in district—like epidemics, flood, fire, etc. The committee comprises of members from DDC, CDO, WCO, Hospitals, RedCross, Army, Police, and any other stakeholders working in health sectors. In order to promptly respond todisasters, Community Rapid Response Team (CRRT) is formed at local level. RRT and CRRT both are active in district and local level respectively.

District AIDS Coordination Committee (DACC) is another committee formed at DPHO chaired by DDC Chairperson. The committee is formed to manage programs on HIV/AIDS in district, and coordinate with other stakeholders working in this area. The committee also ensures if there is any duplication of HIV/AIDS related program and also monitors such activities. The last meeting of DACC in Dang was held in Mar 22, 2013.

There are three other monthly meetings held in district—Ilaka Monthly Meeting, District Level IlakaIncharge Meeting, and FCHV Monthly Meeting on 3rd, 7thand 29th of Nepali month respectively. Ilaka monthly meeting was an interactive forum where issues on health facilities, service delivery, reporting and recording, etc pertaining to that particular ilaka were discussed among health workers. However, this meeting has been discontinued in this FY 2069/70 due to budget constraints. District Level IlakaIncharge Meeting on the other hand is still active and is considered to be an important meeting at DPHO for discussion on issues and regular interaction among health workers in district. Likewise, FCHV monthly meeting at the end of every Nepali month is active and ongoing, where they talk about their day-to-day challenges and issues during their work.FCHV’s district alliance meets on 14th of Nepali month at DPHO every month.

5 3.2.2 Program Management Team Table 3.2: Current Status of DPHO Team DPHO Team Status DPHO, Dang has all the key positions 1. District Public Health Officer Filled fulfilled as noted during the time of rapid 2. Sr./Public Health Officer/ Filled assessment. Table 3.2has the list of 3. Administrator DPHO key positions and their status as 4. Public Health Nurse Filled 5. FP Focal Person Filled found during RA. As per the table, all the 6. Malaria Focal Person Filled important positions have been filledin 7. District TB Leprosy Officer Filled Dang. 8. EPI Supervisor/Officer Filled 9. Cold Chain Assistant/ Officer Filled 3.3 HEALTH WORKFORCE 10. Computer Officer Filled 11. Store Keeper Filled This section presents the current status 12. Child Health focal person Filled 13. Lab Technician Filled of health workforce in Dang district as provided to RA team.Table 3.3 below mentions the number of sanctioned positions, filled-in, temporary and contract positions; and also the number of positions supported by DDC/VDC, National Planning Commission (NPC) or any other resources. As per the below table, out of total 200 sanctioned positions in Dang, 197 have been filled. Likewise, there is one Medical Officer in temporary position and 24 ANM and one AHW in Contract (by DPHO). There are eight positions supported by NPC out of which there arefive ANM and three AHW.There are 22 ANMs supported by different VDCs in Dang. Table 3.3: Current status of health workforce Number GoN Number supported from Type of human resources Sanctioned Filled-in Temporary Contract VDC NPC Others a. Medical Officer 4 1 1 0 0 0 0 b. Staff Nurse 4 4 0 0 0 0 0 c. PHN 1 1 0 0 0 0 0 d. FP officer 1 1 0 0 0 0 0 e. Sr. ANM 0 0 0 0 0 0 0 f. ANM 29 29 0 24 22 5 0 g. HA/Sr. AHW 21 19 0 0 0 0 0 h. AHW 62 65 0 1 0 3 0 i. PadNam AHW 32 30 0 0 0 0 0 j. PadNam ANM 21 21 0 0 0 0 0 k. Lab Assistant 6 6 0 0 0 0 0 l. Adm. Assistant/Officer 2 2 0 0 0 0 0 m. Store Keeper 1 1 0 0 0 0 0 n. Support Staff 4 4 0 0 0 0 0 o. Statistics Officer 1 1 0 0 0 0 0 p. Computer Officer 1 1 0 0 0 0 0 q. Account Assistant/Officer 2 2 0 0 0 0 0 r. DTLO 1 2 0 0 0 0 0 s. Lab Technician 1 1 0 0 0 0 0 t. EPI Supervisor 1 1 0 0 0 0 0 u. VCO 1 1 0 0 0 0 0 v. Driver 1 1 0 0 0 0 0 w. Malaria Inspector 1 1 0 0 0 0 0 x. Cold Chain Assistant 2 2 0 0 0 0 0 Total 200 197 1 25 22 8 0 Source: DPHO, Dang

6 3.4 MONITORING AND SUPERVISION

DPHO Dang has monitoring and supervision system which works along with annual supervision plan. During the monthly integrated monitoring and supervision, a standard checklist is also used to ensure quality service delivery in HFs. It was however mentioned during RA that the system of monitoring and supervision has not been effective in practice. The supervisors mention that it is not possible to follow everything as per the plan, mainly due to (a) budget constraints; and (b) time constraints. There are several hard to reach areas in Dang that need focused monitoring, supervision and on-site coaching, but the limited budget allocation and tight schedule of supervisors limit the annual working plan into paper. It was also mentioned that amidst numerous workshops, seminars and other invitations, visits to health facilities for monitoring and supervision purpose does not fall under priority. Likewise, the monitoring and supervision from ilaka level health facilities to SHPs is also very limited. It was reported that DPHO Dang usually provides verbal feedback to HFs with very few cases of written feedback because health workers at HF level find it uncomfortable having to report back in written. Thus, the feedbacks to HFs are generally discussed during the ilaka level monthly meeting with some follow-ups done in the later meetings.

3.5 INFORMATION TECHNOLOGY

The RA team also explored the existing IT infrastructure at DPHO Dang as per which there are 12 desktop computers, 4 laptops and 12 printers that are said to be functional. The district supervisors are said to have enough computer skills to perform their daily responsibilities. The web-based HMIS reporting requires faster internet speed for which the office has Worldlink’s internet connection, but there has been issues gathering resources for payment. DPHO has to pay around NPR 92,000 per year for internet connection against which around NPR 30,000 was only received through different programs this year; the rest of the fund has to be managed from internal resources.

“Initially full budget was allocated for internet facility but now we have been asked to manage most of it on our own. The issue with having to manage funds for internet payment at DPHO is like giving birth to children and then abandoning them in the middle of the road, for them to grow on their own. Managing and pulling funds from other resources is more likely to effect the original program for which the fund was meant for.” -- Staff at DPHO, Dang

In Dang, altogether six HFs have computers—3 PHCCs in Lamahi, Syuja and Shrigaun and 3 HPs in , Gadhawa and Sisahaniya. Other technologies, like information dissemination through mobile phone or tablet have however not been used in the district for recording and reporting purpose. Likewise, Dang does not have social inclusion reporting so far. Such reporting could be one of the important tools to collect, track and analyze GESI gaps required for effective program planning and implementation.

3.6 HEALTH INFORMATION MANAGEMENT

DPHO Dang has been using web-based HMIS to record and reportHF level data. The Statistics Officer has received web-based HMIS reporting training to meet the need. So far, service data is easily available for last five years. Although data validation program was implemented in district in the FY 2068/69 to improve data quality, there is no such program this year due to budget constraints.

7 3.7 NATURAL DISASTER RESPONSE MECHANISM

There is the presence of Rapid Response Team (RRT) at DPHO Dang which is formed to respond to sudden disasters that might happen in district. In order to immediately respond to such disasters at local level, Community Rapid Response Team (CRRT) is formed in four HFss—3 PHCCs and 1 HP in Manpur. Dang has maintained buffer stock in these sites as a response mechanism to natural disasters to provide emergency assistance.

3.8 STRENGTH AND OPPORTUNITIES

Formation of important committees at DPHO: All the important committees like RHCC, GESI working committee, RRT, QAWG and DACC have been formed at DPHO under different focal persons. Although all committees were formed with some specific purpose to fulfill and address certain needs, not all of them are active. Some meetings are organized on regular basis, some on need basis, while others were just formed with no follow-ups in the later stage. If these committees can be revitalized and held on regular basis, there are opportunities to use them as platform to discuss issues and take it further for effective program planning and implementation.

Regular District Level IlakaIncharge Meeting and FCHV Monthly Meeting:District level ilakaincharge meeting is held every 7th of Nepali month at DPHO where all ilakaincharge meet to discuss the issues of HF, service delivery, reporting and recording and any issues related to health service. This is an interactive forum among district supervisors and Ilaka/HF level health workers. Likewise, FCHV monthly meeting is also held on regular basis at the end of every Nepali month where they discuss about their challenges and issues while at work. If both these meetings could be utilized for wider discussion on how to provide quality services to deprived groups, challenges health workers face every day, etc, DPHO could use the inputs for effective program planning.

Proper documentation and functional web-based HMIS: DPHO Dang has proper documentation of population profile, annual health report as well as easy availability of five-year service data. They also have functional web-based HMIS system. If data verification can be done and validated, HMIS can provide meaningful data that can be used to prepare annual plan to reach deprived group of people.

Annual plan for monitoring and supervision: DPHO Dang has annual plan for monitoring and supervision where a standard checklist is also used at HFs. However, the plan has not been used regularly for effective supervision due to several constraints—mostly budgetary. Also written feedback is not much common in DPHO Dang where most of it is done verbally with very limited follow ups. Thus, if the annual supervision plan can be effectively followed for on-site coaching and mentoring, health workers at HF level could benefit much more, which would ultimately help them provide quality service to people at local level.

All key positions fulfilled at DPHO: As per the information provided during RA, DPHO Dang has all the key positions fulfilled. Out of 200 sanctioned positions in DPHO, 197 have been filled and there are positions that have been supported by DDC/VDC and NPC. DPHO has 25 contract staffs to support the existing human resource in providing uninterrupted services to people at local level. Likewise, there are eight positions supported by NPC and 18 supported by different VDCs.

8 3.9 KEY ISSUES AND CHALLENGES

Budget constraint for Ilaka Level Monthly Meeting:The ilaka level monthly meeting used to be held on 3rd of every Nepali month in Dang. This meeting was an interactive forum where review of work, HMIS reporting/recording, service delivery as well as any other important issues were raised for wider discussion among health workers. This meeting, however, has been discontinued for last few months due to budget constraints. Although district level ilakaincharge meeting is held at DPHO despite budgetary issues, DPHO has not been able to conduct ilaka level monthly meeting. Gathering local resources to overcome budget issues to conduct regular meeting is a key challenge to DPHO Dang.

Revitalization of QAWG and GESI working committee:More than just conducting regular meetings, having proper agenda for such meetings look important at DPHO Dang. No QAWG meeting or follow up of GESI meeting has been held in Dang since its formation. Revitalization of both these committees look important when H4L is coming up with working plan to ensure quality service delivery to people esp. the ones who are at hard to reach areas and deprived groups.

Regarding GESI, the focal person at DPHO mentioned that more than budgetary problems, the meeting has not been held as they are not aware of the importance of GESI in health nor are they aware of what they are supposed to do. This indicates the lack of proper skill and knowledge on GESI which is very important for H4L while developing work plan and capacity building plan and strategy. Explaining the cross cutting issues of GESI and QAWG in regular health services and illustrating their importance in programs can be challenging to explore gaps in existing service delivery. But if done, can provide ample opportunities to intervene in program planning and implementation.

9 4 SERVICE STATISTICS

The RA team also sought information on service statistics of Immunization, Child Health, Safe Motherhood and Family Planning. For this purpose, selected HMIS data for the last four years were collected and analyzed. The selected indicators of HMIS for the FY 2065/66 to 2068/69are presented in this section with trend analysis to see how service utilization have changed or remained over the last few years. Data for the running FY 2069/70 has not been presented in this report as complete data was not available. Table 4.1 shows the trend of service utilization in Dang for last four years. Figure 4.1: Measles Coverage

Immunization 97 4.1 92 92 88

100 86 86 79 75 The trend analysis for child immunization 80 ge shows that there is no uniform pattern in 60 nta immunization coverage for BGC, DPT3 and 40 Measles. However, the coverage for the Perce 20 mentioned antigens is above 90 percent in the last three-year period. In addition, the 2065/66 2066/67 2067/68 2068/69 child immunization coverage in Dang is Years better than national statistics. Focus is National District required to maintain the current achievements and not to miss any children for immunization in the district.

4.2CB-IMCI Figure 4.2 and 4.3 shows that severe pneumonia and severe dehydration cases are decreasing in Dang. The severity is below one percent for both pneumonia and dehydration. Both these numbers portray a promising picture of Dang in implementing community-based programs which is helpful in decreasing the child mortality rate. The graphs also show that both the severe dehydration and severe pneumonia cases were higher than that of Nepal’s overall statistics in the first two FYs which declined than that of Nepal’s in the last two FYs.

Figure 4.2: Percent of Severe Pneumonia Figure 4.3: of Severe Dehydration among among New Cases New Cases

1.5

1.5

1.1 1.0 1.00 ge

1.0 ge

1.0

nta 0.6

nta

0.58

0.5

0.50

0.4 0.4

0.38

0.3 0.37 0.5

0.3 0.5 0.26

0.17

0.04 0.0 0.0 2065/66 2066/67 2067/68 2068/69 2065/66 2066/67 2067/68 2068/69 Years Years National District National District

Table 4.1 presents that the diarrhea treatment cases in the last two FYs is very promising in Dang which is nearly 100 percent in the last two FYs. The proportion of pneumonia cases treated with antibiotics has also increased in the last two FYs.

10 In Dang, programs like CB-NCP, MSC and Infant and Young Child Feeding (IYCF) have been implemented already. Such programs were implemented to help decrease the incidence of infant and child mortality.During RA, it was mentioned that there was no stock out of MSC in district for last 12 months, and the distribution is based on pull system.

4.3 Safe Motherhood

Four-year trend analysis of ANC first visit coverage shows that the trend is Figure 4.4: ANC 1st Visit and Four ANC Visits as not uniform in Dang, with 77 percent percent of Expected Pregnancy coverage in the FY 2068/69. About a 100 quarter of ANC first was among the 78 73 77

80 adolescents (<20 years) in all the 64 ge 60 years, indicating the prevalent early 37 40 43 nta 34 40

marriage and child bearing practice

in Dang. This calls for a need of 20 focused program on adolescent’s reproductive health. There is a sharp 2065/66 2066/67 2067/68 2068/69 decline from ANC first to ANC fourth Years visit.TT coverage (both TT2 and ANC 1st visit Four ANC visits TT2+) among pregnant women has increased from 72 percent in 2065/66 to 82 percent in 2068/69 and stayed nearly constant in the following years. Coverage for pregnant women taking Iron tablets and that for postpartum women receiving Vitamin A within 6 weeks did not have a uniform pattern which was 81 and 73 percent respectively

Despite increasing number of birthing centers in Dang over the last few years, the institutional delivery is less than 50 percent. These are important issues that need more focused interventions to bring pregnancies and deliveries into health institutions. The trend in PNC service utilization is also not uniform with PNC 1st visit as percent of expected live births being 54 percent in the most recent year.

Analysis of HMIS data on safe motherhood shows that interventions are required to help mothers and newborns utilize safe motherhood services in Dang. Mobilization of FCHV might be effective in reaching families to explain the importance of ANC, delivery and PNC services.

4.4 Family Planning

Figure 4.5: CPR as percent of MWRA In Dang, the CPR increased remarkably from 41 percent to 48 percent from 50 48 49 46 2065/66 to 2066/67 and then almost 44 45 43 43 stagnated in 2067/68 and then declined to ge 42 41 nta

46 percent in FY 2068/69. Graph 4.5 also 40

compares CPR of Dang with CPR of Nepal. The CPR of Dang is greater than that of 35 National expect in the first year of 2065/66 2066/67 2067/68 2068/69 comparisons. Years National District

11 During RA, FP Focal person of DPHO and officer from FPAN also mentioned the decreasing trend of CPR. They emphasized the need for expansion of long term FP methods service sites as well as training, mentoring and coaching of health workers. It also looks important to ensure the inclusion of the services provided from private sector in FP reporting. In addition, if long term FP methods can be provided to couples on regular basis instead of just Voluntary Surgical Contraception (VSC) service camps, it would provide easy access to service receivers on a fixed site, thus results in increased service utilization. If awareness on all FP methods is provided, counseling improved and defaulters traced, CPR is more likely to be increased.

Table 4.1: Trend in utilization of services in Dang from 2065/66 to 2068/69 SN Indicators 2065/66 2066/67 2067/68 2068/69 1. BCG coverage 82.13 99.10 97.45 93.30 2. DPT 3 81.49 92.22 94.92 92.04 3. Measles vaccination coverage 79.49 96.95 92.29 91.56 4. TT 2 & TT2+ coverage among pregnant women 71.98 80.34 79.71 81.83 5. Percent of postpartum mothers receiving Vitamin A 46.03 59.98 50.58 73.10 within 6 weeks 6. Percent of pregnant mothers receiving iron tablets 69.32 81.39 74.54 81.32 7. Percent of severe pneumonia among new cases 1.07 0.95 0.28 0.33 8. Proportion of new pneumonia cases treated with 35.37 32.98 57.07 56.24 antibiotics 9. Percent of severe dehydration among new cases 1.00 0.50 0.17 0.04 10. Proportion of new diarrheal cases treated with ORS - - 97.17 99.80 +Zinc (under 5 years children) 11. ANC 1st visit as percent of expected pregnancies 63.87 78.10 73.13 77.45 11.1 <20 years 20.71 25.13 24.99 25.92 12. Four ANC visits among as percent of expected 34.03 37.45 39.75 42.96 pregnancies 13. Delivery conducted by SBAs (both home and 21.83 34.21 35.62 47.53 institutions) as percent of expected live births 14. PNC First visit as percent of expected live births 43.83 54.85 48.99 54.22 15. Contraceptive prevalence rate (modern methods) as 40.78 48.21 48.69 45.89 percentage of MWRA

12 5 HEALTH FACILITY OPERATION MANAGEMENT COMMITTEE AND LOCAL HEALTH GOVERNANCE

Information on Health Facility Operation and Management Committee (HFOMC) was sought from both DPHO and DDC. Both quantitative and qualitative methods were used to collect information on HFOMC functionality, capacity building, presence of different community-based groups at VDC level and their federations at district level. This chapter presents the major findings of the assessment on HFOMC.

5.1 FUNCTIONING HFOMC

The concept of decentralization and its implementation in health sector seems exemplary in Dang where most of the HFs- HPs and SHPs have been handed over to the local bodies, except for 13 ilaka level HFs. Dang was one of the first few districts tohand over HFs to local bodies, asking them to cater local health needs through participatory planning. Out of 39 HFs, a total of 26 SHPs were handed over to VDCs three years back; and out of them fivehave been upgraded to HP.

In order to find out the exact number of HFs with functional HFOMCs, district supervisors were asked to categorize HFOMCs based on the following five criteria. a) whether the meeting is conducted once a month and minute is maintained; b) participation of 70 percent of members in meeting that includes at least one female member; c) activeness of members during interaction/meeting; d) taking ownership and are involved in planning and/or review process; and e) HFOMC members monitoring Mother’s Group meetings.

Any HFOMC meeting three of the above criteria were categorized as active or else inactive.Based on the information collected from district supervisors, 33 HFs out of 39 are active, which means 85 percent of HFOMCs in Dang are active. Table 5.1 in the next page shows the number of HFs that arehanded over to local bodies along with their status based on the above mentioned criteria.

However, district supervisors have their own criteria to measure the functionality of HFOMCs in general. Below are the four major criteria on the basis of which DPHO staffs monitor HFOMCs. a) Whether the committee is formed as per guideline, ensuring the inclusion of women and people of marginalized and disadvantaged groups; b) Whether regular meeting is held—at least three meetings in a year; c) Whether the committee prepares work plan and implements the same; d) Whether the committee follows up and monitors the health activities and programs.

HFs with inactive HFOMCs, as judged by district supervisors, include one PHCC in Shreegaun, 3 HPs in , Hekuli and Phulbari and 2 SHPs in and . Based on the information provided to RA team, there are 33HFs with active HFOMCs that have been working to gather resources at local level and mobilize them to provide quality health services.

13 Table 5.1: Number of HFs handed over to local bodies and activeness of HFOMCs Handed over to Activeness Handed over to Activeness SN VDCs/HFs local bodies? HFOMCs SN VDCs/ HFs local bodies? HFOMCs (Yes/No) (Yes/No) (Yes/No) (Yes/No) 1 Yes Yes 21 LOHARPANI Yes Yes 2 BELA Yes Yes 22 MANPUR No Yes 3 Yes Yes 23 NARAYANPUR Yes Yes 4 No Yes 24 PANCHAKULE No No 5 Yes Yes 25 PAWANNAGAR Yes Yes 6 DHARNA Yes Yes 26 PHULBARI No No 7 Yes Yes 27 PURANDHARA Yes No 8 DURUWA No Yes 28 RAJPUR Yes Yes 9 GADHAWA No Yes 29 RAMPUR Yes Yes 10 Yes Yes 30 SAIGHA Yes Yes 11 Yes Yes 31 Yes Yes 12 GOLTAKURI Yes Yes 32 Yes Yes 13 Yes Yes 33 SHANTINAGAR Yes Yes 14 Yes Yes 34 SHREEGAUN No No 15 HAPUR Yes Yes 35 SISAHANIYA No Yes 16 HEKULI No No 36 SONPUR Yes Yes 17 No Yes 37 SYUJA No Yes 18 No Yes 38 Yes Yes 19 LALMATIYA Yes Yes 39 URAHARI Yes No 20 LAXMIPUR No Yes - - - - Yes-13 Yes-19 Yes-13 Yes-14 Subtotal1 No-7 No-1 Subtotal2 No-6 No-5 Number of Health Facilities handed over to local bodies: 26 Number of Active HFOMCs: 33

5.2 CAPACITY BUILDING OF HFOMC

The HFOMCs in Dang have received capacity building training during NFHP II, which provided orientation and refresher training, and helped with review meetings in close collaboration with DPHO in district. Likewise, NFHP II also did monitoring visits for on-site coaching and mentoring in order to build and enhance the capacity of HFOMCs. At present, there is only one organization i.e. INF working with two HFs (GobardihaHP and Bela SHP) to strengthen HFOMCs. Both these HFs are handed over to local bodies. As per the information provided during RA, activities of INF in Dang are being phased out this year.

5.3 COMMUNITY GROUPS/FEDERATION/ALLIANCE

According to the district supervisors, there are different community groups at local level and district level alliances and networks in Dang. While the presence of community groups varies from VDC to VDC as per the need, there are community forestry user groups, mother’s groups, drinking water user groups, agricultural groups, cooperatives in common. At district level, there are alliances like FCHV District Network, NGO Federation, NGO Coordination Committee, Journalist Federation, Federation of Community Forestry Users Nepal (FECOFUN), and district level cooperative network.

14 5.4 STRENGTH AND OPPORTUNITIES

Majority of HFs with Functional HFOMCs.Having majority of functional HFOMCs is one of the strengths of DPHO Dang helping slowly institutionalize local health governance in district, irrespective of transitional local governance system. Out of 39 HFs, very few are non-functional. Some of the HFs in Dang—like Gadhawa HP, Sisihaniya HP, and Ganga Paraspur HPare exemplary in terms of resource collection and mobilization. Not only have they been regularly working with VDC for resource allocation, but also taking initiatives to collect local resources to build HFs and infrastructure, hire local staffs and have ambulance of their own. HFOMCs having Ownership of HFs.HFOMC members in active HFs seem to have ownership of their HF, helping them to be accountable to their activities. They have been facilitating to create conducive environment for providing access to service delivery, especially for marginalized and excluded, poor, adolescent youths, disabled, senior citizens and disadvantaged people. Thus, DPHO Dang’s exercise to orient and motivate HFOMC members to work for themselves is another important strength, helping people understand their importance to address local health needs. Opportunity for Collaboration with Other District Stakeholders.Although there are limited institutions, like DDC and INF, supporting the local health governance in Dang, DPHO can still collaborate with them to explore possibilities in expanding activities and their roles. While INF has been working to strengthen HFOMCs in Gobardiha HP and Bela SHP, and awareness raising on health and sanitation, their strength in community-based programs, capacity building and empowerment programs can be used by DPHO to integrate health related advocacy and awareness raising activities to cater larger population.

5.5 KEY ISSUES AND CHALLENGES

Challenges to having Active Leaders who can put forward Health Issues. The status of HFOMC also depends upon the presence of active HF in-charge and members. Unless there is someone who can translate health needs into demands, it is less likely that local needs are integrated in the planning process. Thus, having someone who can advocate for the health needs of community and at the same time ensure the use of HFOMC guidelines can be a challenge at the time of committee formation and member selection.

Lack of Knowledge Transfer.In Dang, many new committees have been formed after the expiry of existing HFOMC’s tenure, under DPHO’s initiation. Although new committees are formed, no handing over of responsibilities or sharing of experiences as such happens at local level. This seems to have created gap in knowledge transfer from old committees to the new ones, because of which an entirely fresh orientation has to be provided to HFOMC members. If system of knowledge transfer can be established within old and new members of HFOMCs and if possible with community, this could create an environment of learning and sharing while strengthening the ownership of HFOMC in community.

Health Demands through Proper Channel.DDC staff working for health sector thinks creating a cycle of demand and supply between HFOMCs and DDC/VDCs to fulfill the health needs is a real challenge. Although DDC/VDCs have been supporting in expansion of health services by allocating budget for birthing centers, hiring staffs and building infrastructures, what looks important is having demands received and sent through proper channel—mainly from HFOMCs to VDCs. Bypassing HFOMC during health related planning and resource allocation can bring isolation in HFs, limiting the exercise of management committee.

15 5.6 EFFORTS REQUIRED TO OVERCOME PROBLEMS/CONSTRAINTS

Orientation to newly formed HFOMCs with clear explanation of roles and responsibilities. Although orientation and refresher training was provided to HFOMCs earlier, these committees have been reformed after the expiry of 3 years tenure. As per DPHO staffs, even when new committees were formed as per the guidelines, most of the current (new) members are unaware of HFOMC guidelines, and their roles and responsibilities. Thus, providing orientation to the members of newly formed HFOMCs or refresher training to the existing members, and explaining and assigning them the roles and responsibilities look important to revitalize HFOMCs in HFs. DHO to regularly monitor, supervise and mentor HFOMCs. Based on the information received from different district level DPHO staffs, apart from formation of HFOMCs and orientation/refresher trainings, it is essential to regularly monitor and mentor them. As the committee is voluntary, it needs extra focus on how to regularly engage members and make their participation valuable. Thus, DPHO should visit HFs, take part in HFOMC meetings, and mentor them to collect health needs and take it forward to the planning process. Participatory planning and health demands through proper channel. Participatory planning is one of the main components of local development and this applies to HFs too. Considering the fact that HFOMC members represent different caste, ethnicity, marginalized and disadvantaged groups of people, their involvement in planning process looks crucial. Their engagement in demand collection, issues identification and program planning is as important as placing these demands at the Village Council to have them addressed. Windows of Opportunities at DDC/VDCs. DDC/VDC’s role in health has been limited to resource allocation for building infrastructure and hiring local staffs. Although 8-10 lakh rupees is allocated for health sector every year by DDC/VDC to expand birthing centers, build infrastructure and hire local staffs, there are many windows of opportunities that can be encashed by DPHO. DPHO can closely collaborate with DDC/VDC in making the planning process more participatory by explaining roles of different stakeholders in fulfilling health needs, and what their support can lead to in future. At present, DDC seems unaware of their role in providing access to quality service delivery.

16 6 SERVICE DELIVERY/QUALITY IMPROVEMENT

This chapter presents the RA findings related to service delivery and quality of care. Information on the quality of ANM schools, infection prevention practices at HFs, implementation of community- based interventions, and the provision of IUCD and Implants services were collected at district level. The major finding of the assessment is presented hereunder.

6.1 ANM SCHOOLS

One of the major objectives of H4L is to improve capacity to deliver FP/MNCH/Nutrition services. Under this, H4L intends to improve the quality of ANM pre-service trainings. For this purpose, information on ANM schools in Dang district was sought from DPHO during RA. As per the information, there is one ANM school in Ghorahi, Dang—Rapti Health Institute which is a private institute. When asked whether ANM school coordinates with DPHO for practicum sites and/or on- the-job training, DPHO supervisor shared that ANM schools directly get in touch with HFs instead of going through DPHO.

6.2 INFECTION PREVENTION AND WASTE MANAGEMENT PRACTICES AT HFS

Few questions related to infection prevention and waste management practices followed at HFs were also asked to district supervisors during RA. It was found that different HFs practice different type of infection prevention and waste disposal practices- while some burn waste, some others were mentioned to be burying it in pit. However, what looks good in Dang is having placenta pit in all 31 birthing centers.

6.3 SERVICE DELIVERY

The RA sought information on the availability of Satellite clinics, CEONCs, long acting FP methods, implementation of community- based interventions such as CB-NCP, MSC, Calcium and service integration.It also sought information on the number of health workers and FCHVs who have not received CB-IMCI training in the district; also seeking information on provision of clinical supervision in HFs. In Dang, 2HPs in Gadhwa and Sisihaniya have satellite clinics for family planning. There is only one CEONC site at sub-regional hospital in Ghorahi, and 4 BEONC sites in all three PHCCs in Lamahi, Syuja and Shrigaun and one zonal hospital. In order to provide long term reversible family planning methods there are 15 IUCD service sites and 6 implant services sites in Dang. Table 6.3 (a) shows the list of IUCD and implant sites.

Programs like CB-NCP, MSC and Infant and Young Child Feeding (IYCF) have been implemented in Dang for improving the health of mother, newborns and children. With regards to CB-IMCI training in district, around 20 health workers and 40 FCHVs from 39 HFs have not received the training. Likewise, there are around 10 health workers and 118 FCHVs in Tulsipur and Tribhuwannagar municipalities who have not received this training. During RA, district supervisors also mentioned that clinical supervision to HFs is done occasionally, that too during HF visits for some other purpose.

17 Table 6.3(a): IUCD and Implants Insertion and Removal Sites of Dang IUCD Insertion/removal sites Implants Insertion/removal sites 1. IFPSC*, Rapti Sub Regional Hospital 1. IFPSC*, Rapti Sub Regional Hospital 2. Rapti Zonal Hospital 2. Rapti Zonal Hospital 3. Syuja PHCC 3. Syuja PHCC 4. Lamahi PHCC 4. Manpur HP 5. Manpur HP 5. FPAN, Ghorahi 6. Gobardiha HP 6. Marie Stopes International, Tulsipur 7. Kabhre HP 8. Duruwa HP 9. Laxmipur HP 10. Hekuli HP 11. Lalmatiya SHP 12. Rampur SHP 13. Pawannagar SHP 14. FPAN, Ghorahi 15. Marie Stopes International, Tulsipur

In Dang, there are altogether 62 SBAs providing services from 25 SBA sites (HFs) which include 17 SBAs in Rapti Sub-Regional Hospital, 13 SBAs in Rapti Zonal Hospital and one SBA in Regional Ayurvedic Hospital. There are a total of 31 SBAs in remaining 22 SBA sites. Table 6.3 (b) below shows the list of HFs, the birthing sites and the number of SBAs in each.

Table 6.3(b): Table with the list of birthing centers and no. of SBAs Birthing Health Birthing Site No. of No. of SN SN Health Facilities Site Facilities (Yes/No) SBA SBA (Yes/No) 1 BAGHMARE No 0 22 MANPUR Yes 1 2 BELA Yes 0 23 NARAYANPUR No 0 3 BIJAURI No 0 24 PANCHAKULE Yes 1 4 CHAILAHI Yes 3 25 PAWANNAGAR Yes 1 5 DHANAURI Yes 0 26 PHULBARI Yes 1 6 DHARNA Yes 0 27 PURANDHARA Yes 0 7 DHIKPUR No 0 28 RAJPUR Yes 0 8 DURUWA Yes 1 29 RAMPUR Yes 1 9 GADHAWA Yes 2 30 SAIGHA Yes 0 10 GANGAPRASPUR Yes 1 31 SATBARIYA Yes 1 11 GOBARDIYA Yes 1 32 SAUDIYAR Yes 0 12 GOLTAKURI No 1 33 SHANTINAGAR Yes 1 13 HALWAR No 1 34 SHREEGAUN Yes 4 14 HANSIPUR No 0 35 SISAHANIYA Yes 1 15 HAPUR No 0 36 SONPUR No 0 16 HEKULI Yes 1 37 SYUJA Yes 3 17 KABHRE Yes 1 38 TARIGAUN Yes 0 18 KOILABAS No 0 39 URAHARI No 0 19 LALMATIYA Yes 1 40 RAPTI SUB-REGIONAL HOSPITAL Yes 17 20 LAXMIPUR Yes 2 41 RAPTI ZONAL HOSPITAL Yes 13 21 LOHARPANI Yes 1 42 REGIONAL AYURVEDIC HOSPITAL Yes 1 Subtotal1 13 16 Subtotal2 18 46 Total Birthing Sites: 31 Total No. of SBAs: 62 18 6.4 STRENGTH AND OPPORTUNITIES

Functional Birthing Centers with Placenta Pits.Dang seems to have good status of HFs at local level. Out of 39 HFs, 31 havebirthing centers all of which are functional. Interestingly, all the birthing centers have placenta pit for infection prevention and waste disposal. Having birthing centers in HFs is expected to increase institutional delivery, helping reduce maternal and neonatal deaths by bringing delivery cases in front of skilled health workers. Presence of ANM Schools. The presence of one ANM school in Dang is strength for DPHO which if utilized properly can be of great asset for health service delivery in the district. Although the quality of ANM produced every yearis questionable, DPHO can use this human resource as volunteers and mould them as per the need of district during emergency, disasters, or any regular health programs. Giving internship opportunities for deserving students can also be rewarding to both the students and DPHO; this will not only bring training institution and DPHO close but also increase the opportunities for future collaboration in improving health systems especially quality service delivery. Presence of CEONC and BEONC Sites. Having a CEONC site in Sub-Regional Hospital and 4 BEONC sites in Zonal Hospital and PHCCs is important to achieve MDG goal to reduce infant mortality rate in the district. Dang is geographically dispersed with many hard to reach areas, and bringing deliveries to health institutions is still a challenge. Irrespective of that, referrals and emergency cases of new born can be promptly taken to the nearest BEONC and CEONC sites available in the district, which otherwise would have to be referred to Nepalgunj or other places.Only Sub-Regional Hospital in Ghorahi provides CEONC service because of the presence of skilled human resource, equipment and blood bank required to perform caesarian section. Satellite Clinics and Long Term FP Methods Service Sites.Establishing satellite clinics to provide FP services looks like an effective program in district. Reproductive Health and Family Planning are always important aspects of health systems that determine district’s performance. Dang has been providing IUCD services through 15 sites and Implant services through 6 sites. Collaborating with private/NGO clinics for wider outreach can be important steps in extending FP related services.

6.5 KEY ISSUES AND CHALLENGES

Increasing the number of Institutional Delivery. Despite progressive increase in number of birthing centers in Dang over the last couple of years, a lot of exercise is still needed in terms of bringing deliveries to HFs. The data of 2068/69 clearly shows the sharp decline from ANC 1st visit (77%) to ANC 4th visit (43%). Likewise, PNC 1st visit during the same year is 54%. Despite social, cultural, religious and economic barriers, finding gaps between these numbers and bringing them to service providers for quality health service is a challenge. Lack of coordination between DPHO and ANM schools during practicum.There is one ANM schoolin Dang that can collaborate with DPHO to integrate fresh ANMs into district health systems. As per the conversation with DPHO supervisors during RA, there is no coordination between DPHO and ANM school at present—neither do ANM school coordinate with DPHO for practicum or on-the- job training, nor do they seek any advice on curriculum and activities. Creating an environment where both DPHO and ANM schoolcan regularly interact and support each other’s activities looks important. Also, having one-door policy for health systems in district is important. Integration of service data from NGO Clinics.Apart from government services, there are some NGO/private clinics providing long term FP services in Dang—like FPAN, MSI. Institutions as such have been working in district for many years, establishing themselves as service providers of FP methods. These clinics are providing the same services as offered by DPHO but in isolation i.e. the reporting of clinics has not been incorporated in the district recording and reporting. Thus, there is

19 an immediate need of integration of service statistics ofsuch private/NGO clinics with district reporting. Low number of trained health workers for IUCD Services. One of the biggest challenges Dang is facing is the lack of skilled and trained health workers who can provide IUCD services to women. According to FP focal person in DPHO Dang, there is a very limited number of trained health workers who if transferred, retired or expire will lead to the closure of service. Although there is high demand of IUCD service in the district, there are no service providers. This has not only caused service delivery issues, but also questioned the informed choice of receivers who are bound to be diverted to implants.

“We have limited number of staffs who are trained to provide IUCD services. If any of these health workers expire, or are transferred or retired, the health facility has to stop providing the service. There are many such instances where our IUCD service sites have been closed. Although there are many service receivers who come for IUCD service, we are bound to divert them for other family planning options—like implant. There is an immense need of IUCD training to health workers in the district so that we can also provide FP services to people of their choice.”-- KishorAcharya, FP Focal Person

Health Workers and FCHVs without CB-IMCI Training.DPHO Supervisors mentioned that there is high number of health workers and FCHVs who have not received CB-IMCI training in district. CB- IMCI is an important component of community health, so is typically more important for FCHVs who have access to community level information on mother and child. In Dang, there are 20 health workers and 40 FCHVs who have not received CB-IMCI training, and coordinating with Child Health Division to provide training looks important. Focused and Regular Clinical Supervision. Clinical supervision is regarded as an important learning process for health workers as per DPHO staffs. Even though supervision plan is made, it is not strictly followed. Having technically sound supervisors and deputing the responsibilities based on their knowledge and skills is important to provide onsite coaching and mentoring. Thus, technical supervision needs to be improved for quality service delivery.

20 7 LOGISTICS MANAGEMENT SYSTEM

Logistics management is an important part of district health systems. Efficient logistics management is required to smoothly run all the public health programs in district, sub-district and the VDC levels. The RA also sought information from DPHO on logistics management system. The major findings of the assessment are presented below.

7.1 AVAILABILITY OF KEY DRUGS AND COMMODITIES

As a part of RA, the store room of DPHO was visited and store keeper was interviewed to confirm the status of key drugs and commodities. The availability of ten tracer drugs/commodities— Injectable, Oral Contraceptive, Condom, ORS, Vitamin A, Iron FolateTablets, Cotrim (Ped), Zinc, Oxytocin and MgSo4 in the district store was checked. It was found that all these drugs and commodities were available at the time of RA. The store keeper was also asked whether the ten drugs/commodities were out of stock anytime in the last 12 months, and it was found that he have had issues maintaining the stock of Zinc and Cotrim (Ped)due to under supply but did not run out of stock. The RA team members also checked the expiry dates of those drugs/commodities and it was found that all the items were intact with no expired ones in store. Table 7.1: Availability of key drugs/commodities and their expiry dates in Dang SN Drugs/Commodities Availability at Stock out in the last Expired drugs in the time of visit 12 months stock at the time of visit 1 Injectable Contraceptive Y N N 2 Oral contraceptive Y N N 3 Condom Y N N 4 ORS Y N N 5 Vitamin A Y N N 6 Iron Folate Tablets Y N N 7 Cotrimoxazole (Ped) Y N N 8 Zinc Y N N 9 Oxytocin Y N N 10 MgSO4 Y N N

The Store keeper was also asked to list the drugs that have most problems with over stock for the last 12 months. As per his information, there has been over stock of Metronidazole Syrup, Cotrim (P) 480 mg, Vitamin B complex and Chloramphenical eye ointment in district store.

7.2 COLD CHAIN AND FEFO MANAGEMENT

DPHO Dang has eight functioning refrigerators that are sufficient to maintain the cold chain at DPHO. The management of five to ten drugs in the store was checked to see whether First Expiry First Out (FEFO) was maintained or not. Although the store is huge and has large supply of drugs and commodities, it was found that FEFO system was maintained properly.

7.3 LMIS REPORTING

DPHODang is using web-based LMIS system which was up-to-date during RA. The availability of stock as well as the report of third quarter was checked through LMIS in the presence of RA team.

21 The store keeper who has been working in the district for last one year has managed to update LMIS regularly, making the availability of drugs and commodities clear. DPHO has not recruited any dedicated data entry person for entering LMIS data; it falls under the responsibility of store keeper to at present.

7.4 STRENGTH AND OPPORTUNITIES

Well managed and updated web-based LMIS.The recording at web-based LMIS looks updated in DPHO Dang. Information like quarterly reports, availability of drugs in store, and the recent inflow of drugs can easily be seen in LMIS. Maintenance of Cold Chain and FEFO. DPHO Dang has eight functioning refrigerators sufficient enough to maintain cold chain. In case of power cut, generator is used to supply power for cold chain maintenance. Likewise, the store has maintained FEFO system for effective supply and management of drugs and commodities. Re-arrangement of DPHO store for proper management of drugs and commodities. The DPHO store located in the Sub-Regional Hospital is huge. Although FEFO system is maintained and expired drugs are segregated, rearrangement of store looks important for proper management of drugs and commodities. In the absence of store keeper, the store looks inaccessible and hard to explore. If re- arrangement of store can be done, the store could accommodate more drugs and commodities, making it visibly appealing and easy to access. Dedicated and well informed staff as store keeper. Although there is only one staff looking after the DPHO store, he looks well informed on web-based LMIS as well as other requirements of drugs and commodities. Having a dedicated staff, who can take care of store and manage the reporting and recording is strength of DPHO that needs appreciation.

7.5 KEY ISSUES AND CHALLENGES

Inadequate supply of important drugs in time. Although DPHO manages to keep stock of essential drugs and commodities, it is difficult to adequately supply these to all HFs. Less supply of Iron and Cotrim (P) this year created a lot of hassle not only in Dang, but also in other districts. DPHO usually sends request orders to respective supply centers, and if not supplied, they purchase it before running out of stock. This way, the chain of demand and supply is met in the district. Having a scheduled supply of adequate drugs is a challenge for district store. Delay in budget release causing difficulty in logistic management. As per DPHO Store keeper, the budget is released at the very end of FY which makes it difficult to manage logistics. There is a huge cost involved in store maintenance, vehicle cost and labor cost for supply to HFs, which they have to arrange on their own until the budget is received. Normally, the fund is internally managed within different programs and once the budget is released, it is settled. Insufficient human resource for store maintenance. It is important to have a clean and visible store for easy access of drugs and commodities. DPHO store in Dang is huge and have been maintaining FEFO, but the store looks messy and difficult to explore. On the other hand, a huge amount of energy needs to be spent for cleaning the store on daily basis which has not been realized at the management side. Thus, having someone to clean and maintain store besides storekeeper would be a great relief for DPHO Dang, which can be managedthrough the DPHO support staff.

22 8 BEHAVIOR CHANGE COMMUNICATION

H4L aims to understand legal, cultural/religious, and policy dimensions of GESI inequities on health service access and use and design interventions to ensure sustainable, high-quality BCC and IEC approaches that respond to local realities, and include groups not commonly targeted, but crucial to meeting Nepal’s health goals.One of the objectives of the RA was to explore the range of BCC interventions that is being implemented for healthy behaviors. Following are the major findings on BCC.

8.1 EXISTING DPHO PROGRAMS ON BCC

DPHO Dang has major partnerships with four FM stations chosen based on their coverage area and areas of focus. There are several health related programs and public service announcements (PSAs) that are aired through these FM stations. Some of these health programs and PSAs cover the topics like Health and Message (SwasthyaraSandesh), reproductive health, population, CB-IMCI and CB- NCP as well as announcements during vaccination, polio, health camps, Japanese Encephalitis, or any other done by DPHO.

DPHO has also been working on awareness raising and interaction programs in different communities. In April this year, DPHO organized two different awareness raising programs in Badi communities in Nayabasti and Motipur of Tulsipur municipality. The interaction was focused on issues like safe motherhood, safe abortion, communicable diseases, STDs, HIV/AIDs. Likewise, interaction programs were held in 5 VDCs—Purandhara, Goltakuri, Fulbari, Hasipur and Gobardiha on issues like smoking, communicable diseases, cleanliness and hygiene.

8.2 FM STATIONS/CABLE TELEVISION NETWORKS

There are altogether 12 FM stations in Dang as listed below and based in different locations. Out of them, DPHO usually partners with four FM stations Table 8.1: List of FM Stations in Dang chosen mostly based on their coverage—Tulsipur FM, Name of FM Station Address FM, Radio Madhyapaschim and Highway FM. 1. Radio Madhyapaschim Ghorahi Tulsipur FM and Swargadwari FM usually have larger 2. Swargadwari FM Ghorahi coverage from Pyuthan to Banke, and Highway FM usually 3. Indreni FM Ghorahi has programs in Tharu dialects. So, if DPHO needs to 4. Jharana FM Ghorahi provide PSAs in Tharu dialect, Highway FM is used. 5. Ganatantra FM Ghorahi 6. Radio Highway Lamahi There are few cable TV networks in Dang but none of 7. FM Lamahi 8. Radio Nawa Yuba Lamahi them broadcast any district-based health programs. They 9. Tulsipur FM Tulsipur usually broadcast national health related programs that 10. Prakriti FM Tulsipur are sent to district from central level in DVDs. Such 11. Radio Saryuganga Tulsipur programs are distributed to cable TV networks who then 12. HamroPahunch Tulsipur broadcast them, without any change from district level.

23 8.3 ORGANIZATIONS WORKING IN IEC/BCC ACTIVITIES

As per the information provided by BCC Focal Person in DPHO, there are five different organizations working in IEC/BCC activities in Dang as listed below. These organizations work on different areas of health and support IEC/BCC programs but unfortunately, all of them work on their own without any information and consultation with DPHO. However, FM stations confirm the content of program with focal person of DPHO before airing it publicly. 1. Women and Child Office (gender-based violence, reproductive health, peer education) 2. FPAN (street drama on RH, FP, HIV/AIDS, health awareness) 3. Dang Plus (HIV/AIDS) 4. INF (Leprosy, HIV/AIDS, communicable disease, sanitation) 5. Nepal Red Cross Society (RH, peer education)

H4L plans to use mobile phones to reach target groups with messages on health in selected district. The RA also explored whether any organization has used mobile phones to communicate health messages to target groups or entire district population together with D/PHO. It was found that there has been no intervention in technology in Dang and no mobile phones or tablets or anything as such has been used to disseminate information to larger public.

One other area of intervention of H4L is to improve the quality of counseling provided by health workers and community-based health workers to clients. It is therefore essential to find out whether there is pool of resources available at district level to improve counseling services. Hence, RA tried to collect information on the district health staff who received training on COFP/C in the last three years, but no data/list was found. However, as per the information provided by BCC focal person, most of the DPHO staffs have attended COFP counseling course except for some 20 new staffs.

8.4 SCHOOL HEALTH PROGRAM

DPHO has been regularly conducting school health education programs in schools covering the topics like reproductive health, family planning, adolescent health, communicable diseases, TB, leprosy, gender-based violence etc. BCC Focal Person (HETO) mentioned that DPHO has to conduct 140 classes every year through PHCCs and HP/SHPs. PHCCs and HP/SHPs have to conduct at least 3 classes and 2 classes respectively for students of class 8, 9 and 10 under school health program.School health program was running in each VDCs of Dang with the number of students ranging from 45 to 150, depending on school. As per HETO, the minimum number of students enrolled in 140 classes under school health program last year was around 7,000 (seven thousand only). Despite a large number of students benefiting from this program, it could not be conducted this year due to budget constraint.

Last year, there was Peer Education program targeted to youths on health education and awareness with more focus on family planning and reproductive health. Under this program, 40 people were provided training from 10 different schools for 3 days. This number comprised of a girl student from grade 8, a boy student from grade 8, a health and population teacher from the same school and a health incharge from that locality/VDC. Altogether 4 people each from 10 different VDCs— Purandhara, Hekuli, Duruwa, Manpur, Laxmipur, Gadhawa, Gobardiha, Lalmatiya, Satbariya and Kavra—were provided training. The following years, new students studying in grade 8 are provided the same training, which means a school usually has 6 peer educators after three years of training. Like school health program, peer education program could not be conducted this year due to budget constraint. 24 According to the HETO, besides school health education program, activities like street dramas, radio dramas and wall painting can be effective in reaching adolescents with health messages that are more specific to district. There are several radio programs on health but with less focus on adolescents and youths. If BCC programs can be designed for adolescents, esp. on early marriage and early pregnancy, it can be effective. During interaction with DPHO staffs, it was also mentioned that the people living in municipalities, especially the ones in slum areas and other poor communities are out of health services. So, BCC program is equally important for people living in urban areas to bring them into HFs for service delivery.

8.5 MAPPING OF DAG AND EXPLORING CULTURAL PRACTICES AFFECTING HEALTH

During RA, in-depth information on DAG communities residing in Dang was also collected from supervisors in DPHO. Below are the major findings of the assessment.

8.5.1 Villagesand ethnic communities deprived of service utilization - Naka area of Rajpur, Bela, Gobardiha, Koilabas, Gadhawa VDCs - Gangate area of Purandhara and Panchakule VDCs - Furkesalli village of Goltakuri VDC - Barahkoti village of Lalmatiya VDC - Sinnebas (Ward No. 1) of Lalmatiya VDC - Bastikhola and Baghkhor villages of Shantinagar VDC - Halide village of Baghmare VDC - The northern areas of Pawannagar VDC - Rajje and Manname of Dharna VDC - Ethnically, Badi communities, Yadav communities are deprived of service utilization - People living in urban areas of both municipalities are deprived of service utilization in Dang because (a) FCHVs are inactive; (b) Health Workers have not been able to provide service as needed; and (c) no programs on awareness raising - VDCs with larger areas have people who are deprived of health service utilization. For e.g. In VDCs like Rajpur, Bela, Purandhara, Panchakule and Satbariya, the population is large but is sparsely populated. In some of these areas, service receiver has to walk for nearly 6 hours to reach health facility. One health facility per VDC is not sufficient for such cases.

8.5.2 Villages/communities that still practice Early marriage and Early Child Bearing Addressing the issues on early marriage and early pregnancy has been a challenge to Dang. Service statistics of district shows that 25 percent of women going for ANC 1st visit are less than 20 years of age. There are, however, no particular VDCs or villages practicing early marriage as reported by district supervisors. Based on the information provided by DPHO supervisors, early marriage is more prevalent in Madeshi communities, mostly Yadav living in naka areas—Rajpur,Bela, Gadhawa, Gangaparaspur and Gobardiha. The trend is culturally embedded in communities and has been developed as a culture over the years.

There are also instances of early marriage and early pregnancies among Dalits, Janajatis and poor communities compared to other groups living in Dang. Interestingly, more than arrange marriage at an early age, the trend of love marriage among adolescents and youth is increasing.Apart from some awareness raising programs, there has not been any focused intervention in Dang to address early marriage and early child bearing. Focused programs targeted to adolescents and youths, parents and communities look important to discourage practice of early marriage and mitigate the risks caused by early pregnancies.

25 8.5.3 Migration pattern Based on the interaction with different district level stakeholders, there are mostly three patterns of migration in Dang as below: 1. Fewpeople going to India for work. The trend of going to India is common among Dalits and economically poor communities scattered around Dang. These are the unskilled group of people who work under low pay jobs. Some of these people are seasonal migrants, who go to India after harvesting agricultural produces at home. The number of people under this category is very few. 2. Many youths going to Malaysia, and Gulf countries. Although no particular VDC, area or community has been identified as the one with “most migrants”, the trend of youths going to Malaysia and Gulf countries is very common. There are also few migrants from Dang going to South Korea. 3. People going to Kapilvastu or other neighboring areas as agricultural laborers. This trend is common among people living in Deukhuri, who go to neighboring districts especiallyKapilvastu to harvest crops. These are termed as agriculture laborers who migrate for a very short period of time and are back to their place once the harvesting is completed in those areas.

8.6 STRENGTH AND OPPORTUNITIES

IEC/BCC activities conducted by different organizations. In Dang, there are many BCC activities being conducted by different organizations apart from DPHO Dang. Organizations like WCO, FPAN, Dang Plus, INF, and Red Cross have been working on different health issues and awareness raising programs. Except for some, most of the organizations have been working as stand-alone without any coordination with DPHO. If DPHO can collaborate with them to reach different target groups, there are opportunities to have long term effect on behavior change.

Use of FM stations for information dissemination. DPHO Dang has been using different FM stations to disseminate health information to wider audience. Use of FM to air health messages in local dialect, particularly the use of Highway FM for messages in Tharu language is an important step undertaken by DPHO. Likewise, there are several health related programs and PSAs aired through these FM stations.

8.7 KEY ISSUES AND CHALLENGES

Lack of district specific BCC materials. DPHO Dang has been providing BCC materials to all HFs and centers for information and health awareness. But these materials are mostly supplied by central level and covers national issues. If district specific BCC materials could be made and supplied by DPHO itself, that would be more effective. Here, the main challenge is coming up with innovative ideas and collecting resources to have such materials distributed throughout the district or specific target areas. Use of BCC to address the issues raised by early marriage. Early marriage is one of the major problems in Dang and the HMIS data shows that 26 percent of ANC 1st visit is done by women less than 20 years. Use of BCC materials and at the same time respecting cultural and traditional practices in locality is quite a challenge not only in Dang but elsewhere. But through proper use of such materials, prevention of early marriage can be advocated and at the same time awareness raising on RH and FP/MNCH can help mitigate the possible risk that can be caused by early pregnancies.

26 8.8 H4L INTERVENTION ON BCC

Focused program to bring urban population in health service utilization.People living in municipalities have been identified as the population who are out of health service utilization by DPHO and other district level stakeholders. The service utilization is typically poor among people living in urban slums. Although identified as deprived group of people, no focused intervention has been done to bring them into health services. Thus, H4L can collaborate with different stakeholders to introduce programs and activities in these areas. Collaborate with district level stakeholders to design focused BCC programs/materials on early marriage and early pregnancy. Early marriage and early child bearing are important issues in Dang. Although district level stakeholders (like DPHO, DDC, WCO, UNFPA, FPAN) have identified early marriage as a problem in district that has affected district health indicators, there has been no focused intervention to address the issue. H4L can collaborate with these identified district level stakeholders and design focused BCC program or material jointly, so that it can have wider and long term effect on people.

Coordinate with organizations working on IEC/BCC, and utilize and adopt different materials, ideas and concepts used so far. There are several programs and ideas being implemented on IEC/BCC under different themes within and out of district. Different materials, ideas and concepts developed and used by other organizations can be utilized and adopted in close coordination with them. H4L can coordinate with these organizations, which will not only help share innovative concepts and ideas but also help in cost reduction, avoiding duplication and joint planning.

27 9 ADOLESCENTS AND YOUTH FRIENDLY SERVICES

H4L will also work with DPHOs in selected districts to improve service accessibility of adolescents under its Objective 6. The RA also explored different aspects of Adolescents and Youth Friendly Services in the public health facilities of Dang district. Following are the major findings under this section:

9.1 EXISTING SERVICES FOR ADOLESCENTS AND YOUTHS

There are several programs running for adolescent and youths in Dang and several organizations have been supporting to make the service youth friendly. Programs like peer education, adolescent and youth friendly services, adolescent girl’s information and counseling centers and youth friendly service centers are currently running in Dang with support from organizations like GIZ, UNFPA, WCO, FPAN, and MSI. Similarly, INF Dang has been working with adolescent and youth groups in few VDCs to raise awareness on cleanliness, sanitation, communicable diseases, adolescent health, RH, FP, etc. Under adolescent and youth friendly services, special hour has been assigned for youths in HF level making them easily accessible for service use.

One of the programs with special focus on adolescent and youth friendly services has been implemented by GIZ in 13 HFs of Dang. The program was introduced in 2012 which provided orientation to district level stakeholders, followed by AFS training to health workers from all 13 HFs. Under this program, adolescents are given priority at HFs, special hour is assigned to address their needs, confidentiality in maintained and services on family planning is provided. Apart from these, counseling is one of the important aspects of AFS, which is provided through the assigned HFs. Based on the information received from DPHO supervisors and UNFPA representatives, GIZ supported HFs are being revitalized by UNFPA this year who will continue providing AFS.

9.2 ORGANIZATION WORKING FOR ADOLESCENT

GIZ has been working to introduce and extend Adolescent and Youth Friendly Services in health facilities of different districts in Nepal and Dang is one of them. This program has been implemented in selected HFs of Dang, so is in close coordination with DPHO. GIZ has supported such services to 13 HFs of Dang—RaptiZonal hospital in Tulsipur, 3 PHCCs in Lamahi, Syuja and Shrigaun, HPs in Manpur, Hekuli, Gadhwa, Kavre, Sisihaniya, Duruwa, SHPs in Rampur and Pawannagar and Institutionalized Family Planning Service Center (IFPSC) in DPHO. Through theseHFs, youth friendly services are provided to adolescents and youths, with special focus on RH, FP, adolescent health as well as counseling. As per AFS focal person, all 13 HFs send report to DPHO on monthly basis, who then forward it to Family Health Division at central level through which the final report is provided to GIZ. However, there is no regular reporting from HFs at DPHO, nor is there much follow up from GIZ. Reports from some of the HFs for the month of March 2013 were observed at DPHO during RA.

United Nations Population Fund (UNFPA). Decentralization of health planning system is a prime concern of UNFPA and they have been articulating this strategically through evidence-based programs and participation of youth, marginalized and disadvantaged groups. They have been extensively working on awareness raising programs and activities over the years and in order to promote adolescent and youth friendly services, they are working with FPAN on youth friendly

28 service centers through five service centers- Tulsipur, Gadhwa, Sonpur and Ganga Paraspur, and district clinic in Ghorahi. These centers specifically provide family planning and counseling services to adolescents and youths through a dedicated staff assigned to each center.

At VDC level, committees comprising of these adolescent girls are formed and life skill training is provided with information on RH, adolescent health, menstruation cycle, early marriage, gender based violence, etc. In the next phase, they are given skillful training for income generation. Likewise, WCO has also established Information and Counseling Center for adolescent girlsin working VDCs. Thus, WCO has been working closely with adolescent girls who are marginalized, disadvantaged and are out-of-school mostly, and provide them access to information, skillful training, counseling and awareness on reproductive health, family planning, adolescent health, gender based violence, early marriage, etc.

Family Planning Association of Nepal (FPAN).Apart from providing clinical services on FP, RHand counseling, FPAN has beensupporting the formation of Youth Clubs and Youth Friendly Service Centers in Dang. They are providing youth friendly service centers from 4 community clinics in Tulsipur, Gadhwa, Sonpurand Ganga Paraspur, and district clinic in Ghorahi. FPAN also has 25-30 Peer Learning Groups in Dang with 10 people in each group who learn about different health related issues and discuss among groups. Likewise, FPAN has also financially supported Gadhawa HF to provide Adolescent and Youth Friendly Services in the locality. Although the number of youth clubs under FPAN could not be found, there are around 300 youths involved in providing BCC and adolescent friendly services throughout district.

Marie StopesInternational (MSI)has been providing clinical service to adolescent and youths in Dang with special focus on RH, FP and abortion. Although they have been providing clinical services for many years now, they are not much involved in awareness raising programs.

International Nepal Fellowship (INF) in Dang also has adolescent and youth groups in each ward of Rajpur and Saiga VDCs where they provide information and counseling on HIV/AIDS, Leprosy, and awareness raising activities on sanitation and hygiene, communicable diseases, prevention, care and support on health issues.

9.3 STRENGTH AND OPPORTUNITIES

Different organizations working with adolescents and youth. There are different organizations working on providing services to adolescent and youths. Organizations like WCO, UNFPA, GIZ, FPAN, MSI and INF have been working in this sector to ensure youth friendly services. DPHO has been closely coordinating with some of these organizations making the services easily accessible to the target groups. However, there are further areas of collaboration with these organizations in expanding adolescent friendly services throughout district.

Information and Counseling Center for adolescent girls in 5 VDCs (WCO).WCO has been working with adolescent girlsin 5 VDCs of Dang, providing them information, awareness and livelihood trainings. They work with girls who are 10-19 years of age, mostly those who are out of schools. They provide livelihood trainings to these groups of girls as income generation activities. Apart from that, WCO has also established Information and Counseling Center for adolescent girls in these 5 VDCs—Manpur, Bijauri, Tarigaun, Gadhawa and Gangaparaspur to provide counseling and information on adolescent health, reproductive health, early marriage, gender-based violence, women rights, etc.

29 9.4 KEY ISSUES AND CHALLENGES

Expansion of adolescent and youth friendly services throughout district.Although there are adolescent and youth friendly services in different VDCs and HFs of Dang, its expansion in all VDCs and HFs is a challenge. What is more challenging is making these services regular and sustainably such that the services are continued even after supporting agencies and their programs phase out. The coverage of such services has been to be expanded in all VDCs to ensure none of the youths are deprived of health services.

Bringing adolescent and youths to health facilities. What looks difficult in providing the services to adolescent and youth is the service hour offered by HFs in case of school children. HFsare mostly open from 10am-2pm during which the target group is in school. When they are free, it happens that HFs are closed for service hours. As some of the programs has started dedicating special hour to increase visits, expansion of this services is very essential. Not only those in schools, tracking out-of-school youths and adolescents and bringing them to serviceare a big challenge.

Providing adolescent related awareness programs in mitigating the risk caused by early marriage. Early marriage looks very common in Dang like in many hilly districts of Nepal, which is the cause of several issues on RH and FP/MNCH. It is very essential to come up with awareness raising programs among parents and youths/adolescents such that issues can be widely discussed to prevent early marriage. Besides that, programs with focus on RH and FP/MNCH need to be focused at young girls and boys who are married at the young age to mitigate the possible risks that can be caused by early pregnancy. Bringing target groups to such floor for open discussion on these issues can be a real challenge to DPHO and other stakeholders.

Ensuring participation of adolescents and youths in decision making process.Youth and adolescent targeted programs are in place and having their representation in different local and district level meetings is vital. Their participation should be ensured by different stakeholders providing them friendly forum where they can discuss on their issues and raise their demands. Involving youths and adolescents in decision making process is important, which needs focused intervention. Based on the interaction with district level stakeholders, if the participation of youths and adolescent is ensured, their needs and demands can be placed forward so that the programs and activities are designed based on the need.

30 10 GENDER EQUALITY AND SOCIAL INCLUSION

H4L is designed to support the Government of Nepal’s stated commitment and responsibility to ensure that quality health services are accessible to all citizens. As such, it is critically important that sound, ongoing GESI-sensitive analysis and gender integration underpin H4L program interventions. H4L’s GESI Objectives are designed to redress gender and social inequities, and dove-tail with the objectives set forth in the MOHP’s 2009 Health Sector Gender Equality and Social Inclusion Strategy as follows:

Objective 1: Support existing MOHP policies, strategies, plans and programs that create a favorable environment for integrating GESI in Nepal’s health sector; Objective 2: Support MOHP’s efforts to enhance the capacity of service providers and ensure equitable access and use of health services by the poor, vulnerable and marginalized castes and ethnic groups; and Objective 3: Improve health-seeking behavior of the poor, vulnerable and marginalized castes and ethnic groups in collaboration with local government partners, community- based organizations (CBOs) and other stakeholders.

The first objective is related to policy while the latter two are directly related to DPHO systems.The RA also included assessment and analysis of the health programs of the DPHO Dang from GESI perspective. The major findings were as following:

10.1 FORMATION AND FUNCTIONALITY OF GESI COMMITTEE

In DPHO Dang, GESI committee was formed on Dec 4, 2012 in accordance with the GESI institutional guidelines provided by central level, with 18 male and 8 female members. Out of 26 members in the committee, there isoneChaudhari female and one Muslim male. The committee also formed a 15 members GESI working committee the same day with members from DPHO, DDC, DEO, WCO, WOREC Nepal, Sub-Regional and Zonal hospitals, Rural Women Development Center (graminmahilauththaankendra) and FPAN.

NHSSP supported the formation of GESI committee and NHSSP GESI specialist based in Regional Health Directorate, Surkhet provided a partial orientation of 3 hours to all the stakeholders. The committee thus formed agreed to meet in every four months, but no meeting or follow ups has been held since its formation. As per the information provided by GESI Focal Person at DPHO Dang, not a single activity has been undertaken by the committee till date. He mentioned that the committee was formed as per the guidelines but is not aware of the importance of GESI in health services nor does he have any TOR. Interaction with district supervisors at Dang clearly illustrates that none of them are aware of MOHP GESI Strategy and Operational Guidelines.

GESI Committee in Dang has been formed to fulfill the mandate as per focal person and there is a strong need to provide complete orientation on GESI approach, indicators and ways to integrate GESI into programs and activities. Once they are sensitized enough, they think they would not require any meeting agenda or a separate budget allocation to integrate GESI—instead each programs and activities at DPHO would be GESI focused. Despite these constraints, GESI Focal Person mentioned that sensitivity is undertaken while providing services at HF level. For eg: having a private space with curtains for pregnant women, allocating specific hour for adolescent girls, etc.

31 10.2 ACTIVITIES ON GESI AND INFORMATION ON DISAGGREGATED DATA

DPHO Dang does not have disaggregated data reporting system by age, caste, ethnicity, wealth quintile and region, nor do they have any recent DAG mapping. The availability of such data and its analysis would help initiate programs to address GESI gaps. Likewise, the district also lacks GESI sensitive process indicators to measure utilization and health care services and disparities between different caste and ethnicities.

DPHO staffs mention that the integration of GESI into district level programs and activities would be effective if they could be sensitized on GESI issues. Even though they are not aware of GESI Strategy and Operational Guidelines, they have done a couple of programs focused at M/DAGs and low performing VDCs as below: Awareness raising program in Badi communities.DPHO organized two different awareness raising programs in Badi communities residing in Nayabasti and Motipur areas of Tulsipur municipality. The interaction was on family planning, reproductive health, STDs, HIV/AIDS with special focus on safe motherhood, safe abortion and communicable diseases. Around 75 people attended these two programs which were held in April 2013, under the budget of Information and Communication. Interaction program on 5 VDCs with low performance.Interaction programs were also held in 5 VDCs—Purandhara, Goltakuri, Fulbari, Hasipur and Gobardiha that have been categorized as VDCs with low performance. The interaction was held to raise awareness on epidemics, communicable diseases, smoking, cleanliness and hygiene, etc. The fund to organize these events comes through Nepal Government with allocation of 50 thousand for 5 VDCs.

10.3 ORGANIZATIONS WORKING ON GESI

The RA team came across four organizations working on GESI in Dang—DDC, WCO, UNFPA and INF, and visited all of them, seeking information on what kind of activities are they conducting, who are the beneficiaries, level of sensitivity, their programs and coverage.

District Development Committee (DDC).The interaction with focal person of Health in DDC explained that they have recently conducted five phases of GESI orientation on district during Nov 2012 to Mar 2013. As per the information, 3 days orientation was given to the following: 1st Phase: All VDC Secretaries of 39 VDCs and Chief Executive of Municipalities 2nd Phase: Social Mobilizers under LGCDP 3rd Phase: Village Facilitators under WCO 4th Phase: Political party leaders 5th Phase: Members of target groups (Dalit Network, Jajajati group, women’s network, disabled network, child club, etc.) The main purpose of this orientation was to inform and sensitize different layers of local level leaders on GESI, so that they can go back to their village and explain the concept to the wider population. This was the first step of GESI integration in DDC and local governance, and now they are hopeful that some of the aspects will be covered during program planning and implementation.

Women and Children Office (WCO).GESI has been an integral part of WCO, but with more focus on women and adolescent girls. They have been working on group formation at Tole, Ward and VDC level to include deprived and disadvantaged women into their programs that include awareness raising programs on RH, HIV/AIDS, women and reproductive rights, etc. WCO also has programs for adolescent girls wherein committees are formed at VDC level who are then provided life skill

32 training that also includes awareness raising program on RH, early marriage, menstruation, gender- based violence. They are also given skill development training for income generation.

United National Population Fund (UNFPA). UNFPA’s district office started in Dang in 2001 during conflict period with the working modality of providing service delivery through doctors and nurses. In post conflict situation, regional structure was established in 2010 and since then UNFPA is working with DDC as a partner and DPHO as a sub implementing partner. Right based and right holders empowerment is the existing working modality especially focusing on young girls and women’s barriers for accessing health services and promoting for demand creation for health services. UNFPA’s areas of work in health sector are population dynamics, health system esp. adolescent reproductive health and GESI. International Nepal Fellowship (INF). INF has been working on health sector for last 40 years in Dang. They have their own mapping based on which services and programs on community development, empowerment, counseling, awareness raising, advocacy, etc. are taken to selected areas. Under GESI, they have focused their programs on HIV/AIDS, Leprosy as well as people living with disability (Pyuthan, Rolpa and Salyan) on advocacy and awareness raising.

10.4 AREAS OF SYNERGY AND COLLABORATION IN GESI

There are different organizations working in Dang—DPHO, DDC, WCO, UNFPA, GIZ, INF, FPAN, etc. with some level of GESI focus. There are areas of synergy and collaboration with these organizations or any other stakeholders in identification of hard to reach areas, deprived population (elderly, disabled, children, women, people living with HIV/AIDs, etc), marginalized and disadvantaged group of people, and bring them into health service utilization. As mentioned by DDC, district level orientation on GESI has been provided to different district level stakeholders and line agencies. It is expected that the programs and activities for the upcoming FY will have some level of GESI sensitivity. GESI is a cross cutting issue so H4L can collaborate with any organizations to ensure that nobody is deprived of health services based on age, sex, caste/ethnicity, geographical region, disability, etc.

10.5 ONE-STOP CRISIS MANAGEMENT CENTER (OCMC)

One-stop Crisis Management Center (OSCMC) was established in Rapti Sub-Regional Hospital in Ghorahi on February 14, 2013 with the objective to provide one-door service to victims of gender- based violence. Since the establishment of this center, 53 cases have been registered at OCMC ranging from normal cuts and wounds to complicated uterine surgery; and legal issues ranging from rehabilitation at home to divorce cases. OCMC has been established in 15 different districts of Nepal as pilot program; and Dang is one of them.

There is a District OCMC Coordination Committee at district level chaired by CDO. The committee has members from DDC, WDO, DEO, District Police, District Court, District Bar Association, Medical Officer and many other district level stakeholders, and has Medical Superintendent of Rapti Sub- Regional Hospital as Member Secretary. As per the guideline, the committee has to hold meeting at least 4 times a year. At OSCMC, there is a 5 member committee called Case Management Committee with Focal Person (the staff nurse) and Medical Officer at Rapti Sub-Regional Hospital as Member Secretary and Coordinator respectively. The other three members are from Women and Children Office, District Police Office and District Office of Attorney General.

OCMC has been established at the hospital with the assumption that most of the physical abuse ends up at hospital for treatment. Providing all the required treatments from the same center 33 without having to repeat their trauma at different places is the main thrust of this center. The scope of OCMC’s work is wide and it provides services in 6 different areas—health services, psycho-social counseling services, legal counseling and services, information and education, safe shelter during the treatment period and rehabilitation services. Out of the six areas of work, DPHO has direct linkage with three of them i.e. providing health services, psycho-social counseling and providing information and education to the victim. Thus, H4L can provide technical assistance to DPHO or directly to OCMC to address issues raised by gender-based violence.

34 Annexes Annex 1: Contact information of DPHO Staff, Dang Years of D/PHO Team Added Years of Name service in Contact No. Responsibility service (Current) district Sr./Public Health DPHO 26 5 Officer/ Administrator Public Health Nurse RH/MNH 30 5 Statistics Officer HMIS, HFOMC 23 16 Child Health focal CH, Health 30 12 person Education FP focal person AFS, GESI, FCHV 17 13 Vector Control Officer Vector Borne 20 20 Diseases DTLA/Officer TB, Leprosy 19 7 TB, Leprosy 20 3 EPI Supervisor/Officer EPI 26 7 Cold Chain Officer Cold Chain 27 8 Cold Chain 26 25 Computer Officer Computer 17 17 Store Keeper Logistics 18 1 Nutrition Focal Person Nutrition 24 4 mth Lab Technician Lab 9 6 Lab 9 4 Lab 9 1 Public Health Officer Punarjagaran 33 1

Annex 2: List of RHCC member organizations, DPHO/Dang SN Name of the organization/ Focused area (technical) of intervention Organization type 1. District Public Health Office  Implementation of RH activities in district  Supervision & monitoring of RH activities  Facilitation of RHCC meeting 2. District Development Committee Support to VDCs on health issues 3. Women & Children Office Adolescent girls, RH, Women’s Right, Child Rights 4. United Nations Population Fund Adolescent health and FP 5. District Education Office Integration of health education in schools 6. Nepal CRS Company Promotion of FP services through private sectors 7. Rural Women Upliftment Center Reproductive health 8. Nepal Red Cross Society Peer education-- adolescent health, disaster management 9. Family Planning Association of Nepal Clinical services on FP/RH 10. Dang Plus HIV/AIDS 11. Blue Diamond Society Contraceptive distribution; HIV/AIDS 12. Sisa Nepal HIV/AIDS, FP, RH 13. Marie Stopes International FP, RH 14. International Nepal Fellowship Leprosy, HIV/AIDS, Adolescent, HFOMC, empowerment 15. Institute of Community Health Community health

35 Annex 3: List of Individuals/Organizations visited during RA/Dang SN Name Designation/Department Organization Contact No. 1. Sr. DPHA DPHO 2. Statistics Officer/HFOMC DPHO 3. FP/AFS/ GESI/FCHV DPHO 4. CH, Health Education Officer DPHO 5. PHN DPHO 6. EPI Officer DPHO 7. Cold Chain Officer DPHO 8. Cold Chain Officer DPHO 9. Store Keeper DPHO 10. DACC Coordinator DPHO 11. District Coordinator MaxPro 12. Information & Communication Dept DDC 13. Social Development Officer, DDC GESI-Focal Person 14. MukhyaMahilaKaryakarta WCO 15. Regional Development Coordinator UNFPA 16. Administration Officer FPAN - 17. Program Manager INF -

36 HEALTH FOR LIFE

REPORT ON

RAPID ASSESSMENT

OF DISTRICT HEALTH SYSTEMS 2013 JAJARKOT A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013 JAJARKOT

TEAM MEMBERS

MAY 2013

i TABLE OF CONTENT

ABBREVIATIONS……………………………………………………………………………………………………………………………………...... I KEY FINDINGS FROM RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEM OF JAJARKOT ...... II

1 RAPID ASSESSMENT ...... 1

2 INTRODUCTION OF DISTRICT ...... 3

3 DHO STRUCTURE AND SYSTEMS...... 4

4 SERVICE STATISTICS ...... 8

5 HEALTH FACILITY MANAGEMENT COMMITTEE AND LOCAL HEALTH GOVERNANCE ...... 10

6 SERVICE DELIVERY/QUALITY IMPROVEMENT ...... 12

7 LOGISTICS MANAGEMENT SYSTEM ...... 14

8 BEHAVIOR CHANGE COMMUNICATION ...... 16

9 ADOLESCENTS AND YOUTH FRIENDLY SERVICES ...... 18

10 GENDER EQUALITY AND SOCIAL INCLUSION ...... 20

Annex 1 Contact information of D/PHO Staff, Jajarkot…………………………………………………………….………….21 Annex 2 List of RHCC member organizations, DHO/Jajarkot………………………………………………………………21 Annex 3 List of Individuals/Organizations visited during RA/Jajarkot …………….……………………………….22

i ABBREVIATIONS

AYFS Adolescents and youth Friendly Services AHW Auxiliary Health Worker ANM Auxiliary Nurse Mid-wife BC Birthing centre BCC Behavior Change Communication BEONC Basic Essential Obstetric and Newborn Care BNMT Britain Nepal Medical Trust CB-IMCI Community-Based Integrated Management of Childhood Illness CB-NCP Community-Based Newborn Care Package CEONC Comprehensive Essential Obstetric and Neonatal Care DAG Disadvantaged Group FCHV Female Community Health Volunteer FEFO First expiry first out FMC Facility Management Committee FP Family Planning FY Fiscal Year GESI Gender Equality and Social Inclusion HA Health Assistant H4L Health for Life HF Health Facility HP Health Post HFOMC Health Facility Operation and Management Committee HMIS Health Management Information System I/NGO International/Non-Governmental Organization IT Information Technology IUCD Intra Uterine Contraceptive Device LDO Local Development Office LMIS Logistics Management Information System MO Medical Officer MNCHN Maternal Neonatal Child Health and Nutrition MgSO4 Magnesium Sulphate MSC Matri Surakshya Chakki M&S Monitoring and Supervision MWDR Mid-western Development Region N Number NPC National Planning Commission PHCC Primary Health Care Center QI Quality Improvement QAWG Quality Assurance Working Group RA Rapid assessment RHCC Reproductive Health Coordination Committee RHD Regional Health Directorate SAC Social Awareness Centre SHP Sub Health Post SN Staff Nurse USAID Unites States Agency for International Development VDC Village Development Committee W(C)DO Women (and Child) Development Office WDR Western Development Region

ii KEY FINDINGS FROM RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEM TOTAL POPULATION 171,394 NUMBER OF VDCS 30 DHO STRUCTURE AND Public Health facilities: SYSTEMS  District Hospital-1, PHCCs-2, HPs -11 and SHPs-21, district Ayurvedic Centre - 1 Meetings:  Ilaka In charge Monthly meeting disrupted due to budgetary constraints told by focal person  QAWG- No meeting held in the last one year  RHCC- Meets quarterly Health Workforce:  Major technical positions at DHO are vacant (Family planning supervisor, health education technician and DTLA)  Vacant positions at HFs–MO, SN, ANM, HA and AHW. 20 ANM, 8 HA, 8 AHW and 12 Vaccinators and computer operator hired on contract basis. Few health workers like 8 HA. 8 ANM, 8 ANM are hired from RHD Monitoring and Supervision:  M&S system and plan exists at district level only. Integrated supervision tools are not in use. IT infrastructure at DHO:  Desktops-5, Laptops-5, Printers-2  Lack of power back up and poor internet connectivity.  Supervisors skilled in using MS Word and Excel-2.  Health Facility level entry in HMIS software. Rapid Response Team: Functioning well at the district and cluster (HP) level SERVICE STATISTICS  BCG and Measles coverage shows fluctuating trend, however it is higher than national figure and more than 90%..  Severe pneumonia and diarrheal cases shows increasing trend.  Drop out from ANC first to ANC fourth visits is high and in the FY 2068/69 it was 95 percent and 45 percent respectively.  SBA deliveries are in increasing trend (9.05 percent in FY 2065/66 to 24.14 percent in FY 2068/69)  Contraceptive Prevalence Rate in FY 2068/69 was 26.06% percent HEALTH FACILITY  HFOMC are not handed over to local government /agencies. MANAGEMENT COMMITTEE  HFOMC have been formed in all VDCs/ HFs AND LOCAL HEALTH  No focal person are designed to look after HFOMC functioning, GOVERNANCE Orientation, monitoring, supervision and follow up of HFOMC functionality.  HFOMC are not orient about their role and responsibilities, monitor, supervise and provide feedback to HFOMC. SERVICE  Regular BEONC services provided at district. DELIVERY/QUALITY  Community-based service delivery-MSC, CB-IMCI,IMAM, has implemented IMPROVEMENT piloted in district.  IUCD services- 3 health facilities and Implants- 2 HFs.  Birthing centers-16  Placenta pits-17 LOGISTICS MANAGEMENT  All tracer drugs and commodities available on the day of visit. SYSTEM  Drugs with most problems of stock outs in the year-Tab. Iron folate,

iii Ibuprofen, Metronidazole and Hyosine Bromide.  Drugs with most problems of over stock in the last year- MgSO4.  Functioning refrigerators-7, sufficient for maintaining cold chain, and have regular power back up system for the cold chain room.  First Expiry First out (FEFO)- maintained well  Web-based LMIS reporting system. But not function in this fiscal year.. BEHAVIOR CHANGE  FM stations-2 COMMUNICATION  Several I/NGOs engaged in BCC activities  In the FY 2068/069, total 150 session of school health program on HIV/AIDS, RH, GBV, early marriage etc were organized in 30 schools. In current FY, no activities were planed and conducted for school health program.

Villages that were highly populated by DAG- Majhakot, , Rokayagaun, Dandagaun

VDCs deprived from service utilization by Ethnic/Caste group - Ragda, Bhagawati, Kortang, Garkgakot, Talegaun, , , Daha, etc.

 Villages that still practice early marriage and Early Child Bearing- Early marriage, early child bearing and polygamy practice is prevalent throughout the district

 VDCs with hiigh migration - Bhoor, Punama, , Salama, Suwanauli, Majhakot, Sima, Thalaraiker, Jungathapachaur. ADOLESCENTS AND YOUTH  AYFS- 13 HFs supported by UNICEF. FRIENDLY SERVICES  DHO conducted Peer Education training to 10 schools in the current FY.  WCDO have female adolescent youth clubs to enhance life-skill trainings and give information on RH issues. GENDER EQUALITY AND  14 members GESI committee formed but not active. The committee didn’t SOCIAL INCLUSION receive orientation.  GESI focal person assigned to is a Public Health Nurse.  DDC, WCDO and DPO have GESI related activities in Jajarkot.  At DDC, GESI committee under the chairmanship of LDO was also formed.

iv 1 RAPID ASSESSMENT

1.1 HEALTH FOR LIFE

Health for Life (H4L) is a five-year bilateral agreement between the Ministry of Health and Population (MoHP) and the Unites States Agency for International Development (USAID) which focuses on Systems Strengthening and improving the Maternal Neonatal Child Health and Nutrition/Family Planning (MNCHN/FP) service delivery at district and sub-district levels in 14 districts. 12 of the 14 districts are in the Mid-western Development Region (MWDR) –Jajarkot, Bardiya, Dang, Surkhet, Salyan, Pyuthan, Dailekh, Kalikot, Jumla, Rukum, Jajarkot and Rolpa and two are in the Western development Region (WDR) of Nepal-Arghakhanchi and Kapilvastu. The project will be implemented between December 2012 and 2017.

1.2 RAPID ASSESSMENT AND ITS OBJECTIVES

Rapid assessment (RA) is a method of analyzing situation of a district where issues are not well defined and where there is not sufficient time or other resources for in-depth quantitative research. RA uses intensive team interaction in both the collection and analysis of data instead of prolonged field work and iterative data analysis and additional data collection to quickly develop a preliminary understanding of a situation from the insider’s perspective. The main purpose of carrying out the current Rapid Assessment is to understand the current situation of the health service delivery system and other associated systems of the so as to help in planning activities at district level.

Specifically, the objectives of the RA includes  Understanding the demographic profile of the district  Understanding the existing health care delivery system of the district  Knowing the functionality of the Facility Management Committees  Understanding the status of health indicators  Analyze strengths and weakness of the DHO systems  Exploring feasibility for the implementation of specific programs for adolescents and youth  Exploring feasibility of using Information Technology in information management

1.3 METHODOLOGY

A mix of both qualitative and quantitative methods was used to execute Rapid Assessment in Jajarkot district. These includes  Visit to District Health Office (DHO)  Interaction and interview of key staff  Observation of DHO

A structured tool was developed to collect necessary information which was supplemented by qualitative tools to interview key informants at District Development Committee and Local

1 Development Office (LDO), International/Non-Governmental Organizations (I/NGOs) working on different areas of health, Gender Equality and Social Inclusion (GESI), Behavior Change Communication (BCC), Information Technology (IT) in Health, Service delivery, and Governance. A team was composed for carrying out RA which included which included H4L staff and Government counterpart staff. Skill mix was ensured while forming team where staff was skilled/ knowledgeable on the following- Governance, service delivery, monitoring and evaluation, GESI and BCC. Involvement of Project Center, regional and district office was ensured.

Before carrying out of the RA, introductory visit was done in DHO. During the visit brief introduction of project and objectives were shared among DHO officials. Hence we also highlighted methods and process of data collection.

1.4 ORGANIZATION OF THE REPORT

The findings of the RA are presented in ten Chapters. Chapter one presents the purpose of carrying out RA and the methodology. Chapter two presents the introduction of Jajarkot district along with its demographic information; chapter 3 talks about the structure and systems of DHO, and provides detail information on service delivery points, management systems, status of health workforce, the practice of monitoring and supervision, status of information technology and information management as well as mechanism of natural disaster response. Chapter 4 presents the service statistics of district; chapter 5 presents information on health facility operation and management committee (HFOMC) and local health governance. Similarly, chapter 6 discusses on what has been done for quality improvement of health service delivery; chapter 7 presents information on logistics management system of DHO; chapter 8 discusses several windows of IEC/BCC activities conducted by DPHO; chapter 9 explains the status of adolescent and youth friendly services in district, and chapter 10 presents information on gender quality and social inclusion (GESI), and whether or not the committees have been formed and are functional. Each chapter discusses the strength and opportunities based on the data collected through RA and explains key issues and challenges to fulfill them.

2 2 INTRODUCTION OF DISTRICT

2.1 GEO-POLITICAL SITUATION

Jajarkot District is situated in Bheri zone, and in the Mid-Western Development Region of Nepal. Khalanga is the districts headquarter. Jajarkot covers areas of 2,223.36 square km. Jajarkot is bordered on the west by Kalikot, Dailekh and Surkhet districts, on the north by , on the east by Rukum and Dolpa districts and on the south by Rukum and Surkhet districts. There are 30 VDCs in Jajarkot.

JAJARKOT: DISTRIBUTION OF POPULATION BY VDC/MUNICIPALITY, 2011

2.2 DEMOGRAPHIC INFORMATION Table 2.1: Population of District Number Percent The 2011 Census reports total population of Total Population 171,304 - Male 85,537 50 Jajarkot district as 1, 71,304. The proportion of Female 85,767 50 female and male is equal in the district. Household number 27,156 - Source: Census 2011 Table 2.1 shows the caste/ethnicity distribution of the population residing in Jajarkot district. The Caste/Ethnicity distribution proportion of Brahmin/Chhetri is greatest in Brahmin/Chhetri 84090 62.35 Dalit 36430 27.01 Jajarkot district (62 percent) followed by Dalit Disadvantaged Janajati 12210 9.05 (27 percent). The proportion of disadvantaged Other Terai Caste group 1729 1.28 Janajati is 9 percent. The district is also populated Relatively Advantages Janajati 329 0.24 by few other Terai caste caste groups, relatively Muslims 80 0.05 advantaged Janajatis and Muslims. Source: Census 2011, 2001

3 3. DHO STRUCTURE AND SYSTEMS

This chapter presents the findings related to the DHO structure and systems collected from the RA. The findings covers following areas: service delivery points, management system, health workforce, monitoring and evaluation system, IT and health information management and disaster management system.

3.1 SERVICE DELIVERY POINTS Table 3.1: Number of service delivery points in district The District Health Office, located in Type of service delivery points Number Khalanga is the main responsible District Hospital 1 institution of the MOHP at Jajarkot to PHCCs 2 provide preventive, promotive and Health Posts 11 curative health services to the people of Sub-health Posts 21 Jajarkot. There are a total of 35 peripheral Birthing centers 16 public health facilities (2 PHCCs, 11 HPs SBA sites 8 PHC Out-Reach Clinic 101 and 21 SHPs) and a District Hospital in Immunization Clinic 129 Jajarkot district. There are 16 birthing FCHVs 270 centers out of which 8 birthing centers are Source: DHO Annual Report SBA sites. There are 101 PHC/ORCs and 129 Immunization Clinics. There are 270 ward-based Female Community Health Volunteers (FCHVs) in the district.

3.1 MANAGEMENT SYSTEMS

3.2.1 MEETINGS

DHO Jajarkot holds different meetings. The monthly meetings of the HF in-charge used to be organized in the past but have been stopped at present because of budgetary constraints. Reproductive Health Coordination Committee (RHCC) is conducted once in FY 2069/070.

Gender Equality and Social Inclusion (GESI) committee is formed in this district but it does not meet. Similarly, Rapid Response Team (RRT) is another committee formed at DHO Table 3.2: Current Status DHO Team in order to respond to the disasters that DPHO Team Status might happen in district—like epidemics, a. District Health Officer Filled b. Sr./Public Health Officer/ Administrator Filled flood, fire, etc. The committee comprises of c. Public Health Nurse Filled members from DDC, CDO, WCO, Hospital, d. Statistics Assistant/Officer Filled Red Cross, Army, Police, and any other e. FP focal person Vacant stakeholders working in health sectors. f. Health Education Tech/ Officer Vacant g. DTLA/Officer Vacant 3.2.2 PROGRAM MANAGEMENT TEAM h. EPI Supervisor/Officer Filled i. Cold Chain Assistant/ Officer Filled The DHO Jajarkot has three key positions j. Computer Operator/Officer Filled vacant during the time of RA. These k. Store Keeper Filled positions are FP focal person, HETO and l. Child Health focal person Filled DTLA. Refer to Table 3.2.

4 3.3HEALTH WORKFORCE

Table 3.3 presents the current status of health workforce in Jajarkot district. Both the PHCCs in Jajarkot do not have Medical officer. Out of the total 5 sanctioned positions of staff nurse in the district, 4 are filled in. However, out of the four, only one is working in district hospital, two are in study leave and remaining one on deputation in Banke district. Recently RHD contracted two staff nurses for District hospital. Overall, out of the 211 sanctioned positions in Jajarkot, two-third were filled-in during the time of RA.

There are a remarkable number of health workers recruited by VDC on contract basis or temporarily in Jajarkot.

Table 3.3: Current status of health work force Type of human resources Number GoN Number supported from Sanctioned Filled-in VDC Contract Temporary** a. Medical Officer 5 0 b. Staff Nurse 5 4 2 c. ANM 18 8 5 20 8 d. HA/Sr. AHW 16 8 8 8 e. AHW 42 36 8 8 f. VHW 30 15 12* g. MCHW 30 23 h. Lab Assistant 3 1 i. Adm. Assistant 3 3 j. Store Keeper 1 1 k. Support Staff 57 33 10 3 l. Computer operator 1 0 1 m. 211 132 (63%) 15 37 29 Source: District annual Report *AHW(As Vaccinator), ** From RHD

3.4 MONITORING AND SUPERVISION

DHO Jajarkot has Monitoring and Supervision System in place where DHO monitors ilaka level HFs according to the Monitoring and Supervision Plan that is developed every FY. However, its implementation is questionable and integrated monitoring and supervision tools were not used by DHO supervisors. Monitoring and supervision from ilaka level to community level is not taking place.

3.5 INFORMATION TECHNOLOGY

The RA also explored the existing IT infrastructure at DHO Jajarkot. At present there are 5 desktop computers, 5 laptops, and 2 functioning printers. Only 3 staffs in DHO are skilled in MS Word and Excel. Though there is ADSL internet facility in DHO, the power supply and internet connectivity pose serious problems in timely reporting and communication.

3.6 HEALTH INFORMATION MANAGEMENT

DHO Jajarkot has a system to enter HF level data in HMIS software. HF level data is available for the last four year period in HMIS. Recently the Statistics Assistant received four days training on web- based HMIS reporting. From the next FY, HMIS data by HFs will be entered in the web-based HMIS

5 software. For improving data quality, DHO organized an event of data verification and Validation program in the current FY2069/70.

3.7 NATURAL DISASTER RESPONSE MECHANISM

DHO Jajarkot has Rapid Response Team (RRT) to respond to natural disaster and disease outbreak throughout the district. Furthermore, there are 8 community rapid response team (CRRT) at cluster level to support and communicate with HF at the time of natural calamities. Cluster-based CRRT and DHO RRT focal person have communication plan regarding the issues and DHO RRT focal person has been reporting to Center on weekly basis.

District-based Rapid Response Team comprises following key positions from DHO: 1. DHO 2. PHN 3. EPI Officer 4. PHI 5. Statistical Assistant 6. Nayab Subba 7. Accountant 8. PHI 9. SN 10. Sr. AHW 11. Sr. AHW 12. Sr. ANM 13. Sr. ANM 14. CCA 15. AHW 16. Lab Assistant 17. Lab Technician (Focal Person)

The followings are the cluster of Community Rapid Response Team-  Dalli Cluster, Dalli HP  Bhoor Cluster, Bhoor HP  Limsa Cluster, RokayaGaun PHC  Sima Cluter, Sima HP  Gharanga Cluster, SHP  Dasera Cluster, Dasera HP  Kudu Cluster, Jagtipur SHP  Gharkakot Cluster, Garkhakot PHC

Essential medicines for Response Team are located in following 10 HFs of Jajarkot district. S.N. Name of Health Facility with Coverage of VDCs sub stock 1 (Dalli HP) Khagenkot, Ragda, Bhagawati & Dandagaun 2 Limsa PHC Rokayagaun, Lahana, Sakala, Ramidanda and Nayak bada 3 Gharanga HP (Dhime) Dhime, Paink, Talegaun & Archhani 4 HP Karkgaun, Bhoor & 5 Sima HP Sima, Jungathapachaur & Thalaraiker 6 Dasera HP Dasera, Suwanauli, Salma & Majhakot 7 Garkhakot PHC Garkhakot, Pajharu, Kortang & Daha 8 Kortang SHP Kortang 9 SHP Pajaru 10 DHO Remaining all VDCs

6 3.8 STRENGTH AND OPPORTUNITIES

The major strength of the DHO as observed during the RA is as following  Formation of important committees like RHCC, QAWG, and GESI, RRT All these committees are formed to performed specific task and achieve specific achievement.

3.8 KEY ISSUES AND CHALLENGES

The major challenges and constraints faced by the DHO Jajarkot are as following:  Monthly meeting of Ilaka in charge has stopped due to budgetary limitation.  Functionality of various health committees is questionable and revitalization of such working committees is mandatory.  Only 2 staffs of DHO have computer skilled in office packages.  Reliable power supply and internet connectivity is poor for timely communication and reporting.  Large numbers of human resources (including medical officers at district hospital and PHCCs) are vacant. Some staff are recruited by RHD but their continuity after the end of current fiscal year might pose serious consequences in regular service delivery.  Khalanga, District HQ is located in south-east corner and poor road infrastructure pose challenge in visiting to VDCs for supervision or other purposes

7 4. SERVICE STATISTICS

The RA also sought information on the service statistics of the following programs: Immunization, Child health, Safe Motherhood and Family Planning. HMIS data for the last four years, 2065/66 to 2068/69 were analyzed. The four year trend analysis of the selected indicators is presented in this section. Data for the current FY (2069/70) is not complete, therefore, it has not been analysed here.

4.1 IMMUNIZATION Figure 4.1: Trend in Measles coverage As shown in Figure 4.1, measles coverage is consistently high in Jajarkot and was 126% in last fiscal years. Achievements for immunization in Jajarkot are always more than that of Nepal’s aggregate. As per the statistical assistance target of such program is reduced by DoHS as compare to previous -10 year as well as poor quality of data from peripheral level are the reasons for such a high coverage. He also expressed his dissatisfaction as the data in DHO is inconsistent since long period but trying to correct in reality.

4.2 CB-IMCI Figure 4.2 shows that the proportion of severe pneumonia cases in Jajarkot is much higher compared to that of Nepal’s aggregate. From 2065/66 to 2066/67, the severe pneumonia cases increase from 1.8 to 7 percent and then decreased to 1.5. In the last year it again increased to 1.9 percent. The proportion of new pneumonia cases treated with antibiotics is gradually increasing and was 54 percent in the most recent year. Figure 4.3 shows that the severe dehydration cases have been declining in Jajarkot in the first three years but was increased slightly in 2068/69. This could be because of diarrohea outbreak in that year. However, the proportion of severe cases is much higher than that of Nepal’s aggregate. Proportion of new diarrhoeal cases treated with ORS has drastically increased in the third year which decline slightly in the following year. Figure 4 .2: Percent of severe pneumonia Figure 4.3: Percent of severe dehydration casses among new among new cases

8 4.3 SAFE MOTHERHOOD Figure 4.4: ANC 1st visit & 4th ANC visit as The adjoining table shows that the percent of Expected Pregnancy data of ANC 1st visit as percent of the expected women is much higher than that of Nepal’s aggregate was almost 100 percent in the last year. However, the four ANC visit is consistently low and almost low than one-half of the first ANC visit in all four years of comparison.

AMILY LANNING 4.4F P Figure 4.5: CPR as percent of MWRA

44 The above graph shows that the CPR 100 42 43 43.14 (all modern methods) as percent of 29 32 34 26 MWRA of the district is fluctuating 50 over the time and was 26 percent in the last fiscal year and has dropped 2065/66 2066/67 2067/68 2068/69 nearly 8 percentage point compared to previous year. DHO staff could not District National point out any obvious reason or this. The trend shows consistently lower CPR than national level in Jajarkot district.

Table 4.1: Utilization of service in Jajarkot district SN Indicators 2065/66 2066/67 2067/68 2068/69 1 BCG coverage 102.5 122.94 139.94 129.21 2 Measles vaccination coverage 96.17 126.58 132.46 126.25 3 TT 2 coverage among pregnant women 66.57 91.74 77.67 66.00 4 DPT3 coverage 96 112 148 123 5 Percent of postpartum mothers receiving Vitamin 54.53 64.24 56.94 47.1 A within 6 weeks 6 Percent of pregnant mothers receiving iron tablets 89.57 125.38 105.15 94.15 7 Proportion of new pneumonia cases treated with 32.26 31.87 51.81 53.81 antibiotics 8 Percentage of Severe Pneumonia among new cases 1.83 7.0 1.53% 1.9% 9 Percent of new diarrheal cases treated with ORS 20.66 15.13 96.06 88.56 (under 5 years children) 10 Percent of Severe dehydration among new cases 1.92 3.00 0.92 1.2

11 ANC 1st visit as percent of expected pregnancies 71 79 107.63 99.6 <20 years NA NA NA NA >20 years NA NA NA NA 12 Four ANC visits among as percent of expected live 35.63 50.96 44.59 42.09 births 13 Delivery conducted by SBAs (both home and 9.05 16.4 17.49 24.14 institutions) as percent of expected pregnancies 14 PNC First visit as percent of expected live births 42.82 48.27 43.15 41.54 15 Contraceptive prevalence rate (all methods) as 29.13 31.87 33.89 26.06 percentage of MWRA

9 5. HEALTH FACILITY MANAGEMENT COMMITTEE AND LOCAL HEALTH GOVERNANCE

Information on Health Facility Operation and Management Committee was sought from both DHO and DDC. Both quantitative and qualitative methods were used for collecting information. Information was collected on the following topics: HFOMC functionality, capacity building, presence of different community-based groups at VDC level and their federations at district level. This chapter presents the major findings of the assessment on HFOMC.

5.1 FUNCTIONING HFOMC

In Jajarkot all HFs (PHCCs, HPs and SHPs) has formed HFOMC. DHO chief and the program supervisors were asked to give their opinions on measuring the functionality of HFOMCs and most opined that the functionality of HFOMCs can be measured by their meetings. According to them the HFOMCs that meet once in every three months or at least three meetings in a year and those keeping meeting minutes can be counted as functioning HFOMCs. However, the meetings are not being held at regular interval and systematically.

5.2 CAPACITY BUILDING OF HFOMC

No capacity building training has been provided to HFOMC members. However, HFOMC members have received orientation on some programs such as TB/DOTS, HIV/AIDS etc. There are no supporting agencies for HFOMC capacity building other than DHO.

5.3 STRENGTH AND OPPORTUNITIES

 HFOMC have been formed in all VDCs/HFs.  They are supporting during national health events like polio campaign and Vitamin A program day.

5.4 KEY ISSUES AND CHALLENGES

 HFOMC in most of the VDCs are not meeting regularly.  No focal person are designated to look after HFOMC functioning. No orientation, monitoring, supervision and follow up of HFOMC.  HFOMC are not oriented about their role and responsibilities  HFs are not handover to local bodies  Lack of community ownership towards the HFs.  Low level of motivation of pubic towards HFOMC committee than towards other committee existing at community level.  The HFOMC is not GESI friendly which suggest that it does not follow the guidelines as well as poor participation from remote and hard to reach community.  Majority (more than 75%) of HFOMCs are not formed according to guidelines however, its verification is mandatory via real field observation.  Limited knowledge of local health governance, planning and exploring resources for health.

10  No meaningful participation of HFOMC members during meeting, which means poor involvement in planning, decision making, formulation of agendas and their roles are confined for signatory purpose.  Less monitoring from DHO/DDC.

Following activities could be fruitful to empower HFOMCs members and solve the problems in the local context.  Reformation of HFOMC with key consideration of GESI  Capacity building and follow up training to HFOMCs and community for effective local health governance  Inter and intra district visits of HFOMC members, which helps them to learn from best practices.  Organize VDCs level stakeholders coordination meeting is mandatory to explore community resources and develop self- help mechanism system.  Designation of HFOMC focal person is crucial for its periodic monitoring, supervision, follow up and reactivation.  Physical support to HFs is solely need-based but its operation and maintenance is done though HFOMC  Essential physical support to HFs with HFOMC accountability  District level HFOMC gathering to formulate plan, review their activities and sharing good practices

11 6. SERVICE DELIVERY/QUALITY IMPROVEMENT

The RA sought information on the availability of Satellite clinics, CEONCs, long acting FP methods, implementation of community- based interventions such as CB-NCP, MSC, Calcium, and service integration in Jajarkot district. This chapter presents the RA findings related to service delivery and quality of care. Information on the quality of ANM schools, infection prevention practices at HFs, implementation of community-based interventions, and the provision of IUCD and Implants services were collected at district level. The major finding of the assessment is presented hereunder.

6.1 ANM SCHOOL

H4L intends to improve the quality of pre-service ANM trainings. As such basic information on the ANM schools of Jajarkot district were sought from DHO and the ANM schools during RA. In Jajarkot there are no ANM Schools.

6.2 INFECTION PREVENTION AND WASTE MANAGEMENT PRACTICES AT HFS

Few questions related to infection prevention and waste management practices followed at HFs were also asked to district supervisors during RA. It was found that different HFs practice different type of infection prevention and waste disposal practices. In district hospital autoclave and Bleaching powder (Virex) are used to disinfect and sterilize the instruments and equipment. There are 16 birthing centers in Jajarkot and out of them six have placenta pit for the proper disposal of placenta.

6.3 SERVICE DELIVERY

The RA sought information on the availability of Satellite clinics, CEONCs, long acting FP methods, implementation of community- based interventions such as CB-NCP, MSC, Calcium and service integration. It also sought information on the number of health workers and FCHVs who have not received CB-IMCI training in the district; also seeking information on provision of clinical supervision to HFs.

With regards to providing long acting reversible FP methods, IUCD service is being provided from 3 HFs and Implants from 2 HFs. In Jajarkot there are altogether 13 SBAs in 8 HFs. It was reported that all SBAs in Jajarkot are trained on IUCD, but, only few were providing the service. Other SBAs are not being able to provide service because of inadequate supply of IUCDs sets and infection prevention measures. There are 16 birthing centers out of which eight are without SBAs as reported by PHN.

Programs like IMAM and MSC Table 6.1: IUCD and Implants Insertion and Removal Sites have been implemented in IUCD Birthing Implants Birthing Jajarkot district. CB-NCP, Center? Center? District Hospital Yes District Hospital Yes Calcium, IYCF are not Kudu Yes Bhoor Yes implemented in Jajarkot. Bhoor Yes Information with regards to CB- IMCI training of health workers and FCHVs in district are not available. Those health workers who

12 are recruited on contract have not received training on CB-IMCI for the reason that they are temporary staff whose contract will end every year.

6.4 STRENGTH AND OPPORTUNITIES

 There are 16 functional birthing centers and 8 nursing staffs’ trained in SBA in the district. Out of 16 birthing centers, 6 have placenta pit for the proper disposal of placenta. Out of total 35 HFs, 3 HFs are providing long term FP methods regularly.  QAWG and RHCC committees are formed.  Programs like CB-IMCI, CMAM, IMAM and MSC has been implemented in the district which is very good opportunity to improve the health status of mother and child of Jajarkot district.

6.5 KEY ISSUES AND CHALLENGES

 Problem in logistic supply (Instruments/equipment needed for birthing centers and infection prevention measures)  Delay release of budget  Lack of satellite clinic and limited numbers of HFs are providing long acting family planning methods. Few numbers of trained health workers to provide IUCD and implants services  Problem in the infrastructure of some birthing centers  Problem in staff retention in the district.  Lack of focused clinical and integrated supervision.  Various committees like RHCC, QAWG are non - functional.

13 7. LOGISTICS MANAGEMENT SYSTEM

Logistics management is an important part of district health systems. Efficient logistics management is required to smoothly run all the public health programs at district, sub-district and the VDC levels. The RA also sought information from DHO on the logistics management system. The major findings of the assessment are presented below.

7.1 AVAILABILITY OF KEY DRUGS AND COMMODITIES

During RA, the store room of the DHO was also visited and the store keeper was interviewed. The availability of 11 commodities/some essential drugs (Inject able, Oral Contraceptive, Condom, ORS, Vitamin A, Iron Folate Tablets, Cotrim (Ped), Zinc, Oxytocin, Gentamycin and MgSO4) in the district store was checked at the time of visit. It was found that all of them were available when checked. The store keeper was also asked whether the 11 drugs/commodities were out of stock anytime in the last 12 months, and it was found that there has not been stock out of Iron folate tablets in the last 12 months. The RA team members also checked the expiry dates of the drugs/commodities and not any of them were expired at the time of visit.

Table 7.1: Availability of key drugs/commodities and their expiry dates SN Drugs/Commodities Availability at Stock out in Expired drugs in the time of the last 12 stock at the time of visit months visit 1 Injectable Contraceptive Y N N 2 Oral contraceptive Y N N 3 Condom Y N N 4 ORS Y N N 5 Vitamin A Y Y N 6 Iron Folate Tablets Y N N 7 Cotrimoxazole (Ped) Y N N 8 Zinc Y N N 9. Oxytocin Y N N 10. Gentamycin Y N N 11. MgSO4 Y N N

The Store keeper was also asked to list the drugs that have most problems with stock outs in the FY 2069/70 and found that tablet Amoxicillin 125 mg, tablet Metronidazole 200mg, tablet salbutamol, tablet Doxycycline and tablet Ibuprofen were the drugs with the most problems of stock outs in the year. It is also found that MgSO4 is the most problems with over stock in the year.

7.2 COLD CHAIN AND FEFO MANAGEMENT

DHO Jajarkot has only two functioning refrigerators. The available refrigerators are not sufficient to DHO for maintaining cold chain; however it have regular power back up system for the cold chain room. The management of five drugs in the store was checked to see whether First Expiry First Out (FEFO) was maintained or not. It was found that FEFO system is maintained in the district store at the time of visit.

14 7.3 LMIS REPORTING

DHO is using web-based LMIS to report to center. According to store keeper, in this current fiscal year there were problems in web-based reporting due to discontinuation of contracted computer operator from Regional health directorate.

7.4 STRENGTH AND OPPORTUNITIES

 DHO Jajarkot has well managed district store and cold chain system. Newly constructed warehouse.  FEFO system is well maintained in the district store. PULL system have been implemented in the district for the proper management of drug supply to the HFs.

7.5 KEY ISSUES AND CHALLENGES

 Lack of vehicle and insufficient budget for the drug supply.  Congested store room at district level.  Inconsistent power supply and inadequate back up system  Delay in budget release causing problems in logistic management and drug supply to peripheral institution.  Difficult to follow the PULL system at all time

15 8. BEHAVIOR CHANGE COMMUNICATION

H4L aims to understand legal, cultural/religious, and policy dimensions of GESI inequities on health service access and use and design interventions to ensure sustainable, high-quality BCC and IEC approaches that respond to local realities, and include groups not commonly targeted, but crucial to meeting Nepal’s health goals.

One of the objectives of the RA was to explore the range of BCC interventions that is being implemented for healthy behaviors. Following are the major findings on BCC:

8.1 EXISTING DHO PROGRAMS ON BCC

DHO Jajarkot has been organizing BCC program activities as per the DoHS’s yearly plan provided from the National Health Education Information and Communication Center (NHEICC) such as production and distribution of IEC materials, short massages broadcasting through local FM radio, school health program, orientation to teachers, journalists etc.

8.2 FM STATIONS/CABLE TELEVISION NETWORKS

In Jajarkot there are two FM stations and one form Rukum also has coverage. Following are the name and address of the FM stations:  Radio Hamro Pahial, Khalanga Jajarkot  Radio Khalanga, Khalanga Jajarkot  Radio Sani Bheri, Rukum

DHO Jajarkot has partnered with all of the above FM stations (partnership with Radio Sani Bheri FM to convey health related message/ information especially for eastern belt of the district) for airing radio health related interview of DHO/ District Supervisors and Public Service announcements (PSAs) on various programs like polio campaign, Vitamin A program etc. However it has not developed any district-based health related programs.

8.3 ORGANIZATIONS WORKING IN IEC/BCC ACTIVITIES

H4L plans to use mobile phones to reach target groups with messages on health in selected district. The RA also explored whether any organization has used mobile phones to communicate health messages to target groups or entire district population together with DHO. It was found that there are no organizations working in IEC/BCC in Jajarkot.

8.4 SCHOOL HEALTH PROGRAM

Conducting health education classes at schools is one of the activities of DHO. In the last FY (2068/2069), a total 150 session of school health program were organized in 30 School in which 3,000 students are benefited. The topics that were mostly covered during the School Health Education Program include- Early marriage, Basic sanitation, Communicable disease, HIV/AIDS, Reproductive Health, Safe motherhood, Immunization, Tuberculosis etc. But in current FY, no activities were planed and conducted for school health program from red book.

16 According to the Health Education focal person, beside school health education program, Peer Education among adolescent group will be effective in reaching adolescents with health messages.

When asked about the IEC/BCC activities implemented for M/DAG to increase access to service in the last FY it was found that due to lack of disaggregated data in the district (DDC/DHO) there are no any specific health related interventions among M/DAG community to increase access to services till this date.

Information related health staff who attended COFP counseling course in the last years is not available or maintained in the district due to frequent transfer of staffs both administrative as well as technical.

8.5 MAPPING OF DAG AND EXPLORING CULTURAL PRACTICES AFFECTING HEALTH

During the RA, in-depth information on DAG communities residing in Jajarkot district was also collected. The Health Education Technician Officer was interviewed for this. The major findings of this assessment are as following:

Villages that were highly populated by DAG

Majhakot, Punama, Rokayagaun, Dandagaun etc. are the VDCs of Jajarkot that are inhabitated by greater proportion of dalit/deprived groups. They need more support from development partners and government.

Villages deprived of service utilization by Ethnic/Caste group:  Mulsam area of Rokayagaun VDC.  Jurka mulpani area of Daha VDC  Ragda, Bhagawati, Kortang, Garkgakot, Talegaun, Paink, Archhani, Daha, Suwanauli etc. VDCs are inhabitated by population that are deprived of health services because of difficult terrain, scattered households, limited numbers of FCHVs (ward basis) and non-functional PHC/ORC.

Villages that still practice early marriage and Early Child Bearing:  Early marriage, early child bearing and polygamy practice is prevalent in the Jajarkot district. Due to low socio-economic condition and lack of education these kinds of practices are prevailing in majority of VDCs in the district among dalit, kami, sharki and thakuri community.  The probable cause of early marriage, polygamy, early child bearing might be poverty, low educational status, lack of awareness and exposure to exterior world.  There are no interventional activities till this date to address these issues in the district.

Migration pattern: People of productive age group from Bhoor, Punama, Dasera, Salama, Suwanauli, Majhakot, Sima, Thalaraiker, Jungathapachaur VDCs (especially the dalit, chhetri, janajati etc.) migrate to India for economic reasons during winter season.

On asking about what kind/type of communication intervention should H4L plan so that it would be supportive in supplementing the district need, the health education focal person reported that the key role in making people aware by means of communication is very crucial. The following

17 interventions will be beneficial in district-  Information through FM radios  Periodic journalist assembly to disseminate the health messages from local newspapers  Hoarding board in massive public gathering sites  Video documentary shows  Peer educators in school among adolescent groups  District specific BCC/IEC activities formulation could be the core essence of IEC/BCC programs.

8.6 STRENGTH AND OPPORTUNITIES

There are total two FM stations in Jajarkot district which can be used for the airing of different Health massages (PSA) and radio interview programs.

8.7 KEY ISSUES AND CHALLENGES

 It is difficult to increase awareness and provide health services among people who have strong traditional and cultural beliefs, practice of early marriage, early child bearing practice and polygamy tradition.  There is lack of district specific BCC/IEC activities and NGO/CBOs focusing activities on BCC.  Due to difficult terrain it is hard to disseminate health information through FM radio whose catchment area is limited around district headquarters.  Bulk amount of BCC materials supply from center Vs use at local level due to improper distribution at local level.

18 9. ADOLESCENTS AND YOUTH FRIENDLY SERVICES

H4L will also work with DHOs in selected districts to improve service accessibility of Adolescents and youths under its Objective 6. The RA also explored different aspects of Adolescents and Youth friendly services in the public health facilities of Jajarkot district. Following are the major findings:

9.1 EXISTING SERVICES FOR ADOLESCENTS

In Jajarkot, there is focused program for Adolescents in 13 sites (HFs) viz. District Hospital, Ramidada, Laha, Karkigaun, Kudu, Bhoor, Sima, Dasher, Garkhakot, Limsa, Dalli, Sakala and Gharanga etc. These facilities are providing Adolescent and youth friendly services with special focus on Reproductive Health, family planning, adolescent health, basic sanitation, Communicable diseases, HIV/AIDS, as well as counseling. This program is supported by UNICEF.

9.2 ORGANIZATION WORKING FOR ADOLESCENT

In Jajarkot, WCDO has been closely working with adolescent girls aged 10-19 years who are in or out of the school of in 10 selected VDCs of the district. They are providing information on various issues like gender-based violence, Menstruation cycle, early marriage, reproductive health, HIV/AIDS, migration, adolescent health, coping skills etc. In addition, they also provide information and training on life skill and income generation activities such as vegetable gardening, tailoring, weaving and knitting etc. However, these income generating activities are being solely conducted in selected VDCs rather than socially excluded groups or hard to reach community.

9.3 STRENGTH AND OPPORTUNITIES

 Thirteen HFs of Jajarkot district provides Adolescent and Youth Friendly Services.  DHO has conducted Peer Review training to 10 schools in the current FY.  WCO have female adolescent youth clubs to enhance life-skill trainings and to give information on RH issues.

9.4 KEY ISSUES AND CHALLENGES

 Limited government programs and financial constraints provision to expand peer review learning in to schools which is not sufficient.  Despite having 13 AYFS sites, no services available at special hours. The monitoring and supervision and reporting of the Adolescent and sexual reproductive health (ASRH) activities is not proper.  Government provides fund to implement programs in 10 schools, which is not sufficient for the district-wide coverage.

19 10. GENDER EQUALITY AND SOCIAL INCLUSION

H4L is designed to support the Government of Nepal’s stated commitment and responsibility to ensure that quality health services are accessible to all citizens. As such, it is critically important that sound, ongoing GESI-sensitive analysis and gender integration underpin H4L program interventions. H4L’s GESI Objectives are designed to redress gender and social inequities, and dove-tail with the objectives set forth in the MOHP’s 2009 Health Sector Gender Equality and Social Inclusion Strategy as follows:  Objective 1: Support existing MOHP policies, strategies, plans and programs that create a favorable environment for integrating GESI in Nepal’s health sector;  Objective 2: Support MOHP’s efforts to enhance the capacity of service providers and ensure equitable access and use of health services by the poor, vulnerable and marginalized castes and ethnic groups; and  Objective 3: Improve health-seeking behavior of the poor, vulnerable and marginalized castes and ethnic groups in collaboration with local government partners, community-based organizations (CBOs) and other stakeholders.

The first objective is related to policy while the latter two are directly related to D/PHO systems.

The RA also included assessment and analysis of the health programs of the DHO Jajarkot from GESI perspective. The major findings were as following:

10.1 FORMATION AND FUNCTIONALITY OF GESI COMMITTEE In Jajarkot, Public Health Nurse is given the responsibility of GESI focal person. GESI committee of 14 members (Male-9, Female-5) was formed on 23rd Falgun 2069 in accordance with GESI institutional guidelines. However, the committee is not aware of the importance of GESI in neither health services nor does the committee has a terms of reference. Interaction with district supervisors at Jajarkot clearly illustrates that none of them are aware of MOHP GESI Strategy and Operational guidelines. GESI committee is not working properly after its formation due to budgetary constraints; members of GESI committees didn’t get orientation about GESI as cross cutting issues in health services delivery. The functional status of GESI committee can be reviving after the provision of orientation on GESI issues. Similarly, DHO Jajarkot does not have disaggregated data by age, caste, ethnicity, wealth quintile and region, nor do they have any recent DAG mapping information. The availability of such data and its analysis would help to initiate programs to address GESI gaps. Likewise, the district also lacks GESI sensitive process indicators to measure utilization and health care services and disparities between different caste and ethnicities.

10.2 ORGANIZATIONS WORKING ON GESI Three organizations- DDC, District Police Office, and WCDO working on GESI were also visited during RA. Interaction with the staffs revealed that DDC has formed a GESI committee under the chairmanship of LDO on Magh 14, 2068. The committee members were orientated including chief of the different office in the district, VDC secretary and social mobilizes. There are no INGO/NGO that are currently working in the area of GESI. . *****************

20 Annex 1 Contact information of D/PHO Staff, Jajarkot Years of Years of service Cell Phone Name Position service in district no. District Health Officer/ Sr.Public 28 - Health Officer Public Health Nurse 22 22 Statistics Assistant/Officer 3 2 Vacant FP focal person - - - Vacant Malaria focal person - - - Vacant Health Education Tech/ Officer - - - Vacant DTLA/Officer - - - EPI Supervisor/Officer 19 8 - Cold Chain Assistant/ Officer 3 3 Computer Operator/Officer 17 10 Store Keeper 3 2 Child Health focal person/ Nutrition 19 15 Focal Person/ CMAM Focal Person PHI/ Free Health 26 26 Sr.AHW/ HET/CB-IMCI/DTLA 19 3

Annex 2: List of RHCC member organizations, DHO/Jajarkot Name of the organization/ SN Focused area (technical) of intervention Organization type 1. District Health Office  Implementation of RH activities in district  Supervision & monitoring of RH activities  Facilitation of RHCC meeting 2. District Development Committee Support to VDCs on health issues and infrastructure development 3. Women & Children Office Adolescent girls, RH, Women’s Right, Child Rights 4. District Education Office Integration of health education in schools 5. Nepal Red Cross Society Peer education-- adolescent health, disaster management 6. Family Planning Association of Nepal Clinical services on FP/RH 7. Care Nepal, CSP Infrastructure Development of Birthing Centers 8. Women Right Forum ,Jajarkot Screening of Uterine Prolapsed

21 Annex 3 - Table 3: List of Individuals/Organizations visited during RA/Jajarkot Name of SN Individuals Visited Designation Contact No Organization 1 District Health officer 2 Public health Nurse officer 9848223850 3 Sr. ANM 4 PHI 9748051325 5 Stat Assistant 9841850460 6 DHO, Jajarkot Sr. ANM 7 Lab Technician 9848012162 8 Cold chain assistant 9 AHW 9848064899 10 Na.Su. 11 Ty. Na.Su. 12 Local Development officer DDC, Jajarkot 13 Program Officer 15 WCO WCO, Jajarkot 16 Chief women worker 17 Food for Education 18 WEO, Jajarkot Food for education 19 ………………………………… Act. DEO 20 CDO, Jajarkot Chief District Officer 21 Care Nepal, Jajarkot District Program Coordinator 22 Five Star Youth Club Chairperson Development, Jajarkot 23 Nepali Congress Ex. President 24 United Maobadi District co. member 25 Helvetas , Jajarkot Link prog. coordinator 26 ……………………… NEAT/USAID Program Assistant 27 Health Facility staffs HPs(Karkigaon, Bhoor, HP/SHP in charges Sima,Dhime, Kudu) SHPs(Thalaraikar, Jungathachour, Lanha, Bhagawati, Jhapra)

28 Publics Journalists, teachers, students, retail shopkeepers, Hotel owners

22 HEALTH FOR LIFE

REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS

2013 JUMLA

A REPORT ONRAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, JUMLA A REPORT ON RAPID ASSESSMENT

OF DISTRICT HEALTH SYSTEMS 2013

JUMLA

MAY 2013

TEAM MEMBERS

i TABLE OF CONTENTS

ABBREVIATIONS………………………………………………………………………………….………………………. iii

KEY FINDINGS FROM RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS –JUMLA…………………… v

1. RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS…………………………………………………..………. 1

2. INTRODUCTION OF JUMLA DISTRICT……………………………………………………………..……………….… 3

3. DHO STRUCTURE AND SYSTEMS ……………………………………………………………..…...... 4

4. SERVICE STATISTICS ……………………………………………………………………………...……...... 7

5. HEALTH FACILITY MANAGEMENT COMMITTEE AND LOCAL HEALTH GOVERNANCE……………….…. 10

6. SERVICE DELIVERY/QUALITY IMPROVEMENT ………………………………………………………………..….. 12

7. LOGISTICS MANAGEMENT SYSTEM ………………………………………………………………………………….. 14

8. BEHAVIOR CHANGE COMMUNICATION …………………………………………………………………..……….... 16

9. ADOLESCENTS AND YOUTH FRIENDLY SERVICES …………………………………………………………..…….. 19

10. GENDER EQUALITY AND SOCIAL INCLUSION …………………………………………………………..………..… 21

Annexes  Contact Details of DHO program focal persons ………………………………………………………….. 22  List of RHCC members ………………………………………………………………………………………..…… 22  List of organization and individuals visited/contacted during RA……………………….……. 23

ii ABBREVIATIONS

AHW Auxiliary Health Worker ANC Antenatal Care ANM Auxiliary Nurse Mid-wife ASRH Adolescent Sexual and Reproductive Health AFHS Adolescent Friendly Service BCC Behavior Change Communication BEONC Basic Emergency Obstetric and Neonatal Care CA Computer Assistance CB-IMCI Community Based Integrated Management of Childhood Illness CB-NCP Community Based Newborn Care Program CBO Community Based Organization CCA Cold Chain Assistant CEONC Comprehensive Emergency Obstetric and Neonatal Care CFLG Child Friendly Local Governance CPR Couple Protection Rate DAG Disadvantaged Group DDC District Development Committee DHO District health Office/Officer DTLA District TB/Leprosy Assistance FCHV Female Community Health Volunteer FEFO First expiry first out FP Family Planning FPA Family Planning Assistance GESI Gender Equality and Social Inclusion H4L Health for Life HA Health Assistant HETO Health Education Technician Officer HF Health Facility HFOMC Health Facility operation &Management Committee HMIS Health Management Information System HP Health Post I/NGO International/Non-Governmental Organization IEC Information Education Communication IMAM Integrated Management of Acute Mal Nutrition IT Information Technology IUCD Intra Uterine Contraceptive Device IYCF Infant and Young Child feeding KTS Karnali Technical school LDO Local Development Officer

iii LMIS Logistics Management Committee LTFP Long Term Family Planning MCHW Maternal & Child Health worker MgSO4 Magnesium Sulphate MNCH Maternal & Neonatal Child Health MO Medical Officer MSC Matri Surakshya Chakki MWDR Mid-western Development Region N Number NFHP Nepal Family Health Program NPC National Planning Commission NRCS Nepal Red Cross Society ORS Oral Rehydration Solution Ped. Paediatric PHC ORC Primary Health Care Out Reach Centre PHCC Primary Health Care Center PHN Public Health Nurse PNC Post Natal Care PSA Public Service Announcement QAWG Quality Assurance Working Group QI Quality Improvement RA Rapid assessment RHCC Reproductive Health Coordination Committee RHD Regional Health Directorate SAHW Sr. Auxiliary Health Worker SBA Skilled Birth Attendance SHP Sub Health Post SK Store Keeper SN Staff Nurse USAID Unites States Agency for International Development VDC Village Development Committee WCO Women and Children Office WDR Western Development Region WVI World Vision International

iv KEY FINDINGS FROM RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS - JUMLA

Total Population 108,921 Number of VDCs 30 DHO STRUCTURE AND SYSTEMS Public Health facilities:  PHCCs-1, HPs -12 and SHPs-17, Karnali Academy of Health Science - 1 Private Health facilities:0 Meetings:  Ilaka Incharge Monthly at District- 7th of every month  QAWG- No meeting held in the last one year  RHCC- Once (Mangsir 19, 2069) Health Workforce:  All technical positions at DPHO filled in except Statistics Assistant/Officer  Unfilled positions at HFs–HA/Sr. AHW – 10. ANM (17), Lab Technician (1) and Support Staff (5) hired on contract basis from DHO, VDC and NPC. Monitoring and Supervision:  M&S system and plan exists at district level only. Integrated supervision tools are in irregular use. Clinical supervision not in practice. IT infrastructure at DHO:  Desktops-2, Laptops-5, Printers-2  Well established internet facility.  One HFs has computer.  Supervisors skilled in using MS Word and Excel-4.  Health Facility level entry in web-based HMIS software.  Web-based LMIS reporting system Rapid Response Team: Functioning well at the district and Ilaka level SERVICE STATISTICS  BCG and Measles coverage is in increasing trend. In the year FY 2068/69 measles coverage was more than 100 percent.  Severe pneumonia and diarrheal cases shows decreasing trend.  Drop out from ANC first to ANC fourth visits is high and in the FY 2068/69 it was 125 percent and 32 percent respectively.  SBA deliveries are in increasing trend (9 percent in FY 2065/66 to 42 percent in FY 2068/69)  Contraceptive Prevalence Rate in FY 2068/69 was 41 percent which is stagnant in last 3 years HEALTH FACILITY MANAGEMENT  All HFs handed over to local bodies. COMMITTEE AND LOCAL HEALTH  About 25% of the HFOMCs are said to be functioning GOVERNANCE  All HFOMCs received capacity building trainings, refreshers and technical support visit from NFHP II.  At community level groups such as -Forestry Users Group, Mothers’ Group, Drinking Water Users Group, Irrigation Users Group, Cooperatives and Media are functioning. SERVICE DELIVERY/QUALITY  CEONC services provided at district. IMPROVEMENT  Community-based service delivery-MSC implemented in Jumla in 2008, CB-NCP implemented in 2011

v  Satellite FP clinics-0  IUCD services- 4 health facilities and Implants- 5 HFs.  Birthing centers-13  Placenta pits-13 LOGISTICS MANAGEMENT SYSTEM  All tracer drugs and commodities available on the day of visit.  Drugs with most problems of stock outs in the year- Tab Paracetamole, Cotrim P and Iron  No drugs had problems of over stock in the last year  Functioning refrigerators-6, sufficient for maintaining cold chain, and have regular power back up system for the cold chain room.  First Expiry First out (FEFO)- maintained well  Web-based LMIS reporting system. BEHAVIOR CHANGE  FM stations-2 COMMUNICATION  I/NGOs (3) engaged in BCC activities  In the FY 2068/069, total 300 session of school health program on TB/Leprosy, RH, AFHS, Water, Hygiene and sanitation etc. were organized ( About 4000 students benefited). In current FY, no activities were planed and conducted for school health program.

 Villages that were highly populated by DAG- , Chandan Nath, , Kudari, Dhapa, Pandav Gufa, Haku, Lamra, and

 Ethnic/Caste group deprived from service utilization- Poors, Dalits/Janjati from VDCs like , Ghode Mahadev, Bumramadichaur, Manisanghu, Birat, Badki and Jumlakotwere the deprived castes group.

 Villages that still practice early marriage and Early Child Bearing-Almost in all VDCs and more common in Poor and Dalits.

 High Migrants VDCs- Bumramadi Chaur, Malikabota, Kanaka Sundari, Birati, Pandav Gufa, Dhapa, , Sanigaon, Badki, and Mahabepatar Khola ADOLESCENTS AND YOUTH  AFHS- 13 HFs FRIENDLY SERVICES  DHO conducted Peer Review training and schools health program in the current FY.  WCO have adolescent youth clubs to enhance life-skill trainings and give information on RH issues. GENDER EQUALITY AND SOCIAL  18 member GESI committee formed but not active. INCLUSION  DDC, WCO have GESI related activities.  At DDC, GESI committee under the chairmanship of LDO was also formed.

vi 1. RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS

1.1 HEALTH FOR LIFE

Health for Life (H4L) is a five-year bilateral agreement between the Ministry of Health and Population (MoHP) and the Unites States Agency for International Development (USAID) which focuses on Systems Strengthening and improving the Maternal Neonatal Child Health and Nutrition/Family Planning (MNCHN/FP) service delivery at district and sub-district levels in 14 districts. 12 of the 14 districts are in the Mid-western Development Region (MWDR) –Jumla, Bardiya, Dang, Surkhet, Salyan, Pyuthan, Dailekh, Kalikot, Jumla, Rukum, Jajarkotand Rolpaand two are in the Western development Region (WDR) of Nepal- Argakhanchi and Kapilbastu.The project will be implemented between 2012 Dec and 2017 Dec.

1.2 RAPID ASSESSMENT AND ITS OBJECTIVES

Rapid assessment (RA) is a method of analyzing situation of a district where issues are not well defined and where there is not sufficient time or other resources for in-depth quantitative research. RA uses intensive team interaction in both the collection and analysis of data instead of prolonged field work and iterative data analysis and additional data collection to quickly develop a preliminary understanding of a situation from the insider’s perspective. The main purpose of carrying out the current Rapid Assessment is to understand the current situation of the health service delivery system and other associated systems of the Jumla district so as to help in planning activities at district level.

Specifically, the objectives of the RA includes  Understanding the demographic profile of the district  Understanding the existing health care delivery system of the district  Knowing the functionality of the Facility Management Committees  Understanding the status of health indicators  Analyze strengths and weakness of the DHO systems  Exploring feasibility for the implementation of specific programs for adolescents and youth  Exploring feasibility of using Information Technology in information management

1.3 METHODOLOGY

A mix of both qualitative and quantitative methods was used to execute Rapid Assessment in Jumla district. These includes  Visit to District/Public Health Offices (DHO)  Interaction and interview of key staff  Observation of DHO

A structured tool was developed to collect necessary information which was supplemented by qualitative tools to interview key informants at District Development Committee and Local Development Office (LDO), International/Non-Governmental Organizations (I/NGOs) working on

1 different areas of health, Gender Equality and Social Inclusion (GESI), Behavior Change Communication (BCC), Information Technology (IT) in Health, Service delivery, and Governance.

A team was composed for carrying out RA which included which included H4L staff and Government counterpart staff. Skill mix was ensured while forming team where staff was skilled/knowledgeable on the following- Governance, service delivery, monitoring and evaluation, GESI and BCC. Involvement of Project Center, regional and district office was ensured.

Before carrying out of the RA, one day orientation on RA objective, methods and tools were organized for H4L staff together with orientation on H4L in Hotel Siddhartha, Nepalgunj. Director and three senior officials from the Mid-western Regional Health Directorate, Surkhet and the Senior Public Health Administrator of Jumla DHO also participated in the RA orientation. They provided inputs in further refining the RA tools. RA in Jumla was completed by H4L central, regional & district staff in six days May 12-17, 2013. Information collected was verified on the same day and brief notes were developed for each thematic area for sharing with DHO and other line agencies and also for preparing report. After completing the RA, a half day sharing program was organized on 17 May 2013 that was participated by DHO & other DHO staffs. The interaction processes and the information collection during the RA were confined to district- based offices. The RA team did not make field trips to below district level institutions for information collect because of most information including the sub-district level that the RA required were availability at the district offices. Visiting peripheral health facilities and interaction with HFOMCs and FCHVs would have enriched the RA but this was not done. This can be considered as the major limitation of the RA.

1.4 ORGANIZATION OF THE REPORT

The findings of the RA are presented in nine Chapters. Chapter one presents the purpose of carrying out RA and the methodology followed. Chapter two presents the introduction of Jumla district. Chapter three explains the DHO systems and structures. Fourth and the Fifth chapter present the service statistics and the status of the HFOMCs in Jumla district. Sixth and the Seventh chapter present the findings on service delivery/quality of care and logistics management system. Chapter eight, nine and ten reports findings on BCC, AYFS and GESI in Jumla district.

2 1. INTRODUCTION OF JUMLA DISTRICT

2.1 GEO- POLITICAL SITUATION JUMLA: DISTRIBUTION OF POPULATION BY VDC/ MUNICIPALITY, 2011 Jumla District is situated in , and in the MWDR of Nepal. Jumla is bordered on the west by Kalikot, on the north by Mugu and on the east by Dolpa and on the south by Jajarkot. Khalanga is the district headquarters.

Jumla covers an area of 2531 square km. Jumla is situated from 7,000 feet (2133.6 meters) to 21,077 feet (6424.27 meters) in height from sea level. There are 30 VDCs in Jumla district.

2.2 DEMOGRAPHIC INFORMATION

The 2011 Census reports total population of Jumla district as 108921. The proportion of Male and female is equal in Jumla. The Census 2011 reports that there are 19,903 households in Jumla.

The Census 2011 data by Table 2.1: Population of Jumla District caste/ethnicity is not available Number Percent yet hence, the RA used caste Total Population 108,921 - /ethnicity data from DDC profile Male 54,898 50 2009. Table 2.1 shows the Female 54,023 50 Household number 19,303 - caste/ethnicity distribution of the Source: Census 2011 population residing in Jumla district. The Brahmin/Chhetri is Caste/Ethnicity distribution the predominant caste/ethnic Brahmin/Chhetri 84801 80.5 group in Jumla district (81 Muslim 10 0 Dalit 18941 18 percent) followed by Dalit (18 Janjati 1530 1.5 percent). The proportion of Source: DDC profile 2066 (2009) Janajati is about two percent. There are countable numbers of Muslims living in Jumla district

3 2. DHO STRUCTURE AND SYSTEMS

This chapter presents the findings related to the DHO structure and systems collected from the RA. The findings covers following areas: service delivery points, management system, health workforce, monitoring and evaluation system, IT and health information management and disaster management system.

3.1 SERVICE DELIVERY POINTS Table 3.1: Number of service delivery points in Jumla The Distric Health Office, located in district Khalanga is the main responsible Type of service delivery points Number institution of the MOHP at Jumla to provide preventive, promotive and PHCC 1 curative health services to the people of Health Post 12 Jumla. There are a total of 30 peripheral Sub-health Post 17 Birthing centers 13 public health facilities (1 PHCC, 12 HPs Functioning birthing centers 13 and 17 SHPs). There is none health SBA sites 14 academy-Karnali Academy of Health IUCD/Implant site 8 Science in Jumla district. There are 13 PHC Out-Reach Clinic 93 birthing centers are all functioning well Immunization Clinic 107 and have placenta pit. There are 93 FCHVs (Population based) 550 PHC/ORCs and 107 Immunization Clinics. Karnali Acedemy of Health Science 1 A total of 550 Female Community Health Source: DHO Volunteers (FCHVs) are providing services in the district. There are eight IUCD/Implant sites. Jumla has 13 SBA sites in total. There are no private hospitals and nursing homes in Jumla district.

Table 3.2: Current status of DHO Team 3.2 MANAGEMENT SYSTEMS DHO Team Status a. District Health Officer Filled 3.2.1 MEETINGS b. Public Health Nurse Filled DHO Jumla holds different meeting every month. c. Statistics Assistant/Officer Vacant It includes the Monthly meetings of the HF In- d. FP focal person Filled charge, Reproductive Health Coordination e. DTLA/Officer Filled Committee (RHCC) and the Quality Assurance f. EPI Supervisor/Officer Filled Working Group meeting. The monthly meeting of g. Cold Chain Assistant/ Officer Filled the Ilaka In-charge is organized on 7thof every h. Computer Operator/Officer Filled month. Meeting of SHP in-charge at Ilaka is held i. Store Keeper Filled j. Child Health focal person Filled rd on 3 of every month. RHCC and QAWG meetings k. Health Assistant Filled are not regular in Jumla. The last RHCC meeting l. Account assistant/Officer Filled was held on Mangsir 19, 2069. FCHVs monthly m. Admin officer Vacant meetings are also conducted in all HFs before the end of every month.

3.2.2 PROGRAM MANAGEMENT TEAM

The DHO Jumla has almost all the key positions at the office filled at the time of RA. Two positions- Statistical Assistant and Admin Assistant are vacant at the time of RA. There is no sanctioned position of Health Education Technician in Jumla DHO. Refer to table 3.2.

4 3.3 HEALTH WORKFORCE

Table 3.3 presents the current status of health workforce in Jumla district. Most of the sanctioned position (93%) in the HFs of Jumla is filled in. Two positions of VHW one lab assistant and one admin assistant positions are vacant. Some of the HFs does not have office assistants. Few staff in Jumla is recruited by VDC and NPC.

Table 3.3: Current status of health workforce Type of human resources Number GoN Number supported from Sanctioned Filled VDC NPC Other a. Medical Officer 1 1 b. Staff Nurse 1 1 c. Sr. ANM 3 3 d. ANM 10 10 1 e. HA/Sr. AHW 15 5 f. AHW 31 31 g. VHW (padnam AHW) 28 26 h. MCHW (padnam ANM) 0 12 i. Lab Assistant 2 1 1 j. Adm. Assistant/officer 1 0 k. Store Keeper 1 1 l. CCA 1 1 m. Office assistant 26 19 1 TOTAL 120 111 (93%) 1 2 Source: DHO (Sr. PHO & Ta. Na. Su)

3.4 MONITORING AND SUPERVISION

DHO Jumla has integrated Monitoring and Supervision (M&S) System in place where DHO monitors Ilaka/HF level according to the Monitoring and Supervision Plan that is developed every FY. However, there is no such monitoring and supervision plan developed for Ilaka level HFs to monitor SHPs. District supervisors use the integrated supervision tools during their supervisions. However, the M&S system needs to be improved. Supervisions have to be carried out according to plan which is prepared at the beginning of FY. Clinical supervision are not being carried out in Jumla.

3.5 INFORMATION TECHNOLOGY

The RA also explored the existing IT infrastructure at DHO. At present the DHO has two desktop computers and five laptops. DHO has functioning internet and two printers. Among the district supervisors, four are competent in using MS office. One of the peripheral HF has computer.

3.6 HEALTH INFORMATION MANAGEMENT

DHO Jumla has a system to enter HF level data in web-based HMIS software. HF level data is available for the last one year and the current year. The Statistics Officer of Jumla has been recently transferred. Computer assistant enters data in web-based HMIS. For improving data quality, DHO organized an event of Data validation program in the last year but it has not been conducted in this FY due lack of budget. To ensure data quality, data validation has to be carried out every year. Regular feedback system also needs to be improved after analysis of HMIS data. Further analysis

5 and use of HMIS data for planning and monitoring, quality assurance, and feedback system has to be improved.

3.7 NATURAL DISASTER RESPONSE MECHANISM

DHO Jumla has a Rapid Response Team (RRT) formed at district and Ilaka level to deal with health issues during disaster and epidemic. It is functioning well with health sector contingency plan. In Jumla, Disaster Response Team comprising of CDO, DDC, NRCS, Nepal Army, Police, UNICEF, WVI and other line agencies has been formed in district level.

3.8 STRENGTH AND OPPORTUNITIES

The major strengths of the DHO as observed during the RA are as following:

 RHCC and QAWG have been formed according to guideline. There is regular conduction of District and Ilaka level monthly meetings in every 7th and 3rd of the month. Besides, FCHVs monthly meetings conducted in all HFs before the end of the respective month. There is annual monitoring/ supervision plan from DHO to Ilaka, and HP/SHP.  Sufficient IT infrastructure at District level including 2 Personal Computers, 5 Note Books and 2 Printers. Most of the DHO supervisor (N=4) is skilled on MS Office package. There is Internet Facility available in DHO supporting web based HMIS and LMIS reporting  There is ANM/CMA production at Karnali Technical School. Out of 13 Birthing centers all have Placenta Pit. Long term FP service (IUCD and Implant) are available in 8 sites. Jumla has CB-IMCI/NCP, MSC, IMAM, IYCF program implemented.

3.9 KEY ISSUES AND CHALLENGES

The major challenges and constraints faced by the D/PHO Jumla are as following:

 District needs regularization of district level RHCC and QAWG meetings for quality improvement. DHO needs to follow monitoring and supervision according to plan strictly according to guideline formed.  Internet facility at store needs to be connected for effective web-based reporting of LMIS. Further analysis and use of HMIS data for planning and monitoring/ Quality Assurance, and regular feed- back would be effective. Coordination between DHO and KTS needs improvement for practicum.

6 3. SERVICE STATISTICS

The RA also sought information on the service statistics of the following programs: Immunization, Child health, Safe Motherhood and Family Planning. HMIS data for the last four years, 2065/66 to 2068/69 were analyzed. The four year trend analysis of the selected indicators is presented in this section.

4.1 IMMUNIZATION

Trend analysis of BCG and Measles for the four-year period in Jumla shows that the coverages are above 100% coverage in the last three years. The achievements of Jumla are much greater than that of Nepal’s aggregate. According to Focal Person, Department of Health Service provided low target than actual number of under one year children so achievement is more than 100%. The coverage of TT2 and TT2+ is below 80% in the last four years.

Figure 4.1: BCG coverage Figure 4.2: Measles coverage

116 125 125 97 87 94 96 109 107 105 88 86 75 86 86 85

065/67 066/68 067/69 068/70 065/67 066/68 067/69 068/70

Jumla National

4.2 CB-IMCI

Trend analysis of severe diarrhoea in Jumla shows that there is decline in the cases in the four year period. In the most recent year it is 0.3%. Compared to Nepal’s aggregate figure, the severe diarrhoea cases are greater in Jumla in all four years. In Jumla, the trend in proportion of severe pneumonia cases among the new cases was not uniform. In 2067/69 it was 1.5 percent which dropped to 0.4% in the FY 2068/69.

Figure 4.3: Percent of Severe Pneumonia Figure 4.4: Percent of Severe Dehydration among new cases among new cases 1.5

0.9 0.59 0.48 0.4 0.4 0.45 0.4

065/67 066/68 067/69 068/70

7 Diarrhoeal cases treated with ORS + Zinc are encouragingly increasing in Jumla, therefore the decline in severe dehydration cases is obvious. All these findings show the successes of the community-based interventions on child health. In Jumla, Neonatal death was found 24 and 42 in FY 067/68 and 068/69 respectively. Still births are 35 and 25 in the same years. CB-NCP is implemented in Jumla and it could be hoped that these mortalities will decline in the coming years.

4.3 SAFE MOTHERHOOD

Figure 4.5: ANC 1st &ANC 4th visit as percent of EP Trend analysis of ANC 1st and ANC 4th for the four year period shows huge gap between ANC1st and ANC 4th. 1st ANC visit is more than 100% among expected pregnancy but 4th ANC is very low. However, Delivery conducted by SBA (HF & home) is in increasing trend and above national average. There is need to improve 4th ANC visit. PNC visit is near about in decreasing trend which needs to be improved. Maternal deaths recorded in Jumla are 7 and 6 in FY 067/68 and 2068/69 respectively.

According to DHO the major reason for the ANC achievements being so high is the low targets provided by the DoHS than the actual expected pregnant women. There might be recording reporting problems too. However, ANC 4th visit is low due to less awareness of ANC mothers and lack of receiving proper counseling during 1st visit by HWs.

4.4 FAMILY PLANNING

Trend analysis of CPR for the four year Figure 4.5: Contraceptive Prevalance Rate as period in Jumla shows that the % of MWRA achievements are near to That of National in all four year period. In the last three years, CPR has stagnated at 41% in Jumla. At 33 41 national level too, the CPR has almost stagnated in the last three years. Regular and actual reporting of the services provided from the HFs and other private 065/67 066/68 067/69 068/70 sector is essential in analyzing the actual CPR of Jumla district. Long acting FP Jumla National methods are provided from only eight sites which needs to be increased. It was reported that improper recording and reporting of FP current users by HFs also one of the major problems for achieving CPR.

8 Table 4.1: Trend in utilization of services SN Indicators 2065/66 2066/67 2067/68 2068/69 2069/70 1 BCG coverage 87.26 116.2 125 125 95 2 DPT 3 85.88 98.3 129 117 95 3 Measles vaccination coverage 85.9 108.7 107 105 89 4 TT2 and TT2+ coverage among pregnant 48 74.1 76 73 69 women 5 Percent of postpartum mothers 44.1 70.3 85 77 45.72 receiving Vitamin A within 6 weeks 6 Percent of pregnant mothers receiving 102.6 146.4 137 123 74.7 iron tablets 7 Proportion of new pneumonia cases 52.79 42.64 53.62 48.87 48.82 treated with antibiotics 8 Percent of severe Pneumonia among 0.9 0.4 1.5 0.45 0.3 new cases 9 Proportion of new diarrheal cases NA 37 87 89 38.3 treated with ORS +Zinc (under 5 years children) 10 Percent of severe dehydration among 1.6 0.7 0.5 0.3 0.49 new cases 11 ANC 1st visit as percent of expected 88.6 176.6 131 125 63.3 pregnancies 12 Four ANC visits among as percent of 30 33 40 32 32.3 expected pregnancies 13 Delivery conducted by SBAs (both home 9 30 36 42 18.7 and institutions) as percent of expected 14 PNC First visit as percent of expected - 64.5 65 56 44.07 pregnancies 15 Contraceptive prevalence rate (all 32.9 41 41 41 32.83 methods) as percentage of WRA

9 4. HEALTH FACILITY MANAGEMENT COMMITTEE AND LOCAL HEALTH GOVERNANCE

Information on Health Facility Operation and Management Committee was sought from DHO and DDC. Quantitative and qualitative methods were used for collecting information. Information was collected on the following topics: HFOMC functionality, capacity building, presence of different community-based groups at VDC level and their federations at district level. This chapter presents the major findings of the assessment on HFOMC.

5.1 FUNCTIONING HFOMC

In Jumla, all HFs (PHCCs, HPs and SHPs) have been handed over to the local bodies. They also received orientation in 2062/63 by DHO and DDC after being handed over.

During the RA district supervisors were asked some questions on criteria for measuring HFOMC functioning. They opined following criteria as being key for measuring HFOMC functionality:

 Regular (monthly) meeting of HFOMC participated by majority of the members (51%), and having agenda for discussion in the meeting.  Implementation of Agenda  Regular monitoring of HF’s activities by HFOMC members. Top five functional HFOMCs  Support to human resources and programs 1. Kalikakhetu PHC,  Manage resources for efficiency and smooth running of 2. Pandawagufa HP, HFs 3. Haku HP, 4. SHP, The DHO supervisors also expressed that about 25% (7) of the 5. RaraLihi SHP. total HFOMCs of the district are functional. The top five The bottom four HFOMCs functional HFOMCs as judged by the district supervisors include 1. Guthichaur, Kalikakhetu PHC, Pandawagufa HP, Haku HP, Patmara SHP, 2. Patarasi, RaraLihi SHP. Similarly, bottom four includes Guthichaur, 3. Badki, and Patarasi, Badki, and Ghodemahadev. Besides them, remaining 4. Ghodemahadev. HFOMCs are almost similar in functionality- mostly less functional.

5.2 CAPACITY BUILDING OF HFOMC

All HFOMCs of Jumla district has received capacity building training that was organized in 3 VDCs (Talium, Lamra and Tatopani) that were convenient to all HFOMCs. The training was provided by DHO in support of NFHP II. NFHP II also provided refresher trainings to all 30 HFOMCs of Jumla district. NFHP II staff also used to monitor the HFOMC activities and build their capacity by trough supportive visits. DHO reported that NFHP II/Nepal Red Cross Society were were supporting in capacity building of HFOMCs but at present no organization is working except GiZ in few areas.

10 5.3 COMMUNITY GROUPS/FEDERATION/ALLIANCE

According to the district supervisors’ different type of community groups exists at VDC level of Jumla district. These groups include Forest User’s Group, Mother’s Group, Drinking Water User’s Group, Irrigation User’s Group, Cooperatives Groups and Media. At district level there are federations of Media and FECOFUN (forest user group) but federation of other groups were not reported/found.

It was also found that Social Audit in some VDCs of Jumla is going to be done with the support of GiZ, detailed information cannot be obtained as GiZ do not have office in Jumla and DHO lacks exact information about the GiZ’s workplan.

5.4 STRENGTH AND OPPORTUNITIES

Strengths are as Follows: • All HFOMCs have formed according to guidelines. • All HFOMCs received training • All the HFs has been handed over to VDCs in 2062/63. • Some VDC are supporting in FCHV fund.

Opportunities are:  Quality Improvement in FP/MNCH service delivery.  Increase access to hard to reach populations by strengthening HFOMC.

5.5KEY ISSUES AND CHALLENGES

Following are the key issues and challenges with regards to HFOMC:  Lack of knowledge about role and responsibilities among HFOMC members as they are oriented from HF In-charge who doesn’t want HFOMC to monitor him/her.  HFOMC members holding the post for social prestige.  No Local elected body  HFOMC chaired by VDC secretary who doesn’t stay at VDC.  Few HFOMCs are functional (below 25 Percent, N=7)  Re-formation and capacity building as the members are same since the time it was formed in 2062/63  Less supervision to HFOMC and its meeting by DHO/DDC  Ownership development among HFOMC members.  Budget of HFs not provided to VDCs.

11 5. SERVICE DELIVERY/QUALITY IMPROVEMENT

This chapter presents the RA findings related to service delivery and quality of care. Information on the quality of ANM schools, infection prevention practices at HFs, implementation of community- based interventions, and the provision of IUCD and Implants services were collected at district level. The major finding of the assessment is presented hereunder.

6.1 ANM SCHOOLS

H4L intends to improve the quality of pre-service ANM trainings. As such basic information on the ANM schools of Jumla district were sought from DHO and the ANM schools during RA. In Jumla, there is one ANM School - Karnali Technical School (KTS) in VDC-5. According to DHO, the quality of the ANM pre-service training in this school is not so good. He also shared that the ANM schools has not been coordinating with DHO for practical. Coordination between KTS and DHO needs to be improving for better practicum of students.

6.2INFECTION PREVENTION AND WASTE MANAGEMENT PRACTICES AT HFS

Few questions related to infection prevention and waste management practices followed at HFs were also asked to district supervisors during RA. It was found that different HFs practice different type of infection prevention and waste disposal practices. All 13 birthing centres have placenta pit for the disposal of placenta.

QAWG has been formed as per guidelines but it is not meeting regularly, though the plan is to meet on monthly basis. QWAG meeting minute was not available during RA.

6.3SERVICE DELIVERY

The RA sought information on the availability of Satellite clinics, BEONC, CEONC, long acting FP methods, and on implementation of community- based interventions such as CBIMCI/CB-NCP, MSC and service integration.

In Jumla, no HFs has satellite Table 6.1: IUCD and Implants Insertion and Removal Sites of Jumla clinics at present. In the past, IUCD Birthing Implants Birthing there were 7 satellites clinics. Center? Center? These clinics are being HP Yes Chhumchaur HP Yes upgraded to LAFP sites. Tatopani HP Yes Kalikakhetu PHC Yes SHP Yes Haatsinja HP No District provides CEONC DHO MCH clinic No Tamti SHP No services on regular basis by - - Rasa Malikathata SHP Yes Karnali Academy of Health Science. IUCD are provided from four HFs and Implants are also provided from five HFs. One of the HF (Chhumchaur) provides both IUCD and Implant services. Refer to Table 6.1. IUCD & Implant service sites are still low in number so it is necessary to increase sites to need the FP need and increase methods choice for coupes.

In Jumla, MSC was implemented by DHO in support of NFHP in 2005. Jumla is the district where MSC, CB-IMCI, IYCF, IMAM are implemented. There is training need for 32 Health Workers and 60 FCHVs require on CB-IMCI. CB-NCP was also implemented in Jumla in support of NFHP II.

12 6.4 STRENGTH AND OPPORTUNITIES

In relation to H4L objectives:  ANM/CMA production at Karnali Technical School  13 Birthing centers with Placenta Pit  Long term FP service available from 8 centers  CB-IMCI/NCP, MSC, IMAM, IYCF program implemented

5.5 KEY ISSUES AND CHALLENGES

 Coordination between DHO and KTS for practicum  CB-IMCI training for 32 HWs and 60 FCHVs  Regularization of clinical supervision for FP/MNCH by focal persons.  Focus to M/DAGs and marginalized populations  Active functioning of QAWG  Problem in the infrastructure of some birthing centers  Problem in logistic supply (Instruments, equipment's)  Delay release of budget could not provide transportation allowance at the time of delivery.

13 6. LOGISTICS MANAGEMENT SYSTEM

Logistics management is an important part of district health systems. Efficient logistics management is required to smoothly run all the public health programs at district, sub-district and the VDC levels. The RA also sought information from DHO on the logistics management system. The major findings of the assessment are presented below.

7.1 AVAILABILITY OF KEY DRUGS AND COMMODITIES

During RA, the DHO store room was also visited and the store keeper was interviewed. The availability of 11 tracer drugs/commodities (Injectable, Oral Contraceptive, Condom, ORS, Vitamin A, Iron Folate Tablets, Cotrim (Ped), Zinc, Oxytocin, Gentamycin and MgSO4) in the district store at the time of visit was checked. It was found that all were available during the visited day. The store keeper was also asked whether the 11 drugs/commodities were once out of stock in the last 12 months. The RA team members also checked the expiry dates of the 11 drugs/commodities and it was found that all drugs were intact in terms of expiry dates. Refer to Table 7.1.

Table 7.1: Availability of key drugs/commodities and their expiry dates SN Drugs/Commodities Availability at the Stock out in the Expired drugs in stock time of visit last 12 months at the time of visit 1 Injectable Contraceptive Y N N 2 Oral contraceptive Y N N 3 Condom Y N N 4 ORS Y N N 5 Vitamin A Y N N 6 Iron Folate Tablets Y Y N 7 Cotrimoxazole (Ped) Y Y N 8 Zinc Y N N 9 Oxytocin Y N N 10 Gentamycin Y N N 11 MgSo4 Y N N

The Store keeper was also asked to list the drugs that have most problems with stock outs in the FY 2069/70. It was found that Paracetamol, Cotrim P and Iron had once problem with stock outs in the year.

7.2 COLD CHAIN AND FEFO MANAGEMENT

DHO Jumla has six functioning refrigerators. The available refrigerators are sufficient to DHO for maintaining cold chain. The management of eight drugs in the store was checked to see whether First Expiry First Out (FEFO) was maintained or not. It was found that FEFO was properly maintained in the district store at the time of RA.

7.3 LMIS REPORTING

DHO is using web-based LMIS to report to center regularly.

14 7.4 STRENGTH AND OPPORTUNITIES • Most of the essential key commodities are available • FEFO Maintained • Functional refrigerators (6) with power back up • Web based LMIS reporting to center. • PULL system have been implemented in the district for the proper management of drug supply to the HFs.

6.5 KEY ISSUES AND CHALLENGES

 Space limitation including rack and palate  Internet facility in store room  Limit budget for transportation  Insufficient supply of Medicines  Late reporting of LMIS from few HFs  Difficult to follow PULL system due to insufficient budget for medicine purchase.

15 7. BEHAVIOR CHANGE COMMUNICATION

H4L aims to understand legal, cultural/religious, and policy dimensions of GESI inequities on health service access and use and design interventions to ensure sustainable, high-quality BCC and IEC approaches that respond to local realities, and include groups not commonly targeted, but crucial to meeting Nepal’s health goals..

One of the objectives of the RA was to explore the range of BCC interventions that is being implemented for healthy behaviors. Following are the major findings on BCC:

8.1 EXISTING DHO PROGRAMS ON BCC

There is existence of following BCC programs in DHO Jumla  Distribution IEC material to HFs and communities.  Establishment of IEC/BCC corners at DHO

8.2 FM STATIONS/CABLE TELEVISION NETWORKS

In Jumla, there are two FM stations. Following are the name and address of the FM stations: 1. Radio Karnali FM 2. Radio NaariAawaz FM

DHO Jumla has partnered with both FM stations for airing radio health programs and Public Service Announcements (PSAs) on health messages/jingles, EPI notices and other FP/MN-CH topics. There is one Cable TV networks in Jumla, but it has not been broadcasting district-based programs.

8.3 ORGANIZATIONS WORKING IN IEC/BCC ACTIVITIES

One area of intervention of H4L is to improve the quality of counseling provided by health workers and community-based health workers to clients. It is therefore essential to find out whether there is pool of resources available at district level to improve counseling services. Hence, RA also collected information on the district health staff (permanent) who received training on COFP/C in the last three years. It was found that except PHN, none of the health staff received the training.

RA identified following organizations working in IEC/BCC in Jumla:  INF Jumla  World Vision International  SAADA Nepal

H4L plans to use mobile phones to reach target groups with messages on health in selected district. The RA also explored whether any organization has used mobile phones to communicate health messages to target groups or entire district population together with DHO. It was found that no organization or DHO has implemented such activity.

16 8.4 SCHOOL HEALTH PROGRAM

Conducting health education classes at schools is one of the activities of DHO. In the current FY, 300 school health sessions were organized but number of schools and students is not available. In Jumla, the topics mostly covered during the School Health Education Program includes-  Adolescent’s Sexual And Reproductive Health  Nutrition  TB/Leprosy  Hygiene and sanitation  Environmental Sanitation

According to the HETO, the BCC focal person, beside school health education program, peer group education, informal education program, mass education during festivals and occasions, exhibition, FM broadcasting activities will be effective in reaching adolescents with health messages. There was no any IEC/BCC activities implemented for M/DAGs to increase access to services.

8.5 MAPPING OF DAG AND EXPLORING CULTURAL PRACTICES AFFECTING HEALTH

During the RA, in-depth information on DAG communities residing in Jumla district was also collected. The Health Education Technician Officer was interviewed for this. The major findings of this assessment are as following:

Villages that were highly populated by DAG:

Following 10 VDCs are highly populated by Dalits in Jumla 1. Tatopani, 5. Dhapa, 9. Badki and 2. Chandannath 6. Pandawaguf 10. Birat. 3. Talium, 7. Hanku, 4. Kudari, 8. Lamra,

Ethnic/Caste group deprived from service utilization:

Mostly the Dalit caste group is derived from service utilization in Jumla. Service utilization are difficult and low in the following VDCs: 1. Tamti, 8. Raralihi, 2. Ghodemahadev, 9. Kanakasundari, 3. Bumramadichaur, 10. Mahabaipatarkhola, 4. Madisanghu, 11. Kudari, 5. Birat, 12. Malikathata 6. Badki, 13. Kalikakhetu 7. Jumlakot,

Villages that still practice early marriage and Early Child Bearing:

Most of the VDCs and villages in Jumla practice early marriage. This is more common among Dalits.

Migration pattern:  Seasonal migration mostly to India. In-country migration is less  Some go to Gulf countries for work

17  All mixed groups especially poor M/DAGs goes to India and others go to other districts of Nepal.

8.6 STRENGTH AND OPPORTUNITIES

 DAG mapping has been done by DDC  There are 2 FM stations in Jumla district which can be used for the airing of different Health massages through PSA, Radio Drama etc. Different organizations like INF, World vision, SADA Nepal have been also working on BCC programs in this district which will be very much helpful to improve community awareness on health issues.

8.7KEY ISSUES AND CHALLENGES

 Seasonal Migration  Low income generation  It is difficult to increase awareness and provide health services among people who have strong traditional and cultural beliefs, practice of early marriage and early child bearing.  Bulk amount of BCC materials supply from center vs. low use at local level due to improper distribution at local level.

18 8. ADOLESCENTS AND YOUTH FRIENDLY SERVICES

H4L will also work with DHOs in selected districts to improve service accessibility of Adolescents under its Objective 6. The RA also explored different aspects of Adolescents and Youth friendly services in the public health facilities of Jumla district. Following are the major findings:

9.1 EXISTING SERVICES FOR ADOLESCENT

In Jumla, there is focused program for Adolescents in 13 sites (HFs). Following are the name of those HFs. 1. Kalikakhetu , 6. Tamti, 11. Birat, 2. Chhumchaur, 7. Narakot, 12. Raralihi, 3. , 8. Tatopani, 13. Kudari 4. Pandawagufa 9. Hatsija 5. Jumlakot, 10. Dillichaur,

There is focused program for Adolescents such as- 1. Saathi Sikshya ( peer education)- training and interaction 2. School health Program- lecture and interaction 3. Adolescents Friendly Health Services

There are some adolescent or youth clubs established and working in Jumla. However, these clubs are not so active and confined to district headquarter only. Following are the list of these youth clubs: 1. Janasewa Youth Club – Mahat VDC 2. Paropakar Yuba Club- Mahat VDC 3. Chhinasim Yuba Club –Chandannath VDC (Khalanga Bazaar) 4. Dandthapala Yuba Club – Chandannath VDC (Khalanga Bazaar) 5. Saraswoti Yuba Club – Mahat VDC

9.2 ORGANIZATION WORKING FOR ADOLESCENT

Following organizations are working in adolescent health in Jumla: 1. World Vision International 2. SAADA Nepal 3. PACE Nepal 4. Radio Karnali FM 5. WCO

Though these organizations working for Adolescents, there is lack in the coordination with DHO. They have small component in their other focused program for adolescents.

9.3 STRENGTH AND OPPORTUNITIES

 Adolescent and Youth Friendly Services are provided from 13 HFs.  Adolescent friendly programs implemented i.e. peer education and School Health program  District Line agencies also working on this issue.

19 9.4KEY ISSUES AND CHALLENGES

 Only 56 % AFHS reports received in last 3 months.  District line agencies/partners need to coordinate for AFHS.  Need of AFHS expansion to all VDCs/HFs.  Space for maintaining privacy in service site/room.  Limited government programs and financial constraints to expand peer review learning in to schools.

20 9. GENDER EQUALITY AND SOCIAL INCLUSION

H4L is designed to support the Government of Nepal’s stated commitment and responsibility to ensure that quality health services are accessible to all citizens. As such, it is critically important that sound, ongoing GESI-sensitive analysis and gender integration underpin H4L program interventions. H4L’s GESI Objectives are designed to redress gender and social inequities, and dove-tail with the objectives set forth in the MOHP’s 2009 Health Sector Gender Equality and Social Inclusion Strategy as follows:  Objective 1: Support existing MOHP policies, strategies, plans and programs that create a favorable environment for integrating GESI in Nepal’s health sector;  Objective 2: Support MOHP’s efforts to enhance the capacity of service providers and ensure equitable access and use of health services by the poor, vulnerable and marginalized castes and ethnic groups; and  Objective 3: Improve health-seeking behavior of the poor, vulnerable and marginalized castes and ethnic groups in collaboration with local government partners, community-based organizations (CBOs) and other stakeholders. The first objective is related to policy while the latter two are directly related to DHO systems. The RA also included assessment and analysis of the health programs of the DHO Jumla from GESI perspective. The major findings were as following:

10.1 FORMATION AND FUNCTIONALITY OF GESI COMMITTEE In Jumla, Health Assistant and district supervisor is given the responsibility of GESI focal person. GESI committee was formed in 2069 /08/ 26. The committee has 18 Members (Male-14, Female-4). The committee received orientation from GESI focal person. It is found that the GESI focal person and the GESI committee members do not know about GESI, its goal, objective and activities. The GESI focal person listed following challenges:  Lack of GESI mainstreaming in program  Lack of technical skill in GESI to integrate in health program.  No special package for GESI to include in DHO plans and activities/programs.  No budget to empower human resource on GESI With regards to functionality of the GESI committee, it is non-functional. No meeting has been conducted after its formation. One-Stop Crisis Management Center is established in Jumla district.

9.2 ORGANIZATIONS WORKING ON GESI Two organizations- DDC and WCO working on GESI were also visited during RA. Interaction with the staff working on the organizations revealed that following activities were carried out in Jumla:  Income generation program for women  Training on Gender-Based Violence and “Chhaupadi Pratha”.  Awareness raising  Formation of Para legal committee for judicial support At DDC, GESI committee under the chairmanship of LDO was also formed. There is no I/NGO working specifically on GESI in Jumla.

21 Annex 1

Table: Contact information of DHO Staff, Jumla Years of Years of Cell Phone Name Position service in service no. district District Health Officer 20 1 Public Health Nurse 33 26 Vacant Statistics Assistant/Officer FP focal person 17 8 No sanction post Malaria focal person Notsanction post Health Education Tech/ Officer DTLA/Officer 18 3 M EPI Supervisor/Officer 33 6 Cold Chain Assistant/ Officer 28 6 Computer Operator/Officer 3 3 Store Keeper 4 1 Child Health focal person 28 21 Health Assistant GESI focal person 11 1

Annex 2: RHCC members SN Name of Organization 1 DHO 2 Red Cross 3 World Vision International 4 PACE Nepal 5 SAADA Nepal 6 INF 7 Sangrila Association 8 Merie Stopes 9 Italian Foundation 10 Karnali Academy of Health Science (KAHS) 11 Health For Life (H4L) 12 UNICEF Nepal 13 WCO 14 RCDS (Rural Community Development Service) 15 4S (Surya Samajik Sewa Sangh) 16 BEE-Group

22 Annex 3: List of Organization & individuals/contacted during RA SN Name of Organization Name of contacted person 1 DDC

2 UNICEF 3 PACE Nepal 4 Sangrila Association 5 WCO 6 Nepal Red cross society 7 INF 8 World Vision 9 Italian foundation 10 Nari Awaz FM 11 Karnali FM 12 Karnali Technical School (KTS) 13 SAADA Nepal 14 Marie Stopes

23 HEALTH FOR LIFE REPORT ON

RAPID ASSESSMENT

OF DISTRICT HEALTH SYSTEMS

2013 KALIKOT

A REPORT ONRAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, KALIKOT A REPORT ON RAPID ASSESSMENT

OF DISTRICT HEALTH SYSTEMS 2013

KALIKOT

MAY 2013

TEAM MEMBERS

i TABLE OF CONTENTS

ABBREVIATIONS………………………………………………………………………………….……… …. iii

KEY FINDINGS FROM RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS…………...……… iv

1. RAPID ASSESSMENTOF THE DISTRICT HEALTH SYSTEM…………………………………..…… 1

2. INTRODUCTION OF DISTRICT……………………………………………………………………….....3

3. DHO STRUCTURE AND SYSTEMS ……………………………………………………………..…...... 4

4. SERVICE STATISTICS ……………………………………………………………………………...……...7

5. HEALTH FACILITY MANAGEMENT COMMITTEE AND LOCAL HEALTH GOVERNANCE…..10

6. SERVICE DELIVERY/QUALITY IMPROVEMENT …………………………………………………...12

7. LOGISTICS MANAGEMENT SYSTEM …………………………………………………………………14

8. BEHAVIOR CHANGE COMMUNICATION …………………………………………………………….16

9. ADOLESCENTS AND YOUTH FRIENDLY SERVICES ………………………………………………..20

10. GENDER EQUALITY AND SOCIAL INCLUSION ……………………………………………………..21

Annexes  Contact Details of DHO program focal persons………………………………………….22  Detail list of RHCC member………………………………………………………………………22  List of organization contacted during RA…………………………………………………..22

ii ABBREVIATIONS

AFS Adolescence Friendly Services AHW Auxiliary Health Worker ANM Auxiliary Nurse Mid-wife BCC Behavior Change Communication BEONC Basic Emergency Obstetric and Neonatal Care CB-IMCI Community-Based Integrated Management of Childhood Illness CB-NCP Community-Based Newborn Care Package CEONC Comprehensive Emergency Obstetric and Neonatal Care BNMT Britain Nepal Medical Trust DDC District Development Committee HFOMC Health Facility Operation and Management ommittee FMC Facility Management Committee FP Family Planning GESI Gender Equality and Social Inclusion HA Health Assistant H4L Health for Life HF Health Facility HP Health Post HMIS Health Management Information System IT Information Technology LMIS Logistics Management Committee MO Medical Officer MNCHN Maternal Neonatal Child Health and Nutrition MWDR Mid-western Development Region N Number NRCS Nepal Redcross Society NHSSP Nepal Health Sector Support Program NSI Nick Simon Institute PHCC Primary Health Care Center QAWG Quality Assurance Working Group QI Quality Improvement RA Rapid assessment RH Reproductive Health RHCC Reproductive Health Coordination Committee SHP Sub Health Post USAID Unites States Agency for International Development VDC Village Development Committee WDR Western Development Region WCO Women and Child Office

iii FINDINGS FROM RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS

TOTAL POPULATION 1,41,620 NUMBER OF VDCS 30 MUNICIPALITY 0 DPHO STRUCTURE AND Public Health facilities: SYSTEMS  There are 30 service delivery sites in total in public health facilities: – PHCC- 1 – HPs – 13 – SHPs – 15 - District Hospital- 1 Meetings:  Ilaka Incharge Monthly at District- 8th of every month  QAWG- No meeting held in the last one year  RHCC- on need basis Health Workforce:  All sanctioned position is 150 but only 100 are fulfilled at DHO including all the major supervisory post is vacant  Four key positions at DHO are vacant- Public Health Nurse, FP supervisor, DTLA, EPI supervisor Monitoring and Supervision:  M&S system and plan exists at district level only. Integrated supervision tools are in use. IT infrastructure at D/PHO:  Desktops-5, Laptops-6, Printers-2  Internet not-functioning  Most of the Supervisors skilled in using MS Word and Excel. Rapid Response Team: Functioning well at the district and HF level SERVICE STATISTICS  Target provided by the HMIS is much low than the actual population of the district. Therefore, coverage for many programs are much higher.  BCG and Measles coverage is above 100 percent in FY 2067/68 and 2068/69.  Severe pneumonia and diarrhoeal cases are declining and more children are being treated with antibiotics  Drop out from ANC first to ANC fourth visits is high and in the FY 2068/69 it was 112 percent and 28 percent respectively.  SBA deliveries are in increasing trend (from 8 percent in FY 2065/66 to 40 percent in FY 2068/69)  Contraceptive Prevalence Rate is muvch lower than that of Nepal’s aggregate HEALTH FACILITY  HFs are not handed over to local bodies. MANAGEMENT COMMITTEE  All HFOMCs received capacity building trainings, refreshers and technical AND LOCAL HEALTH support visit from DHO and NFHP II. GOVERNANCE  Nine out of 30 HFOMC are said to be functional.  At community level groups such as -Forestry Users Group, Mothers’ Group, Drinking Water Users Group, Cooperative and Media. SERVICE  Regular CEONC services provided at district. DELIVERY/QUALITY  MSC is implemented IMPROVEMENT  Satellite FP clinics-1

iv  IUCD services- 3 health facilities and Implants- 3 HFs.  Birthing centers-19  Placenta pits-5 LOGISTICS MANAGEMENT  Store hasn't key drugs in stock SYSTEM  Web-based LMIS system is in place in DHO, and isn't being reported due to lack of internet facilities  Stock book maintained well  FEFO system maintained as per the guideline  There are 3 refrigerators that are functioning well for cold chain maintenance. There is alternate to power-cut in place BEHAVIOR CHANGE  Two FM stations air DHO programs throughout district COMMUNICATION  Programs like peer education, radio drama, radio programs were lunched through DHO  Organizations like BNMT, UNICEF, Women and Child Office and NRCS are supporting on BCC activities  Through School Health Program, many components of health like HIV/AIDS, RH, GBV, early marriage, gender discrimination, adolescent education have been conducted  Challenges to provide health services among people who have strong traditional and cultural beliefs, practice of early marriage ADOLESCENTS AND YOUTH  BNMT supported 2 Youth Information Center in 2 VDCs of Kalikot FRIENDLY SERVICES  Peer Review training was given to 10 schools of 10 VDC in the current FY  WCO have female adolescent youth clubs to enhance life-skill trainings and give information on RH GENDER EQUALITY AND  GESI committee is formed which is not functioning SOCIAL INCLUSION  GESI focal person is identified

v 1. RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS

1.1 HEALTH FOR LIFE

Health for Life (H4L) is a five-year bilateral agreement between the Ministry of Health and Population (MoHP) and the Unites States Agency for International Development (USAID) which focuses on Systems Strengthening and improving the Maternal Neonatal Child Health and Nutrition/Family Planning (MNCHN/FP) service delivery at district and sub-district levels in 14 districts. 12 of the 14 districts are in the Mid-western Development Region (MWDR) –Banke, Bardiya, Dang, Surkhet, Salyan, Pyuthan, Dailekh, Kalikot, Jumla, Rukum, Jajarkotand Rolpa and two are in the Western development Region (WDR) of Nepal- Argakhanchi and Kapilbastu.The project will be implemented between 2012 and 2017.

1.2 RAPID ASSESSMENT AND ITS OBJECTIVES

Rapid assessment (RA) is a method of analyzing situation of a district where issues are not well defined and where there is not sufficient time or other resources for in-depth quantitate research. RA uses intensive team interaction in both the collection and analysis of data instead of prolonged field work and iterative data analysis and additional data collection to quickly develop a preliminary understanding of a situation from the insider’s perspective. The main purpose of carrying out the current Rapid Assessment is to understand the current situation of the health service delivery system and other associated systems of the Kalikot district so as to help in planning activities at district level.

Specifically, the objectives of the RA includes  Understading the demographic profile of the district  Understanding the existing health care delivery system of the district  Knowing the functionality of the Facility Management Committees  Understanding the status of health indicators  Analyze strengths and weakness of the DHO systems  Exploring feasibility for the implementation of specific programs for adolescents and youth  Exploring feasibility of using Information Technology in information management

1.3 METHODOLOGY

A mix of both qualitative and quantitative methods was used to execute Rapid Assessment in Kalikot district. These include

 Visit to District Health Offices (DHO)  Interaction and interview of key staff  Observation of DHO  Interaction and interview of District Development Committee  Interaction and interview of Women and Child Office  Interaction with local NGOs and FM stations

1 A REPORT ONRAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, KALIKOT A structured tool was developed to collect necessary information which was supplemented by qualitative tools to interview key informants at District Development Committee and Local Development Office (LDO), International/Non-Governmental Organizations (I/NGOs) working on different areas of health, Gender Equality and Social Inclusion (GESI), Behaviour Change Communication (BCC), Information Technology (IT) in Health, Service delivery, and Governance.

A team composed for carrying out RA which included H4L staff and Government counterpart staff. Skill mix was ensured while forming team where the staff was skilled/knowledgeable on the following- Governance, service delivery, monitoring and evaluation, GESI and BCC. Involvement of Project Center, regional and district office was ensured.

Before carrying out of the RA, one day orientation on RA objective, methods and tools were organized for H4L staff together with orientation on H4L in White Guest House, Kalikot. RA in Kalikot was completed by 6 Staff in 6 days, May 3-8, 2013. Information collected was verified on the same day and brief notes were developed for each thematic area for sharing with DHO and other line agencies and also for preparing report. After completing the RA, a half day sharing program was organized that was participated by DHO and I/NGOs.

1.4 ORGANIZATION OF THE REPORT

The findings of the RA are presented in nine Chapters. Chapter one presents the purpose of carrying out RA and the methodology. Chapter two presents the introduction of Kalikot district. Chapter three explains the DHO systems and structures. Fourth and the Fifth chapter present the service statistics and the status of the HFOMCs in Kalikot district. Sixth and the Seventh chapter present the findings in service delivery/quality of care and logistics management system. Chapter Eight, Nine and Ten report's findings on BCC AYFS and GESI in Kalikot district.

2 2. INTRODUCTION OF DISTRICT

2.1 GEO-POLITICAL SITUATION KALIKOT: DISTRIBUTION OF POPULATION BY VDC/MUNICIPALITY, 2011 Kalikot District is situated in Karnali Zone in the MWDR of Nepal. It is a hilly district and Manama is the headquarter of the district. Kalikot covers an area of 1,741 square km. Kalikot is bordered on the west by , on the north by Bajura and Mugu, on the east by Jumla, and on the south by Dailekh and Jajarkot districts. There are 30 VDCs in the district.

This district is situated at 738 to 5,790 meters height above the sea surface.

2.2DEMOGRAPHIC INFORMATION

The 2011 Census reports total population of Kalikot district as 1,41,620. The distribution of male and female in the total population is fifty-fifty. The total household of this district is 19,289 and average number of members in a household is 7.34 in Kalikot districts.

Table 2.1 shows the Table 2.1: Population of District Number Percent caste/ethnicity distribution of the Total Population 1,41,620 - population residing in Kalikot Male 71,196 50 district. Two out of ten Female 70,424 50 population of Kalikot belongs to Household number 19,289 - disadvantaged caste groups (21 Source: Census 2011 percent) are dalits, one percent Caste/Ethinicity NA are janajatis and 78 percent are Dalit and other Disadvantaged NA 21 Brahaman/Chhetri. Janajatis NA 1 Brahaman/Chhetri NA 78 Source:DDC

3 3. DHO STRUCTURE AND SYSTEMS

This chapter presents the findings related to the DHO structure and systems collected from the RA. The findings cover following areas: service delivery points, management system, health workforce, monitoring and evaluation system, IT and health information management and disaster management system.

3.1 SERVICE DELIVERY POINTS Table 3.1: Number of service delivery points in district The District Health Office, located in Type of service delivery points Number is the main responsible institution Government Hospital 1 of the MOHP at Kalikot to provide PHCC 1 preventive, promotive and curative health Health Post 13 services to the people of kalikot district. Sub-health Post 15 There are a total of 29 peripheral public Private hospital 0 health facilities (1 PHCC, 13 HPs and 15 Birthing centers 19 Functioning birthing centers 12 SHPs) and a District Hospital in Kalikot PHC Out-Reach Clinic 68 district. There are 19 birthing centers out Immunization Clinic 111 of which 12 are functioning. There are 68 FCHVs 294 PHC ORCs and 111 Immunization Clinics. Source: DHO, Kalikot There are 294 Female Community Health Volunteers (FCHVs) in the district.

3.2 MANAGEMENT SYSTEMS

3.2.1 MEETINGS

The DHO Kalikot holds different meetings. It includes the monthly meetings of the HF in-charge, the Reproductive Health Coordination Committee (RHCC), the Quality Assurance Working Group meeting and monthly meeting of the ilaka incharge at district level. The monthly meeting of ilaka incharge at Table 3.2: Current Status of DHO Team district is organized on the 8th of every month. There DHO Team Status is no fixed date and time for RHCC, and QAWG. Such 1. District Health Officer Filled meetings are organized on need basis. QAWG has not 2. Sr./Public Health Officer Filled meet in the last one year period. 3. Public Health Nurse Vacant 4. Statistics Assistant Filled 5. FP focal person Vacant 3.2.2 PROGRAM MANAGEMENT TEAM 6. DTLA/Officer Vacant 7. EPI Supervisor Vacant The DHO Kalikot does not have all the key positions at 8. Cold Chain Officer Filled the office filled-in at the time of RA. Out of 11 technical 9. Computer Operator Filled positions at DHO, four are vacant which includes public 10. Store Keeper Filled health nurse, FP focal person, DTLA/Officer, and EPI 11. Child Health focal person Filled supervisor. Refer to Table 3.2.

4 3.3 HEALTH WORKFORCE

Table 3.3 presents the current status of the health workforce in Kalikot district. The total sanctioned post in district is 150, 100 (excluding the vaccinators recruited by DHO)are filled.

Out of the 3 sanctioned positions of Medical Officer (MO), one is vaccant. None of the three staff nurse position is filled-in but there is one staff nurse recruited by NSI. NSI has also supported one MDGP and one MO in district hospital.

DHO has already made request to Reginal Health Directorate (RHD), Surkhet for filling in the vacant positions. At present, DHO and RHD has hired staff on contract for providing services at HFs but there are problems on this. Contract staff are eligible to provide service only for nine months which is a barrier to contuinity of services according to DHO.

Table 3.3: Current status of health workforce S.N Type fo human Number GoN Number supported from resources Sanctioned Filled In VDC NPC Other 1 Medical Officer 3 2 2* 2 Staff Nurse 3 0 1* 3 ANM 13 7 17 24 (18*** +6**) 4 HA/Sr. AHW 17 9 5** 5 AHW 37 26 6 Padnam AHW (VHW) 30 10 7 Padnam ANM (MCHW) 19 14 8 Lab Assistant 1 1 1* 9 Adm. Assistant 5 4 10 Store Keeper 1 1 11 Peon 21 26 12 Vaccinator 0 13*** Total 150 110 (+13 vaccinators) Source: DHO, Kalikot:- *NSI,**Region, ***DHO

3.4 MONITORING AND SUPERVISION

The DHO has Monitoring and Supervision System in place where DHO monitors ilaka level HFs according to the Monitoring and Supervision plan that is developed in every FY. During monitoring and supervision, integrated check lists are used. However, it was reported that DHO can't monitor HFs according to its plan because some of the key supervisor positions are vacant in the district. In addition, there is no budget for monitoring and supervision. Encouragingly, DHO is in process of maintaining written feedback mechanism and also promoting clinical supervision in the peripherial HFs.

3.5 INFORMATION TECHNOLOGY

The RA also explored the existing IT infrastructure at DHO. At present the DHO has five desktop computers, six laptops and two printers. Some of them are not functioning. Most of the supervisors are familiar with MS Office package. DHO supervisor commented that the computers and printers are not sufficient for all district supervisors. DHO has internet facility, but it is not running

5 smoothly. Because of lack of proper internet facility, DHO is facing problem in online reporting of HMIS and LMIS. The Fax machine at DHO is also not working, which is hampering communication with outside agencies.

3.6 HEALTH INFORMATION MANAGEMENT

The DHO Kalikot has a system to enter Health Facility level data into HMIS software. HF level data is available for the last 3 years. Recently, the Statistics Officer received four days training on web- based HMIS reporting. From the next FY, HMIS data by HFs will be entered in the web-based HMIS software. For improving data quality, DHO organized an event of Data verification program in the current FY 2069/070.

3.7 NATURAL DISASTER RESPONSE MECHANISM

The DHO Kalikot has is a member of district level disaster response team and is chaired by CDO. The DHO has a disaster response team (RRT) formed at district level for responding in the emergency conditions. In addition, all of the Ilaka level HFs has also formed RRT for their responsible areas.

3.8 STRENGTH AND OPPORTUNITIES

The major strengths of the DHO as observed during the RA are as follows:  Different agencies such as CDO, DDC, NRCS, Drinking water and sanitation office , Nepal Army and Police are supporting during Natural Disaster.  RRT team has been formed at district level.

3.9 KEY ISSUES AND CHALLENGES

The major challenges and constraints faced by the DHO Kalikot are as follows:  Lack of regularity of the DHO staff in providing services  The staff members are politically influenced and are often less committed  towards their role and responsibilities.  5-7 Health Workers does not like working in their posted HF and wants to work in district hospital, which hampers service delivery in the HFs.  There are multiple trade unions in DHO affiliated with different political parties and it is difficult to deal with them.  Ccenter and regional officials does not understand the ground reality – this do cause inefficiency in timely service delivery  NSI is helping for BEOC and CEONC service at the hospital but once NSI withdraws the support the service at the hospital will be poor. If Medical Officer is provided with Advance SBA training before joining the post it would be effective for improving the service at district level.  The MOHP is upgrading the SHP to HP and now the district has a total of 13 HF but MOHP o does not provide needful health workers in the HFs  DHO facing problem in instantly responding to the needs of HFs due to difficult geography  Lack of sufficient medicine.

6 4. SERVICE STATISTICS

The RA also sought information on the service statistics of the following programs: Immunization, Child health, Safe Motherhood and Family Planning. HMIS data for the last five years (2065/66 to 2069/70) were collected. In this section four-year (2065/66 to 2068/69) trend analysis of the selected indicators is presented in this section. Data for the current FY is not complete therefore it is not analysed here.

According to the MoHP ranking of the last FY 067/068, Kalokot kanked 72th out of the 75 districts. The major reason for this was mismatches in budget expenditure, late reporting form HFs, less achievement, and contact health workers, which comprise a large chunk of health workers in Kalikot are not trained in HMIS system.

4.1 IMMUNIZATION Figure 4.1: Measles coverage Table 4.1 presents the BCG, DPT3 and Measles coverage in Kalikot district, which is in increasing trend over the four-year period and is usually above 100 percent. Figure 4.1 compareas the trend of Measles vaccine of kalikot with Nepal’s aggregate. The achievement of Kalikot is consistently greater than Nepal’s aggregates. The main reason for the coverage being much higher in Kalikot is because the target provided by HMIS is much lower than the number of under one-year children in the district.

4.2 CHILD HEALTH Figure 4.2 Severe Pneumonia among new cases

In Kalikot, trend in pneumonia cases treated with antibiotics is in increasing trend in the last three years. In the most recent year 47 percent of the pneumonia cases were treated with antibiotics. Treatment of pneumonia with antibiotics needs to be increased. The severe pneumonia cases which were much higher in the first two years have declined sharply in the last two years which is a good impact of CB-IMCI.

7 Figure 4.3 : Severe Dehydration among new cases New diarrhoeal cases treated with ORS has trememdously 2 1.72 increased in kalikot in the last 1.5 two years. In 2065/66 only 42 1.5 percent of the diarrhoeal cases 1 0.76 were treated with ORS, while 0.58 0.6 District

in the year 2068/69, almost all Percentage 0.38 0.37 0.5 0.26 National (98 percent) diarrhoeal cases were treated with ORS. 0 However, severe dehydration 065/066 066/067 067/068 068/069 in Kalikot is much higher than Year that of Nepal’s aggregate, but the trend is declining.

4.3 SAFE MOTHERHOOD Figure 4.4: Percentage of ANC 1st and ANC 4th visit among Expected Pregnancies Service statistics of the fiscal year 2068/69 show that 85 percent of the mothers received first Ante natal care services and only 28 percent of them made four ANC visits indicating that around 60 percent of the mothers did not complete the recommended four ANC visits. Gap betwewn ANC first and ANC four is consistently high in all four years. Skilled birth attendance during delivery has increased from 8 percent in 2065/66 to 40 percent in 2068/69. Postnatal service utilization has also increased at the health facility which is 49 in Figure 4.5: Contraceptive Prevalence Rate as of MWRA the most recent year.

4.4 FAMILY PLANNING

Figure 4.5 shows that over the four year period contraceptive prevalence rate (CPR) of Kalikot has slowly by about three percenbt point every year. The CPR for the modern family planning method is 26 percent in 2068/2069 in Kalikot which is 065/066 066/067 068/069 much less than that of Nepal’s aggregate. There are no agencies in Kalikot that is supporting DHO in providing family planning services. At present And HERD is

8 piloting FP services through the EPI clinic (service integration) with the support of NHSSP. The long acting FP services like IUCD and Implant are provided from three HFs of this district. If these methods can be provided from more HFs, then CPR of Kalikot can increase.

Table: Trend in service utilization in Kalikot SN Indicators 2065/66 2066/67 2067/68 2068/69 1 BCG coverage 115.6 116 127 133 2 DPT 3 99 92 123 134 3 Measles vaccination coverage 89 92 123 112 4 TT 2 coverage among pregnant women 41 58.7 51 54 5 Percent of postpartum mothers receiving Vitamin 29 51 61 72 A within 6 weeks 6 Percent of pregnant mothers receiving iron tablets 72.7 134 130 110 7 Proportion of new pneumonia cases treated with 52.7 38.6 43 47 antibiotics 8 Percentage of severe pneumonia among new cases 1.75 0.97 0.006 0.07 9 Proportion of new diarrheal cases treated with 42 33 94 98 ORS (under 5 years children) 10 Percentage of severe dehydration among new 1.72 1.5 0.6 0.76 cases 11 ANC 1st visit as percent of expected pregnancies 77 126 122 112 12 Four ANC visits among as percent of expected 17.9 21 23 28 pregnancies 13 Delivery conducted by SBAs (both home and 7.8 20 24 40 institutions) as percent of expected pregnancies 14 PNC First visit as percent of expected pregnancies 19.6 25.4 40 49 15 Contraceptive prevalence rate (all methods) as 17.24 20 23 26 percentage of MWRA

9 5. HEALTH FACILITY MANAGEMENT COMMITTEE AND LOCAL HEALTH GOVERNANCE

Information on Health Facility Operation and Management Committee was sought from both DHO and DDC. Both quantitative and qualitative methods were used for collecting information. Information was collected on the following topics: HFOMC functionality, capacity building, the presence of different community-based groups at the VDC level and their federations at district level. This chapter presents the major findings of the assessment on HFOMC.

5.1 FUNCTIONING HFOMC

In Kalikot district, HFs are not handed over to the local bodies. All HFs (PHCCs, HPs and SHPs) has HFOMC formed according to its guideline with the support of NFHP-II. District supervisors and field level staffs were also asked some questions on criteria for measuring HFOMC functioning. They opined following criteria as being key for measuring HFOMC functionality:

 Regular Meetings  Resource (HR and certain budget) Mobilization  Minuting and developing action plan  Regular performance review  Monitoring of HF, EPI and PHC/ORC  Facilitation in coordination with DDC/VDC and line agency

The DHO supervisors also expressed that nine out of 30 HFOMCs of the district are functional. These HFOMCs are: Daha HP, Raku SHP, SHP, SHP, Rachuli HP, Kotwada HP, HP, Mehalmudhi HP and SHP. These functional HFOMCs are actively monitoring staffs regularity and stock status in HFs, functionality of EPI and PHC/ORC. They also developed bottom up planning during HFOMC meeting and have presented their planning in VDC cousil for approval. The HFOMC of Daha has recrucited one ANM, one Lab Assistant, one Sweeper and one Table 5.1: Top five and Bottom five HFOMCs Guard. With regards to other support, HFOMCs SN Top five HFOMCs Bottom Five HFOMCs made appropriate arrangement of drinking water 1 Raku SHP Odanaku SHP and made motor road from main road to HF. 2 Daha HP Dhaulagoha HP 3 Phukot SHP Lalu SHP The top five HFOMCs and the bottom five HFOMCs 4 Sipkhana SHP Chhpre SHP in terms of their functioning as judged by the DHO 5 Rachuli HP staff are presented in Tbale 5.1

5.2 CAPACITY BUILDING OF HFOMC

The HFOMCs of Kalikot district has received capacity building training in the last three years. The training was provided by DHO in support of NFHP II. NFHP II also provided refresher trainings to all HFOMCs of district. NFHP II staff also visited HFOMCs to monitor their activities and to build their capacity. According to DHO, there was no plan of handing over HFs to local bodies in Kalikot.

10 5.2 COMMUNITY GROUPS/FEDERATION

According to the district supervisors’ different type of community groups exists at the VDC level of Kalikot district. These groups include- Mothers’ Group, Drinking Water Users Group, Forestry Users Group, and Cooperatives. There is Safe Motherhood Network Federation at district level.

5.3 STRENGTH AND OPPORTUNITIES

HFOMC have been formed in all VDCs with the support of NFHP II but they aren’t handed over to local communities. If all the HFOMC can be revitalized than there is more chances that the HFOMCs takes greater ownership of their HFs than at present.

5.4 KEY ISSUES AND CHALLENGES

As per discussion and telephonic conversation with DHO and staff at HFs, following are the key issues and challenges:

 21 out of 30 HFOMC are not functioning  HFOMCs are not meeting regularly  Lack of HFOMC ownership regarding HFs  Less facilitation and monitoring from DHO and DDC  VDC Secretary is the Chairperson of more than 10 committees. So, s/he can’t devote his time for HFOMC  No local elected body to take responsibility  NewHFOMC members who have not received capacity bulding orientation are not fully aware about their roles and responsibility  VDC Secretary do not delegate his responsibility to other members  No local elected body to take responsibility

5.5KEY OVERCOME OF THE ISSUES AND CHALLENGES

 Re-vitalize the committees  Capacity building of members  Monitoring support  Self-evaluation by the committees themself  Close coordination with DDC and VDC

11 6. SERVICE DELIVERY/QUALITY IMPROVEMENT

6.1 INFECTION PREVENTION AND WASTE MANAGEMENT PRACTICES AT HFS

Few questions related to infection prevention and waste management practices followed at HFs were also asked to district supervisors during the RA. It was found that different HFs practice different types of infection prevention and waste disposal practices. It was found that out of 19 birthing centers only 6 have placenta pit for the proper disposal of placenta. And remaing BC were disposing placenta by dumping in pits.

6.2 SERVICE DELIVERY

The RA sought information on the availability of Satellite clinics, CEONCs, long acting FP methods, and on implementation of community-based interventions such as CB-IMCI, MSC and also on service integration.

In Kalikot district, one HF has satellite clinic. The district provides CEONC services on a regular basis. There are 19 birthing centers in the district. In the district, MSC was implemented by DHO in support of NFHP-II but the supply of MSC is not properly managed and distributed so HFs are facing problems in MSC distribution at community level.

Table 6.1: IUCD and Implants Insertion and Removal Sites of Kalikot Name of the HFs Birthing Center? Implants IUCD Placenta Pit District Hospital Yes Yes Yes Yes PHCC Yes Yes Yes Yes Daha HP Yes Yes Yes Yes Phukot HP Yes No No No Ramnakot HP Yes No No Yes HP Yes No No Yes Chilkhaya HP Yes No No No Rachuli HP Yes No No No Mehalmudi HP Yes No No Yes Sukatiya HP Yes No No No Dhaulagoha HP Yes No No No Gela SHP Yes No No No Jubitha SHP Yes No No No Varta SHP Yes No No No Khina SHP Yes No No No Raku SHP Yes No No No Malkot SHP Yes No No No SHP Yes No No No Mumra SHP Yes No No No Siuna SHP Yes No No No

In Kalikot, 21 Health workers and 35 FCHVs need training on CB-IMCI. In Kalikot, 20 service providers are trainined on SBA. Refer to Table 6.2. SBA training is needed for other nursing staff as well.

12 Table 6.2 Name list of Trained SBAs SN Name Degisnation Institution Remarks 1 Sr.ANM District Hospital 2 Sr.ANM District Hospital 3 ANM District Hospital 4 ANM District Hospital 5 ANM District Hospital 6 ANM Bharta HP 7 ANM Gela HP 8 ANM Jubitha HP 9 ANM Jubitha 10 ANM Rachuli HP 11 ANM Rachuli HP 12 ANM Dhaha HP Thru VDC 13 ANM Ramnakot HP Thru VDC 14 ANM Thirpu SHP 15 ANM Phukot HP 16 ANM Mehalmudi HP 17 ANM Mehalmudi HP Thru VDC 18 ANM Kotbada HP Thru VDC 19 ANM Kumalgaun PHC 20 ANM Sipakhana SHP

6.4 STRENGTH AND OPPORTUNITIES  CEONC service provided through district hospital  There are 19 birthing centers out of HFs(30 VDCs). Two additional have been proposed  Misoprostol implemented at community level.  Services continue with the help of contract staff of GoN and NSI.  Coordinate with supporting agencies to provide training on CB-IMCI to 21 HWs and 35 FCHVs and SBA training

6.5 KEY ISSUES AND CHALLENGES  There are only 5 plancenta pit out of 19 birthing centers  In each birthing center the ANM posted provide 24 hours service. Because of work load, quality of service is compromised.  Lack of equipment- delivery bed, delivery kit, stirlization equipement etc. in birthing centes  No training to Health Workers, no Infection Prevention equipment and practices are not safe  There are problems with infrastructure in some of the HFs  Most of the birthing centers lacks water supply  Delay in budget release – causing the difficulties in continuing the ANM service  The fresh ANM graduates lack SBA skills, causing poor confident level to conduct delivery. But they were provided service.  The bio-medical equipment in the district hospital is out of order – leading problem in the delivery of health care to the people  Shortage of Misoprostal  IUCD and implant sites are limited  Lack of clinical supervision  District needs to explore and find means to construct placenta pits in remaining 14 birthing centers

13 7. LOGISTICS MANAGEMENT SYSTEM

Logistics management is an important part of district health system. Efficient logistics management is required to smoothly run all the public health programs at district, sub-district and the VDC levels. The RA also sought information from DHO on the logistics management system. The major findings of the assessment are presented below.

7.1 AVAILABILITY OF KEY DRUGS AND COMMODITIES

During RA, the DHO store room was also visited and the store keeper was interviewed. The availability of 11 key drugs/commodities (Injectable, Oral Contraceptive, Condom, ORS, Vitamin A, Iron Folate Tablets, Cotrim (Ped), Zinc, Oxytocin, Gentamycin and MgSO4) in the district store at the time of the visit was checked. It was found that 3 drugs (Iron, Cotrim P and Zinc) were running out of stock during the time of RA. Out of these 11 drugs/commodities, six of them: Oral Contraceptives, Condom, Vitanmin A, Oxytocin, Gentamycin and MgSO4 were reported as being out of stock in the last 12 months. The store keeper was asked how long the drugs were out of stock. And it was found that the drugs were out of stock for more than two months. The RA team members also checked the expiry dates of the eight drugs/commodities and it was found that none of the drugs were expired during the time of RA.

Table 7.1: Availability of key drugs/commodities and their expiry dates SN Drugs/Commodities Availability at Stock out in the Expired drugs in stock the time of visit last 12 months at the time of visit 1 Injectable Contraceptive Y Y N 2 Oral contraceptive Y Y N 3 Condom Y Y N 4 ORS N N N 5 Vitamin A Y Y N 6 Iron Folate Tablets N N N 7 Cotrimoxazole (Ped) N N N 8 Zinc N N N 9 Oxytocin Y Y N 10 Gentamycin Y Y N 11 MgSO4 Y Y N

The Storekeeper was also asked to list the drugs that have the most problems with stock outs in the FY 2069/70. We Found that Cotrim P, Zinc, Iron and ORS had most problems with stock outs in the current FY.

7.2 COLD CHAIN AND FEFO MANAGEMENT

DHO Kalikot has 3 functioning refrigerators and these are not sufficient to DHO for maintaining cold chain. The management of five to ten drugs in the store was checking to see whether First Expiry First Out (FEFO) was maintained or not. It was observed that FEFO is maintained in the store room.

14 7.3 LMIS REPORTING

DHO has been reporting LMIS on a regular basis to the centre but the district face challenge to meet the reporting deadline due to lack of timely and incomplete reporting from HFs. In addition, due to lack of internet services, DHO has not been able to do the web-based reporting. The internet service supported by NSI was broken down during the time of RA.

7.4 STRENGTH AND OPPORTUNITIES  Good managed store  FEFO maintained  Power back up system in cold chain  There is new building constructed for store and cold chain

7.5 KEY ISSUES AND CHALLENGES  Insufficient room for storage and cold chain maintenance  Facing difficulties in receiving and supplying drugs and other commodities  No web-based LMIS reporting due to lack of internet facility in DHO  Out of 11 major drugs 3 were stocked out for about 2 months  The new store has been constructed but not handed over to DHO  Only 3 out of 6 cold chains are maintained  Lack of racks and pallets in the new store building  LMIS reports are incomplete due to lack of skill with HWs on stock maintaining

15 8. BEHAVIOR CHANGE COMMUNICATION

H4L aims to understand legal, cultural/religious, and policy dimensions of GESI inequities on health service access and use and design interventions to ensure sustainability, high-quality BCC and IEC approaches that respond to local realities, and include groups not commonly targeted, but crucial to meeting Nepal’s health goals.

One of the objectives of the RA was to explore the range of BCC interventions that is being implemented in Kalikot district for healthy behaviors. Following are the major findings on BCC:

8.1 EXISTING DHO PROGRAMS ON BCC

The Health education and communication unit in the district Health Office work to meet the increasing demand for health education services by implementing IEC activities utilizing various media and methods according to the needs of the local people in the district. Local media and languages are used in the district for dissemination health messages so that people can understand health messages clearly in their local context. Peer education program are also implemented for Adolescent of 10 schools of 10 VDCs. Two youth information center is running in two (Seuna and Kumalgaun) VDCs with the support of BNMT.

8.2 FM STATIONS/CABLE TELEVISION NETWORKS

In Kalilkot, there are two FM stations. Following are the name and address of the FM stations:  Naya Karnali FM  Naya Awaj FM

DHO Kalikot has partnered with FM stations for airing radio health programs and Public Service Announcements (PSAs) on FP/MNCH, Sanitation, HIV/AIDS, Tobacco, TB/Leprosy and day celebrations topics. There are no Cable TV networks in Kalikot.

8.3 ORGANIZATIONS WORKING IN IEC/BCC ACTIVITIES

RA identified following organizations working in IEC/BCC in Kalikot:  UNICEF  BNMT  Karnali Integrated Rural Development And Research Center  Women and Child Office

H4L plans to use mobile phones to reach target groups with messages on health in selected district. The RA also explored whether any organization has used mobile phones to communicate health messages to target groups or the entire district population together with DHO. It was found that there is not any program which disseminate messages through mobile.

16 8.4 ORGANIZATIONS WORKING IN IEC/BCC ACTIVITIES

One area of intervention of H4L is to improve the quality of counseling provided by health workers and community-based health workers to clients. It is therefore essential to find out whether there is a pool of resources available at district level to improve counseling services. Hence, RA also collected information on the district health staff who received training on COFP/C in the last three years. Regarding COFP training 98 persons was participated. BNMT and Save the Children are supporting in IEC/BCC activities in Kalikot. BNMT and Save the Children are broadcasting massages on Human Resurces in Health and delaying marriage respectively.

8.5 SCHOOL HEALTH PROGRAM

Conducting health education classes at schools is one of the activities of DHO in the current FY 068/069. According to the Health Education Technician Officer, beside school health education program, Peer education and Youth information Center activities is also effective in reaching health messages for adolescents. It was reported that in the last FY that no IEC/BCC activities were implemented for M/DAG to increase access to services.

8.6 MAPPING OF DAG AND EXPLORING CULTURAL PRACTICES AFFECTING HEALTH

During the RA, in-depth information on DAG communities residing in Kalikot district was also collected. The district supervisors were interviewed for this and it was found out that DAG mapping has not been carried out in this district. A report on “Dalit Mukti ko Awaj” published by DDC Kalikot in 2067 reports following villages as highly populated by DAG and Ethnic/Caste group deprived from service utilization in Kalikot.

Table 8.1: Villages that were highly populated by DAG and Ethnic/Caste group deprived from service utilization: S.N Name of VDC Darji Sarki Kami Total Ghardhuri Total Population (household 1 Rachuli 8 4 383 69 395 2 Foimahadev 267 233 145 104 645 3 Jubitha 80 103 98 57 281 4 71 0 1,010 175 1,081 5 138 0 331 80 469 6 Chilkhaya 336 41 494 145 871 7 Gela 200 4 836 164 1,040 8 230 0 599 121 829 9 Sukatiya 245 0 1,063 222 1,308 10 Bharta 248 0 1,716 290 1,964 11 208 0 699 138 907 12 Daha 116 0 951 173 1,067 13 Lalu 698 518 457 260 1,673 14 Kotwada 450 0 983 239 1,433 15 Malkot 214 0 1,492 248 1,706 16 Rupsha 13 0 6 4 19 17 Kumalgau 207 0 882 167 1,089 18 Manma 520 0 2,271 428 2,791 19 Ruku 153 514 699 230 1,366 20 Mehalmudi 262 407 733 207 1,402

17 21 Mumra 256 0 562 138 818 22 Shipkhana 321 889 635 301 1,845 23 Sayuna 257 762 845 313 1,864 24 Fukot 205 33 1,649 321 1,887 25 Ramnakot 88 147 522 137 757 26 224 367 838 290 1,429 27 Thirpu 144 0 637 123 781 28 Dhaulagoh 117 539 804 238 1,460 29 Khina 17 0 898 150 915 30 Wadalkot 83 194 749 139 1,026 Total 6,376 4,755 23,987 5,671 35,118 Source: “Dalit Mukti ko Awaj” DDC Kalikot-2067.

Villages that still practice early marriage and Early Child Bearing:

 Early marriage and early child bearing status can't be specified by VDCs.  Early marriage and early child bearing is found mostly in the Brahamin and Dalit community (not in Chettri and Thakuri). However, it is practised in almost all caste/ethnic groups. The reason behind this practice is multiple; o Low awareness, education and economic status – very limited exposure to outer world. o Adolescent does not have any area for them to get involved. o Desire for good clothing, ornaments and lifestyle in the mind set of youth especially with girls. o Cultural and traditional practice in some community – as society consider it a normal phenomenon and accepts them in the society. Moreover, it is accepted especially in economically deprived/disadvantaged groups. o Due to urbanization – it is also seen as the fusion of rural and urban lifestyle. The rural youth in the process of adapting the urban lifestyle tends to become more open and practice illegitimate relationship leading to early marriage.  The DHO does airing of promotional message from FM radio for delaying marriage and delaying pregnancies and have also aired radio drama serials in the past in on these issues to raise awareness. However, due to lack of budget, DHO has not been able to continue airing throughout year.  There is couple of INGOs working in the10 VDCs through CBOs, adapting the practice of peer education (saathi shikchya). It has addressed the issue to some extent. However, it has not been able to cover the whole district due to lack of resources in DHO.  DHO conducts camps and have school health programs. They distribute leaflets on the subject but these activities are not carried out on regular basis.

Migration pattern:

 It is observed that due to poor economic status of the families in Kalikot district, there are very few individuals who have migrated to gulf countries for job.  It is seen that more than 60% of the population in the district migrate as seasonal migrants to India. Most of the migrants leave the district during the month of Marg/Falguan and come back home in the month of Ashoj/Kartik.  The able families from Kalikot have migrated to Shurkhet, Nepalgunj and Kailali for better life and future.

18  The seasonal migration is found across all caste groups and in almost all VDCs. Usually the population aged 13-50+ yrs are migrating. However, very few female accompany their spouse during migration. The female or housewife stay back at house to look after their children, parents and the field.

Ethnic group /village in this district that are deprived from health service utilization due to geography, economy and other factors

Information on these topics are not available in Kalikot district.

On asking the focal person on the kind/type of communication intervention that H4L should plan in Kalikot, following responses were receved:  Health Exhibition Program  Health massage provided through media  Developing district annual intervention plan  IEC/BCC corner in HFs  Youth Friendly Services  Effective School Health Program

8.7 STRENGTH AND OPPORTUNITIES

 75 prercent of the DHO staff has received COFP training  Promotional radio spots/jingles/PSA on different health issues produced and aired from local FM  There are supports from BNMT and Save the Children in IEC/BCC activities. BNMT and Save the Children are broadcasting massages on Human Resurces in Health and delay marrage in respectively.

8.8 KEY ISSUES AND CHALLENGES

 The district does not have annual IEC/BCC strategy/intervention plan  IEC/BCC programs needs to be developed targeting DAG population  School health program was not conducted effectively and systematically  Irregular supply of IEC/BCC materials from DHO to HFs

19 9. ADOLESCENTS AND YOUTH FRIENDLY SERVICES

H4L will also work with DHOs in selected districts to improve service accessibility of Adolescents and youths under its Objective 6. The RA also explored different aspects of Adolescents and Youth friendly services in the public health facilities of Kalikot district. Following are the major findings:

9.1 EXISTING SERVICES FOR ADOLESCENT

In Kalikot district, the focused program for Adolescents are as following:  PEER Education Program implemented in 10 Schools in 10 VDCs. It is a regular program of DHO. Its provides information to adolescents regarding adolescent health and reproductive health through peers. The peer educators have received 3 days RH training. There is no specific reporting format for this activity. Following are the schools running Peer education program in Kalikot: 1. Nanda Devi H. S. S., Malkot 2. Nanda Devi H. S. S., Kotwada 3. Pancha Dewal H. S. S. Mahelmudhi 4. Janjagriti H. S. S. Fukot 5. Jyan Uday H. S. S. Ramanakot 6. Sharsawati H. S. S. Thirpu 7. Mahadev H. S. S. Sukatiya 8. Ram H. S. S. Gela 9. Pancha Dev H. S. S. Manma 10. Kalika H. S. S. Fuimahadev

 Youth Information Center in 2 VDCs (Siuna and KumalGau) is running with the support of BNMT.

9.2 ORGANIZATION WORKING FOR ADOLESCENT HEALTH

In Kalikot district, there is no specific project that is implementing adolescents focused activities. However, BNMT, WCO, GIZ and ADRA are working in some components of adolescent health.

1. BNNT: BNMT is implementing 2 Youth Information centers in 2 VDCs 2. Women and Child Office: Provide life skill training for Girl Adolescent 3. GIZ and ADRA are planning to implement ASRH program.

9.3 STRENGTH AND OPPORTUNITIES  Peer Education (Saathi Sikcha) going on in 10 schools in 10 VDCs.  10 days “Life Skill” Training is provided to adolescent in 5 VDCs – 2 Youth Information Center running at 2 VDC with support from BNMT.

9.4 KEY ISSUES AND CHALLENGES  Improve school health programs to raise awareness of FP/RH issues  Coordinate to orient HWs on Adolescent Friendly Service at HF level  No Specific program for Adolescent  Health services provided to Adolescent are not friendly towards them.

20 10. GENDER EQUALITY AND SOCIAL INCLUSION

H4L is designed to support the Government of Nepal’s stated commitment and responsibility to ensure that quality health services are accessible to all citizens. As such, it is critically important that sound, ongoing GESI-sensitive analysis and gender integration underpin H4L program interventions. H4L’s GESI Objectives are designed to redress gender and social inequities, and dove-tail with the objectives set forth in the MOHP’s 2009 Health Sector Gender Equality and Social Inclusion Strategy as follows:

 Objective 1: Support existing MOHP policies, strategies, plans and programs that create a favorable environment for integrating GESI in Nepal’s health sector;  Objective 2: Support MOHP’s efforts to enhance the capacity of service providers and ensure equitable access and use of health services by the poor, vulnerable and marginalized castes and ethnic groups; and  Objective 3: Improve health-seeking behavior of the poor, vulnerable and marginalized castes and ethnic groups in collaboration with local government partners, community-based organizations (CBOs) and other stakeholders.

The first objective is related to policy while the latter two are directly related to DHO systems.

The RA also included assessment and analysis of the health programs of the DHO Kalikot from GESI perspective. The major findings were as following:

10.1 FORMATION AND FUNCTIONALITY OF GESI COMMITTEE

In Kalikot, is given the responsibility of GESI focal person. GESI committee was formed in 2069/11/08 in Kalikot. The committee has 19 Members (Male-16, Female-3). It was found that GESI focal person himself has not received any orientation and training on GESI and dis not have well understanding of GESI. However, he reported that he provided orirentation on GESI to the GESI committee.

With regards to the functionality of the GESI committee, the committee has not been functioning well. The main reason of non functioning of GESI is that there is no idea/information on how to include GESI perspectives in DHO programs due to lack of knowledge of GESI among the program focal persond and the GESI focal person. There is no One-Stop Crisis Management Center in Kalikot.

10.2 ORGANIZATIONS WORKING ON GESI

In Kalikot, NHSSP is the only organization that is working on GESI, but there is no specific program for GESI implemented or supported by NHSSP. NHSSP supported in GESI committee formation in the district. NHSSP has has been trying to coordinate for organizing GESI committee meeting have have not been successful yet.

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21 Annex 1 Table: Contact information of D/PHO Staff, Kalikot Added Years of Years of service Cell Phone Name Position Responsibility service in district no. District Health Officer 15 6 mth Sr. Public Health Officer 22 1 Vacant Public Health Nurse Statistics Assistant/Officer 3 3

Vacant FP focal person NA NA NA Malaria focal person NA NA NA Health Education Tech/ NA NA Officer Vacant DTLA/Officer NA NA Vacant EPI Supervisor/Officer NA NA Cold Chain Officer 23 19 Vacant Computer NA NA Operator/Officer Store Keeper 25 1 Public Health Officer FP, FCHVs, 26 26 ORC/PHC Sr. AHW Officer IMIC, Nutrition, 23 1 Epidemic and Malaria Sr. AHW Officer TB/Leprosy, 23 3 HIV, HE & Training Sr. ANM RH 18 5 mths

Annex-2 Name list of District RHCC Commitee SN Committee Designation Office Remarks 1 President District Health Office DHO 2 Secreatry District Health Office PHO/FP Focal Person 3 Member District Development Committee 4 Member District Education Office 5 Member Women and Child Offfice 6 Member Nepal Red Cross Society 7 4 Member NGOs SADA Nepal, VDSEF, BMNT, Sahash Nepal

Annex-3 List of organization and individuals visited/contacted during RA SN Office Remarks 1 DHO 2 DDC 3 WCDO 4 Local FMs 5 Local NGOs 6 District Education Office

22 HEALTH FOR LIFE

REORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS

2013 PYUTHAN

1 A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, PYUTHAN A REPORT ON

RAPID ASSESSMENT

OF DISTRICT HEALTH SYSTEMS 2013

PYUTHAN

MAY 2013

TEAM MEMBERS

2 TABLE OF CONTENTS

ABBREVIATION…………………………………………………………………………………………………ii

KEY FINDINGS OF RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEM..……………………….….iv

1. RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS…………………………………………… 1

2. INTRODUCTION OF PYUTHAN DISTRICT…………………………………………………………..…3

3. DHO STRUCTURE AND SYSTEMS …………………………………………………………………..…4

4. SERVICE STATISTICS ………………………………………………………………………….…….. ……7

5. HEALTH FACILITY MANAGEMENT COMMITTEE AND LOCAL HEALTH GOVERNANCE …..10

6. SERVICE DELIVERY/QUALITY IMPROVEMENT ……………………………………………………12

7. LOGISTICS MANAGEMENT SYSTEM ………………………………………………………………….13

8. BEHAVIOR CHANGE COMMUNICATION …………………………………………………………….15

9. ADOLESCENTS AND YOUTH FRIENDLY SERVICES … ………………………………………… ….18

10. GENDER EQUALITY AND SOCIAL INCLUSION ……………………………………………………...19

Annexes Annex: 1 Contact information of DHO Program focal person…………………….21 Annex: 2 List of RHCC Members ………………………………………………………………21 Annex: 3 List of persons met during RA visit…………………………………………….22

i A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, PYUTHAN ABBREVIATIONS

AHW Auxiliary Health Worker ANC Antenatal Care ANM Auxiliary Nurse Mid-wife ASF Adolescent Friendly Services BCC Behavior Change Communication BCG Bacillus Calmatte Gurine BEONC Basic Emergency Obstetric Neonatal Care CB-IMCI Community-Based Integrated Management of Childhood Illness CB-NCP Community-Based Newborn Care Package CEONC Comprehensive Emergency Obstetric and Neonatal Care CFUG Community Forest Users Group CPR Contraceptive Prevalence Rate CRRT Community Rapid Response Team DDC District Development Committee DDRT District Disaster Response Team DHO District Health Office DPT Diptheria Pertusis Tetanus DTOT District Training of Trainers EPI Expanded Program for Immunization EDCD Epidemiology and disease Control Division EDP External Development Partner FCHV Female Community Health Volunteer FM Frequency Modulation FMC Facility Management Committee FP Family Planning FY Fiscal Year GESI Gender Equality and Social Inclusion H4L Health for Life HA Health Assistant HF Health Facility HMIS Health Management Information System HP Health Post HR Human Resource HRH Human Resource for Health IP Infection Prevention IT Information Technology IUCD Intra Uterine Contraceptive Devices IYCF Infant Young Children Feeding LDO Local Development Officer LAFP long Acting Family Planning LMIS Logistics Management Information System M/DAG Marginalized/Disadvantaged MG Mother Group MNCHN Maternal Neonatal Child Health and Nutrition MO Medical Officer MSC Matri Surakshya Chakki MWDR Mid-western Development Region N Number NGO Non-Government Organization NFHP Nepal Family Health Program NIP National Immunization Program PHC/ORC Primary Health Care/Out Reach Clinic

ii PHCC Primary Health Care Center PHN Public Health Nurse PHO Public Health Officer PNC Post Natal Care QAWG Quality Assurance Working Group QI Quality Improvement RA Rapid Assessment RHCC Reproductive Health Coordination Committee RRT Rapid Response Team SBA Skilled Birth Attendant SHP Sub Health Post TV Television UNFPA United Nations Population Fund USAID Unites States Agency for International Development VDC Village Development Committee WCO Women and Child Office WDR Western Development Region

iii KEY FINDINGS FROM RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS

TOTAL POPULATION 2,28,102 NUMBER OF VDCS 49 DHO STRUCTURE AND Public Health facilities: SYSTEMS  District Hospital-1, PHCCs-2, HPs -18 and SHPs-28, Ayurved Center-1, Ayurved Ausadhalaya-2 Private Health facilities:  Private hospital-1 Meetings:  Ilaka Incharge Monthly at District- on 7th of every month  QAWG- No meeting held since 18-07-2011  RHCC- Meets quarterly last meeting 28-02-2013 Health Workforce:  Total fulfilled positions in DHO and peripheral HFs-77%  All technical positions at DHO filled in except PHO and Health Education Technician  Vacant Positions at peripheral HFs: HA/Sr.AHW-45%, ANM-33% , AHW -16% and Lab Assistant-50% of each sanctioned positions  Staff Nurse-1, HA-3, ANM-27, AHW-8 and vaccinators- 13 are hired on contract and temporary basis. Monitoring and Supervision:  M&S system and plan exists at district level only. Integrated supervision tools are in use sometimes. IT infrastructure at DHO:  Desktops-8, Laptops-5, Printers-4  Well established internet facility.  Four HFs has computers.  Supervisors skilled in using MS Word and Excel-4.  Health Facility level entry in HMIS software. Rapid Response Team: Functioning well at the district as well as Ilaka HF level SERVICE STATISTICS  BCG and Measles coverage is in decreasing trend after 2066/67 FY.  Severe pneumonia and severe dehydration cases are declining over last 5 years and maintained below 1 percent. Children are being treated with antibiotics is high with respect to sev/pneumonia.  Drop out from ANC first to ANC fourth visits is high and in the FY 2068/69 it was 81 percent and 41 percent respectively.  SBA delivery is in escalating trend over last 4 FYs (7 to 20 percent from FY 2065/66 to FY 2068/69)  Contraceptive Prevalence Rate is declining after FY 2066/67 and was 44 and 39 percent in FY 2068/69 HEALTH FACILITY  HFs are not handed over to local bodies. MANAGEMENT COMMITTEE  All HFOMCs received capacity building trainings, refreshers and technical AND LOCAL HEALTH support visit from NFHP II. GOVERNANCE  At community level groups such as -Forestry Users Group, Mothers’ Group, Drinking Water Users Group, Cooperatives are functioning. SERVICE  Regular BEONC services provided at district. DELIVERY/QUALITY  Community-based service delivery: CB-NCP is going to be implemented IMPROVEMENT (1st batch training is completed in May, 2013)

iv  IUCD services- 7 health facilities and Implants- 9 HFs.  Birthing centers-24  Placenta pits-8 LOGISTICS MANAGEMENT  All tracer drugs and commodities available on the day of visit. SYSTEM  Drugs with most problems of stock outs in the year- Tab Ibuprofen and Ranitidine  Drugs with most problems of over stock in the last year- Tab. Vitamin –B complex, Antacid Tablet and Syrup Metronidazole  Functioning refrigerators-4 and are not sufficient for maintaining cold chain, and have one regular power back up system for the cold chain room.  First Expiry First out (FEFO)- maintained well  Web-based LMIS reporting system. Data entry person is not recruited. BEHAVIOR CHANGE  FM stations-3, Local TV cable network 4 COMMUNICATION  Few I/NGOs engaged in BCC activities  In the FY 2068/069, total 130 session of school health program on STI/HIV/AIDS, RH, Communicable diseases, SM, FP, Environmental sanitation, Personal Hygiene, Immunization, Nutrition, Essential health care etc were organized in 58 school (3774 students were benefited). In 2069/70, there are no activities for school health program.

 Villages that were highly populated by DAG- Kochibang, Sworgadwari, Dangbang, Liwang, Damri, Syaulibang

 Ethnic/Caste group deprived from service utilization- Dalits and Jajatis are the deprived castes group.

 Villages that still practice early marriage and Early Child Bearing- , Gothibang, Sari and

 High Migrants VDCs- Raspurkot, Udaypurkot, Pakala (Dhubang), Dhungegadi, Dangbang ADOLESCENTS AND YOUTH  AFS- Total 26 HFs; 13 HFs supported by Save the Children and 13 by FRIENDLY SERVICES UNFPA (Other 15 HFs are providing AFS very soon on the support of save the Children)  DHO conducted Peer Review training to 10 schools in the current FY.  WCO have female adolescent youth groups to enhance life-skill trainings and give information on RH issues. GENDER EQUALITY AND  20 member GESI committee has formed but not active. The committee SOCIAL INCLUSION received one day orientation from the GESI focal person of NHSSP.  GESI focal person assigned to a district supervisor.  DDC, WCO have GESI related activities.  At DDC, GESI committee under the chairmanship of LDO has formed.

v 1. RAPID ASSESSMENT

1.1 HEALTH FOR LIFE

Health for Life (H4L) is a five-year bilateral agreement between the Ministry of Health and Population (MoHP) and the Unites States Agency for International Development (USAID) which focuses on Systems Strengthening and improving the Maternal Neonatal Child Health and Nutrition/Family Planning (MNCHN/FP) service delivery at district and sub-district levels in 14 districts. 12 of the 14 districts are in the Mid-western Development Region (MWDR) –Banke, Bardiya, Dang, Surkhet, Salyan, Pyuthan, Dailekh, Kalikot, Jumla, Rukum, Jajarkot and Rolpa and two are in the Western development Region (WDR) of Nepal- Arghakhanchi and Kapilbastu.The project will be implemented between 2012 and 2017.

1.2 RAPID ASSESSMENT AND ITS OBJECTIVES

Rapid assessment (RA) is a method of analyzing situation of a district where issues are not well defined and where there is not sufficient time or other resources for in-depth quantitate research. RA uses intensive team interaction in both the collection and analysis of data instead of prolonged field work and iterative data analysis and additional data collection to quickly develop a preliminary understanding of a situation from the insider’s perspective. The main purpose of carrying out the current Rapid Assessment is to understand the current situation of the health service delivery system and other associated systems of the Pyuthan district so as to help in planning activities at district level.

Specifically, the objectives of the RA includes  Understanding the demographic profile of the district  Understanding the existing health care delivery system of the district  Knowing the functionality of the Facility Management Committees  Understanding the status of health indicators  Analyze strengths and weakness of the DHO systems  Identification of potential Local Technical Assistance Partners (LTAPs)  Exploring feasibility for the implementation of specific programs for adolescents and youth  Exploring feasibility of using Information Technology in information management

1.3 METHODOLOGY

A mix of both qualitative and quantitative methods was used to execute Rapid Assessment in Pyuthan district. These includes  Visit to District Health Office (DHO)  Interaction and interview of key staff  Observation of DHO

A structured tool was developed to collect necessary information which was supplemented by qualitative tools to interview key informants at District Development Committee (DDC)and Local Development Officer (LDO), International/Non-Governmental Organizations (I/NGOs) working on

1 A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, PYUTHAN different areas of health, Gender Equality and Social Inclusion (GESI), Behavior Change Communication (BCC), Information Technology (IT) in Health, Service delivery, and Governance.

A team was composed for carrying out RA which included H4L staff and Government counterpart staff. Skill mix was ensured while forming team where staff was skilled/ knowledgeable on the following- Governance, service delivery, monitoring and evaluation, GESI and BCC. Involvement of Project Center, regional and district office was ensured.

Before carrying out of the RA, one day orientation on RA objective, methods and tools were organized for H4L staff together with orientation on H4L in Hotel Siddhartha, Nepalgunj. RA in Pyuthan was completed by four Staffs in ten days May 1-10, 2013. Information collected was verified on the same day and brief notes were developed for each thematic area for sharing with DHO and other line agencies and also for preparing report. After completing the RA, a half day sharing program was organized that was participated by RHD, DHO, DDC/LDO, Journalist and non- governmental organizations.

1.4 ORGANIZATION OF THE REPORT

The findings of the RA are presented in nine Chapters. Chapter one presents the purpose of carrying out RA and the methodology. Chapter two presents the introduction of Pyuthan district. Chapter two presents the introduction of the district. Likewise, Chapter three explains the DHO systems and structures. Fourth and the Fifth chapter present the service statistics and the status of the HFOMCs in Pyuthan district. Sixth and the Seventh chapter present the findings on service delivery/quality of care and logistics management system. Chapter Eight, Nine and Ten presents the findings on BCC, AYFS and GESI in this H4L district.

2 2. INTRODUCTION OF PYUTHAN DISTRICT

2.1 GEO-POLITICAL SITUATION

Pyuthan district is PYUTHAN: DISTRIBUTION OF POPULATION BY VDC/MUNICIPALITY, 2011 situated in Rapti zone, and in the Mid- Western Development Region of Nepal. Khalanga is the districts headquarter but District Health Office (DHO) and the hospital are in located in VDC, neighbor VDC of Khalanga. Pyuthan covers an area of 1,309 square km.

This district is bordered on the west by Dang and on the north by Baglung and Rolpa and East by Gulmi and Arghakhanchi on the south by Dang and Arghakhanchi Table 2.1: Population distribution of Pyuthan districts. There are 49 VDCs in this Number Percent district. Total Population 228,102 NA Male 100,053 44 2.2DEMOGRAPHIC INFORMATION Female 128,049 56 According to the Census 2011, total Household number 47,730 NA Source: Census 2011 population of Pyuthan district is 228,102. As shown in Table 2.1 the Caste/Ethnicity distribution proportion of female is greater by 12 Brahmin/Chhetri Gurung/ 82,121 39 percent points than male. Table 2.1 Magar 68,373 32 shows the caste/ethnicity distribution of Dalit 37,550 20 the population residing in Pyuthan Sanyasi 6,563 3 district. Four out of ten (39%) Newar 4,187 2 population of Pyuthan is Kumal 2,827 1 Brahmin/Chhetri and about one-third is Other 10,863 3 Gurung/Magar (32%). The proportion of Source: Census 2001 Dalit is 20%. There are few Sanyasi, Newal, Kumal and other caste groups in the district.

3 3. DHO STRUCTURE AND SYSTEMS

This chapter presents the findings related to the DHO structure and systems collected from the RA. The findings covers following areas: service delivery points, management system, health workforce, monitoring and evaluation system, IT and health information management and disaster management system.

3.1 SERVICE DELIVERY POINTS

The District Health Office, located in Bijuwa is the main Table 3.1: Number of service delivery points responsible institution of the MOHP at Pyuthan to provide Type of service delivery points Number preventive, promotive and curative health services to the 1. Government Hospital 1 people of Pyuthan. As a whole, there are 48 peripheral 2. PHCC 2 public health facilities (2 PHCCs, 18 HPs and 28 SHPs) 3. Health Post 18 4. Sub-health Post 28 and 15 bedded Pyuthan District Hospital. Out of 18 5. Private hospital 1 health posts, 11 are the ilaka health posts and rest of 6. Birthing centers 24 them are upgraded to HP from SHP. There are total 24 7. Functioning birthing centers 14 birthing center however, only 14 of them are functioning. 8. SBA trained 25 9. PHC Out-Reach Clinic 155 Likewise, there are 155 PHC/ORCs and 251 10. Immunization Clinic 251 Immunization Clinics. In this district there are ward- 11. FCHVs 441 based Female Community Health Volunteers (FCHVs), so, 12. IUCD service sites 7 the total number of FCHVS are 441. There is a private 13. Implant service sites 9 hospital, Sworgadwari Life Care Hospital in Source: DHO, Pyuthan VDC-1 which is about 4 km east from the DHO Pyuthan.

3.2 MANAGEMENT SYSTEMS

3.2.1 MEETINGS DHO Pyuthan holds different meeting every month which includes the Monthly meetings of the health facility incharge, Reproductive Health Coordination Committee (RHCC) and the Quality Assurance Working Group meeting. The monthly meeting of the Ilaka in-charge is organized on the 8th day of every month. In this district, RHCC meeting is organized quarterly and last meeting was held on February 28, 2013 (17-11-2069). Save the children as well as FHD are providing some fund for RHCC meeting in the district. Though the Quality Assurance Working Group (QWAG) under the Table 3.2: Program Management Team, DHO chairmanship of DHO has been formed it has not met DHO Team Status a. District Health Officer Filled since the last 18 months, after the phasing out of NFHP II b. Public Health Officer Filled* project. The meeting register of QWAG was also not c. Public Health Nurse Filled found during the RA. d. Statistics Assistant Filled e. FP focal person Filled f. Health Education Tech/ Officer Vacant 3.2.2 PROGRAM MANAGEMENT TEAM g. DTLA/Officer Filled The DHO Pyuthan has all the key positions at the office h. EPI Supervisor/Officer Filled filled-in at the time of RA except the Health Education i. Cold Chain Assistant Filled Technician position, which is a key person for IEC/BCC j. Computer Operator Filled* activities is vacant. Public Health Officer and Computer k. Store Keeper Filled l. Child Health focal person Filled Operator are temporarily recruited by DoHS and DHO n. Nutrition focal person Filled respectively. * Temporary Staff

4 3.3 HEALTH WORKFORCE Table 3.3 presents the current status of health workforce in the peripheral HFs of Pyuthan district. In both of the PHCCs, Medical Officer as well as Staff Nurse positions are filled-in. However, in Bhingri PHCC both Medical Officer and Staff Nurse are on study leave since Aswin, 2069 and Kartik, 2068 for 3 and 2 years, respectively. Out of total 24 sanctioned positions, 16 ANM positions are fulfilled permanently and 5 are temporarily by RHD, Surkhet. Additionally, one is deployed by national Planning Commission (NPC) and 21 by DHO Pyuthan on contract. Furthermore, there are few ANM staffs on birthing centers which are supported by VDC however; updated information is unavailable in DHO. There are total 20 HA/Sr. AHW position in peripheral HFs and 11 of them are fulfilled. Three positions are recruited temporarily and three positions are supported by NPC. On the other hand, out of total 50 sanctioned posts of AHW, 42 are fulfilled permanently and seven are supported by RHD and one is on contract. Twenty VHW and two MCHW are vacant where as 13 vaccinators are on contract by DHO. It is also found that 33% ANM, 45% HA/Sr. AHW and 16% AHW positions are vacant in Pyuthan. Table 3.3: Current status of health workforce at peripheral HFs Type of human resources Number GoN Number supported from Sanctioned Filled-in Tem VDC NPC Contract a. Medical Officer 2 2* 0 0 0 0 b. Staff Nurse 2 2* 0 0 0 1 c. ANM 24 16 5 0 1 21 d. HA/Sr. AHW 20 11 3 0 3 0 e. AHW 50 42 7 0 0 1 f. VHW 49 29 0 0 0 0 g. MCHW 35 33 0 0 0 0 h. Lab Assistant 2 1 0 0 0 0 i. Vaccinator 0 0 0 0 0 13 j. Store Keeper 0 2** 0 0 0 0 k. Office Assistant 26 45** 0 0 0 0 Source: Section Officer, DHO Pyuthan * One is on Study Leave ** On “Fazil” Position

3.4 MONITORING AND SUPERVISION DHO Pyuthan has its own Monitoring and Supervision System where DHO monitors peripheral HFs according to the Monitoring and Supervision Plan that is developed every FY. However, there is no Monitoring and Supervision system in place at DHO to supervise from ilaka level to SHPs. Due to the inadequate allocation of budget from the center level and participation at different programs in district as well as in regional and central level, DHO/PHO/ district supervisors can't follow that plan exactly. According to Statistical Assistant they sometimes use integrated monitoring and supervision tools. Supervisors prefers to supervise selected program (their own program) rather than on integrated way. There is no regular feedback mechanism. Discussions among the staffs in DHO after coming back from supervision need to be focused. However, DHO sends the copy of decision to all peripheral HFs which is made after the quarterly and yearly review meetings at district level. 3.5 INFORMATION TECHNOLOGY The RA also tried to explore the existing Information Technology (IT) infrastructure at DHO. At present the DHO has eight computers as well as five laptops and four printers. Three district supervisors are skilled in using MS word and Excel. Although there is no IT related intervention,

5 DHO has a well-established, good and enough internet facility. Moreover, four peripheral HFs has computers. 3.6 HEALTH INFORMATION MANAGEMENT DHO Pyuthan has a system to enter Health Facility level data in HMIS software. HF level data is available for the last three years. Recently the Statistics Assistant received two days training on web-based HMIS reporting. In addition, Pyuthan is one of the ten districts where Social inclusion reporting was initiated from 2011. However, there is no initiation taken in analyzing the data and assessing the disparities of health service accessibility and utilization by different ethnic groups, since this reporting system was introduced in the district. DHO does not have any plan of strengthening this system in the near future. For improving data quality, DHO has planned to organize an event of Data validation program in Jestha month in this FY (2069/70).

3.7 NATURAL DISASTER RESPONSE MECHANISM Being the member of District Disaster Relief Committee (DDRC), chaired by Chief District Officer (CDO) DHO Pyuthan is playing active role as assigned in the area of disaster focusing on health. Furthermore, DHO has its own Rapid Response Team (RRT) at the district level which is actively mobilized if there is any out breaks and epidemics. In addition, there is Community Rapid Response Team (CRRT) at the ilaka level in 9 ilakas which has members from ilaka level of agriculture, veterinary, forestry, school, post office, and so on and is led by the ilaka health post In-charge. Last meeting of each CRRT was held in last FY and due to lack of budget in this topic there is no plan to hold meeting in this FY. If there is any outbreak or epidemic, at first, CRRT is mobilized and if the condition is out of their control RRT at the district level is mobilized. Likewise, if the district level RRT is also unable to control the situation then EDCD is summoned for further action.

STRENGTH AND OPPORTUNITIES The major strengths of the DHO structure and systems as reported by district supervisors are as following:  Regular RHCC meeting  Good and enough internet facility with web based reporting system (HMIS, LMIS, Social Inclusion)  Functional district and community level RRT The opportunities are as following:  Existence of different committees at district and community level (CFUG, DWUG, saving/ credit group, child clubs etc.)  Contribution of different EDPs in health sector in the district

KEY ISSUES AND CHALLENGES The major challenges and constraints faced by the DHO are as following:  Low retention of HWs at facilities of hard to reach areas and supervision from DHO is limited  23% positions are vacant and temporary/contract workforce are frequently turnover  Some birthing centers are yet to equip by trained HR and make functional  Integrated supervision using checklists and written feedback system yet to be practiced  Basic computer skill of all supervisors need to be enhanced  GESI and QAWG meeting are not regular  Accessibility of Long Acting Family Planning methods is low  Some PHC/ORC are not functional and not regular  Communication/information sharing system in district and peripheral level is not practiced as expected after visits

6 2. SERVICE STATISTICS

The RA also sought information on the service statistics of the following programs: Immunization, CB-IMCI, Safe Motherhood and Family Planning. HMIS data for the last four year period (2065/66 to 2068/69) were analyzed. The four years trend analyzed in selected indicators are presented in this section. Complete data for the FY 2069/70 is not available therefore, it is not presented here.

4.1 IMMUNIZATION Trend analysis of BCG, DPT3 and Measles for the four years period shows that except DPT 3 both the BCG and Measles coverage is decreasing after FY 2066/67. It was reported by the statistics officer that in the FY 2066/67, the HMIS section of the Management Division revised the targets resulted in declining of the targets. Therefore, the coverage of BCG, DPT and Measles had increased drastically since the FY and reached above 100 percent (Table 4.1).

4.2 CB-IMCI Pproportion of new diarrheal cases treated with ORS and zinc is fluctuating over the last five FYs. However, it is almost constant around 99% in last two FYs. Likewise percent of severe pneumonia among total new ARI cases and severe dehydration among total new diarrhea cases is declining throughout the four years, however; percent of severe Pneumonia among total new ARI cases is high in 2065/66, then after all the years it is less than national average. (See the below graph). It might be the impact of community based interventions and comparatively good with national average.

Percentage of Severe Dehydration Percentage of Severe Dehydration among new diarrhoeal Cases among new diarrhoeal Cases

4.3 SAFE MOTHERHOOD ANC 1st and 4th Visits as Percent of Expected Pregnancy ANC 1st visit as percentage of expected pregnancy is in decreasing trend over the last three FYs. In FY 2066/67, ANC 1St visit increased drastically than in the previous FY due to reduction in target of expected pregnancy. After that, it is continuously declining. There is huge gap between ANC 1st and 4th visit. Though ANC first was used by about 90 percent of the pregnant women, ANC 4th was used by about only half of it. Like the ANC 1st visit, ANC 4th visit is also in decreasing

7 trend over the last three FYs. Though the delivery conducted by SBAs (both home and institution) as percent of expected live birth is in increasing trend for the last five FYs, there is huge gap between the ANC 4th visit and SBA delivery as well. In the most recent year, the SBA assisted delivery was about 20% only. These data clearly indicate that there is programmatic lags in continuity of safe motherhood services.

4.4 FAMILY PLANNING Figure 4.4; CPR as percent of MWRA As shown in the in bar graph on CPR trend among MWRA (Figure 4.4), CPR increased from 2065/66 to 2066/67 from 39% to 44% and then after it declined gradually in the following two years. In the most recent year it was 39%. The major cause of declining on CPR is reported as spousal separation due to seasonal migration and lack of reporting Source: DoHS/DHO annual report from private service provider. Contribution of condom on total CPR is remarkably high for last 4 years and on the other hand contribution of long acting devices is extremely low among all other temporary methods. However, CPR of IUCD and Implant is increasing faintly in the last 3 FYs. Though there are 24 birthing centers and SBAs of those centers are skilled to insert IUCD, most of those centers are not providing IUCD service. There are only nine HFs providing the implant service. At present, 13 HWs are trained on implant insertion and UNFPA has planned to provide training for four additional HWs in 2013. These data suggest that there is urgent need to increase the accessibility of the long acting temporary devices in this district. Except the Merie Stopes Center, the FP service provided by the private sector is not included in the DHO as there is no system to collect the data from the private sector. DHO need to take action to increase regular reporting from the private service providers as well.

Table No. 4.1: Trend in service utilization in Pyuthan SN Indicators 2065/66 2066/67 2067/68 2068/69 1 BCG coverage 89.54 126.65 120.68 114.74 2 DPT3 coverage 85.04 111.02 119.42 110.94 3 Measles vaccination coverage 86.47 122.41 116.86 111.94 4 TT 2 coverage among pregnant women 69.89 64.14 57.53 42.71 5 Percent of postpartum mothers receiving Vitamin A within 52.20 70.34 51.64 58.48 6 weeks 6 Percent of pregnant mothers receiving iron tablets 67.64 101.04 87.89 82.20 7 Proportion of new pneumonia cases treated with 41.39 40.42 50.50 47.98 antibiotics 8 Percent of severe Pneumonia among new ARI cases 0.74 0.51 0.29 0.23 9 Proportion of new diarrheal cases treated with ORS and 74.22 70.53 99.04 99.15 Zinc (under 5 years children) 10 Percent of severe dehydration among new diarrhea cases 0.14 0.20 0.04 0.02 11 ANC 1st visit as percent of expected pregnancies 64.13 99.05 90.90 80.86 12 Four ANC visits among as percent of expected pregnancies 32.84 53.23 47.35 41.05 13 Delivery conducted by SBAs (both home and institutions) 7.32 13.98 14.96 19.97 as percent of expected live births 14 PNC First visit as percent of expected live births 43.50 57.77 44.73 35.74 15 Contraceptive prevalence rate (all methods) as percentage 39.37 44.08 42.20 38.96 of WRA Source: HMIS report

8 4.5 STRENGTH AND OPPORTUNITIES

1. BCG, DPT/Hib, Hep B coverage is optimum 2. Three VDCs- , Raspurkot and are in CAT IV i.e Low coverage and High dropout in Immunization program 3. Severity of ARI and diarrhea are declining and maintained below one percent throughout the four-year period as well as less than national average. 4. CB-NCP program will be implemented from FY 2069/70. 5. Increase in birthing centers and institutional delivery in the four-year period 6. DDC is supporting to build birthing center building in HFs 7. VDCs are hiring ANMs locally for providing services 24 hour in birthing centers 8. Birthing centers are increasing and can integrate with long acting family planning methods 9. Private sector is also involved in providing FP service 10. UNFPA is going to support for LAFP method through satellite clinics in coming fiscal year

4.6 KEY ISSUES AND CHALLENGES

11. Refrigerators are not sufficient for maintaining cold chain 12. Use of antibiotic is high with respect to severe/pneumonia cases 13. Health workers (15) and community volunteers (27) yet to be trained on CB IMCI who are newly recruited 14. CB-IMCI logistics supply yet to be maintained (lack of re-supply of job aids) 15. CB-IMCI supportive supervision from district yet to increase 16. Still 14 birthing centers out of 24 have no delivery cases in some months 17. Nursing staff of the birthing centers needs SBA training 18. Delivery bed and other equipment are yet to be managed in birthing centers 19. Delivery coverage is too low with respect to national coverage and need to raise awareness and equip birthing centers for quality service 20. Provide TA to private sector to record FP services and report to HF and DHO regularly 21. Quality service in public and private sector is yet to be ensured 22. Comprehensive information to all clients on all FP methods yet to be ensured

9 5. HEALTH FACILITY MANAGEMENT COMMITTEE AND LOCAL HEALTH GOVERNANCE

Information on Health Facility Operation and Management Committee was sought from both DHO and DDC. Both quantitative and qualitative methods were used to collect information. Information was collected on the following topics: HFOMC functionality, capacity building, presence of different community-based groups at VDC level and their federations at district level. This chapter presents the major findings of the assessment on HFOMC.

5.1 FUNCTIONING HFOMC

In Pyuthan, though the HFs (PHCCs, HPs and SHPs) are not handed over to the local bodies (not the full devolution district), NFHP II and DHO had provided support to strengthen the capacity of HFOMCs through training, refresher training and review meetings as well as supportive visits.

During RA, the district supervisors were also asked some questions on criteria for measuring HFOMC functioning. Following were their opinions for measuring HFOMC functionality: Regular meeting, implementation of meeting decision, supervision of PHC/ORC and NIP (EPI) clinics, infrastructure management in PHC/ORC and NIP clinics, provision of incentive for FCHVs, generation and mobilization of local resources, recruting of health workforce locally.

The DHO supervisors also expressed that about 50% of the total HFOMCs of the district are functional. The top five functional HFOMCs as judged by the district supervisors include Bhingri, Sapdanda, Dharampani, Dharmawati and Puja. On the other hand, the bottom five S.N Top 5 Functional Bottom 5 Functional HFOMCs in terms of functionality are HFOMCs HFOMCs Rajbara, Kochibang, Arkha, Syaulibang 1 Bhingri Rajbara and Dangbang. These entire bottoms five 2 Sapdanda Kochibang HFOMC are from the most remote area of 3 Dharampani Arkha this district. According to HFOMC focal 4 Dharmawati Syaulibang person the participation of women, 5 Puja Dangbang Dalit/Janajati is ensured in committee Source: HFOMC focal person formation and in meetings.

5.2 CAPACITY BUILDING OF HFOMC

The HFOMCs of Pyuthan district has received capacity building training. The training was provided by DHO in support of NFHP II. NFHP II also provided refresher trainings to all HFOMCs. NFHP II district based staff used to visit HFOMCs to provide TA to HFOMCs.

Malla Rani Gramin Bikas Sarokar Kendra, one of the implementing partner of Save the Children’s Human Resource for Health (HRH) project is working with HFOMCs of five VDCs (Kochibang, Puja, Khalanga, Liwang, and Sworgadwari). They have oriented HFOMCs on HR security and availability. They strengthen HFOMC to manage HR locally. DHO and Malla Rani Gramin Bikas Sarokar Kendra organized the social auditing jointly with HFOMC in this year (2069/70). The aim of the project was; s to continue the supports initiated by DHO and DDC.

10 5.3 COMMUNITY GROUPS/FEDERATION According to the district supervisors, different type of community groups exists at VDC level of Pyuthan district. These groups include: community forestry user group, health mothers group, drinking water user group, irrigation user group, road rural user groups, co-operatives, child health clubs, agro-livestock group and media groups.

Moreover, at district level there are various federations like, community forestry user group, NGO federation, child club network and media network.

5.4 STRENGTH AND OPPORTUNITIES  Almost all HFOMC are formed as per to guideline (including Dalits, Janajatis and Women)  NFHP II, DHO and DDC have build capacity of HFOMCs through training, review meeting and workshop (3+2+1 days respectively)  HFOMCs have provided support in infrastructure management using local resources  UNFPA and other organizations are working in the district to provide support in health sector  Federations/networks of CFUG, NGO, Journalists etc. are existing at the district level

5.5 KEY ISSUES AND CHALLENGES

 According to focal person, regular meeting of HFOMCs are held in 50% HFs. Meaningful participation of all members including women/Dalit/Janajatis, listing of agenda, discussion and decision making in HFOMCs remain to be strengthened.  Some HFOMCs have not taken ownership of their local health facilities. They think that it is the responsibility of health workers only.  Joint visit from DHO, DDC and EDPs need to focus on poor performing HFOMCs.

11 6. SERVICE DELIVERY/QUALITY IMPROVEMENT

This chapter presents the RA findings related to service delivery and quality of care. Information on the quality of ANM schools, infection prevention practices at HFs, implementation of community- based interventions, and the provision of IUCD and Implants services were collected at district level. The major finding of the assessment is presented hereunder.

6.1 INFECTION PREVENTION AND WASTE MANAGEMENT PRACTICES AT HFS Few questions related to infection prevention and waste management practices followed at HFs were also asked to district supervisors during RA. It was found that different HFs practice different type of infection prevention and waste disposal practices. Eight birthing centers and BEONCs out of 27 have placenta pit and other birthing centers bury the placentas.

6.2 SERVICE DELIVERY Table 6.1: IUCD and Implants Insertion and Removal Sites of Pyuthan Birthing Birthing IUCD Implants The RA sought Center? Center? information on the 1. Pyuthan Yes 1. Pyuthan Hospital Yes availability of Satellite Hospital clinics, BEONCs, long 2. Bhingri PHC Yes 2. Bhingri PHC Yes acting FP methods, 3. Khalanga PHC Yes 3. Khalanga PHC Yes implementation of 4. Dharampani HP Yes 4. HP Yes community- based 5. HP Yes 5. Dharampani Yes interventions such as, CB 6. Puja HP Yes 6. Khabang HP Yes 7. Okharkot HP Yes 7. Okharkot Yes IMCI CB NCP, MSC, 8. Puja HP Yes Calcium, and other 9. Sworgadwari HP Yes intervention. Source: PHN /DHO There is no satellite clinic in this FY 2069/70 as FHD has cut down the budget in this title. However, UNFPA has planned to support satellite clinics in the coming FY. CEONC service is not available in the district. Programs such as MSC, IMAM and Calcium are not implemented in the district. All health workers are trained on Infant and young Child Feeding (IYCF). JSI/USAID is going to support in implementing CB-NCP program. First batch District Training of Trainers has been completed on May 2013. With regards to providing long acting reversible FP methods- IUCD and Implant services are being provided from seven and nine service sites respectively (Table 6.1). Fourteen out of 24 birthing centers are functional (conducts at least one delivery in per month).

6.3 STRENGTH AND OPPORTUNITIES  CB-NCP program is recently implemented in Pyuthan and at present trainings are going on  UNFPA is supporting in FP program  Private sector are providing FP services (injectable and condom )  DDC /VDCs have provided support to expansion birthing center

6.4 KEY ISSUES AND CHALLENGES  IUCD and Implant service site and satellite clinic expansion  FP services provided by the private sectors are not regularly reported  All birthing centers to be equipped with adequate, infrastructure, equipment and trained HR.

12 7. LOGISTICS MANAGEMENT SYSTEM

Logistics management is an important part of district health systems. Efficient logistics management is required to smoothly run all the public health programs at district, sub-district and the VDC levels. The RA also sought information from DHO on the logistics management system. The major findings of the assessment are presented below.

7.1 AVAILABILITY OF KEY DRUGS AND COMMODITIES

During RA, the DHO store room was also visited and the store keeper was interviewed. The availability of ten tracer drugs/commodities (Injectable, Oral Contraceptive, Condom, ORS, Vitamin A, Iron Folate Tablets, Cotrim (Ped), Oxytocin, MgSo4 and Zinc) in the district store at the time of visit was checked. It was found that all of the above mentioned drugs were available. The store keeper was also asked whether these drugs/commodities were out of stock anytime in the last 12 months, and it was found that none of them were stock out in last one year. Furthermore, the RA team members also checked the expiry dates of the ten drugs/commodities and it was found that none of them had expired dates. Refert to Table 7.1.

Table 7.1: Availability of key drugs/commodities and their expiry dates SN Drugs/Commodities Availability at the Stock out in the Expired drugs in stock time of visit last 12 months at the time of visit 1 Injectable Contraceptive Y N N 2 Oral contraceptive Y N N 3 Condom Y N N 4 ORS Y N N 5 Vitamin A Y N N 6 Iron Folate Tablets Y N N 7 Cotrimoxazole (Ped) Y N N 8 Zinc Y N N 9 Oxytocin Y N N 10 MgSo4 Y N N Source: Storekeeper/observation of store

The Store keeper was also asked to list the drugs that have most problems with stock outs in the FY 2069/70. According to him, Ibuprofen and Ranitidine tablet had most problems with stock outs in the year. On the other hand, condom, magnesium sulfate, vitamin B complex, albendazole, antacid tablets and metronidazole syrup had most problems with over stock in the year.

7.2 COLD CHAIN AND FEFO MANAGEMENT

DHO Pyuthan has six refrigerators in store however, only four of those are functioning and only one is total power guaranteed. The available refrigerators are not sufficient to DHO for maintaining cold chain. Oxytocin injection was stored at room temperature on rack in the store room.

The management of ten drugs in the store was checked to see whether First Expiry First Out (FEFO) was maintained or not. On checking the 10 drugs, RA team found that FEFO was maintained for all of these items.

13 7.3 LMIS REPORTING

DHO is using web-based LMIS entry and reporting. At present, DHO has no data entry person for entering the LMIS data.

7.4 STRENGTH AND OPPORTUNITIES

 Timely reporting of LMIS from peripheral level to district and district to region and center  Availability of essential drugs throughout the year  Drugs are purchased at local level by few HFOMCs

7.5 KEY ISSUES AND CHALLENGES

 Drug transportation in rainy season in remote VDCs is challenging  Delayed and push system of drug supply by the higher level  All free health drugs/commodities item are not adequate for providing services throughout the year

14 8. BEHAVIOR CHANGE COMMUNICATION

H4L aims to understand legal, cultural/religious, and policy dimensions of GESI inequities on health service access and use and design interventions to ensure sustainable, high-quality BCC and IEC approaches that respond to local realities, and include groups not commonly targeted, but crucial to meeting Nepal’s health goals by mobilizing local partners.

One of the objectives of the RA was to explore the range of BCC interventions that is being implemented for healthy behaviors. Following are the major findings on BCC:

8.1 EXISTING DHO PROGRAMS ON BCC

DHO Pyuthan is implementing BCC program activities as per the yearly plan provided by DoHS/ National Health Education Information and Communication Center (NHEICC), some of which includes production and distribution of IEC materials, massages broadcasting through local FM radio, school health program, orientation to teachers, journalists, traditional healers etc.

8.2 FM STATIONS/CABLE TELEVISION NETWORKS

In Pyuthan there are three FM stations. Following are the name and address of the FM stations:  Radio Mandabi, Khalanga  Radio Lisne Awaj, Bijuwar  Radio Pyuthan, Khalanga

DHO Pyuthan has partnered with all three FM stations for airing radio health programs and Public Service Announcements (PSAs) on different campaigns like, NID, and MDA. Information on NIP/EPI is aired regularly from local FMs.

There are four Cable TV networks in Pyuthan out of which three have been broadcasting district- based programs. Only advertisement and news are delivered on health for specific campaigns. No specific health program are produced and delivered. These cable Televisions are delivering news, songs and films.

8.3ORGANIZATIONS WORKING IN IEC/BCC ACTIVITIES

In Pyuthan district; WCO, UNFPA, KIDS, Kalika Bikas Kendra/Save the Children and Malla Rani Gramin Bikas Sarokar Kendra are working on IEC/BCC.

H4L plans to use mobile phones to reach target groups with messages on health in selected district. The RA also explored whether any organization has used mobile phones to communicate health messages to target groups or entire district population together with DHO. It was found that there is no organization doing this type of program.

One area of intervention of H4L is to improve the quality of counseling provided by health workers and community-based health workers to clients. It is therefore essential to find out whether there is pool of resources available at district level to improve counseling services. Hence, RA also collected information on the district health staff who received training on COFP/C in the last three years. It

15 was found that nobody has taken such type of training within the last three year period in this district.

8.4 SCHOOL HEALTH PROGRAM

Conducting health education classes at schools is one of the activities of DHO. According to health education focal person, there is no school health program in this FY. However, school health program on HIV/AIDS and TB/Leprosy was conducted through the HIV/AIDS and TB/Leprosy program. Last year all together 130 sessions were conducted in 58 Middle/High/Higher secondary schools. A total of 3,774 school students participated in these session. The major content of school health program were RH, SM, FP, Immunization, Nutrition, Communicable disease, TB/Leprosy, Personal Hygiene and Environmental Sanitation, STI/HIV/AIDS, Essential Health Care etc.

There is no Health Education Technician position full-filled in Pyuthan. Mr. Siddimani Suvedi (PHO) is looking after the Health Education Program. According to the health education focal person, beside the school health education program, peer education and joint discussion among health worker, teacher and students on the regular basis will be effective in reaching adolescents with health messages. Adolescent Friendly Services are also popular among youths.

No IEC/BCC activities were implemented for M/DAG to increase access to service in the last year (2068/69)

8.5 MAPPING OF DAG AND EXPLORING CULTURAL PRACTICES AFFECTING HEALTH

During the RA, in-depth information on DAG communities residing in Pyuthan district was also collected. DHO has not mapped the DAG but DDC has mapped. The supervisor looking after the Health Education program was interviewed for this. The major findings of this assessment are as following:

Villages that were highly populated by DAG:

Following VDCs are highly populated by DAG: 1. Damri, 2. Kochibang, 3. Syaulibang, 4. Dangbang, and 5. Liwang

Ethnic/Caste group deprived from service utilization:

According to the district supervisors, Dalits are deprived from the service utilization. However, analysis of the social inclusion reporting data showed that the upper caste groups are utilizing less FP, immunization, and safe motherhood health services.

Villages that Still Practice Early Marriage and Early Child Bearing:

Bhingri, Gothibang, Maranthana, Sari are the VDCs where early marriage and early child bearing is more prevalent in Pyuthan district. Early marriage seems more prevalent among

16 Brahmin/ and Janjatis. Kalika Bikas Kendra with the help of Save the Children is doing survey to explore the magnitude of early Marriage in Pyuthan.

Migration Pattern:

In Pyuthan high out-migration is reported from the East and Southern part of district. This covers following VDCs: Baraula, Dangbang, Dhungegadhi, Hanspur, Raspurkot, and Udaypurkot (Dhovaghat).

8.6 STRENGTH AND OPPORTUNITIES

 Good co-ordination with FM stations and airing of health messages  Partners working on IEC/BCC like Kalika Bikas Kendra, KIDS, Malla Rani Gramin Bikas Sarokar Kendra, WCO, UNFPA  Kalika Bikas partner of Save the Children is working on reducing early marriage  Centrally produced and supplied BCC materials are used at periphery level  Three FM radios and four local TV cable are available  Adolescent Friendly Services are running in 26 HFs/VDCs and Save the Children is going to support in 15 more HFs/VDCs  DHO is distributing IEC/BCC materials which are supplied from center

8.7 KEY ISSUES AND CHALLENGES

 Increasing the accessibility of remote areas to health service  Reduction of early marriage and early pregnancy/child birth  Behavior change among the groups who have strong traditional and cultural beliefs  Local level BCC materials to be developed and distributed

17 9. ADOLESCENTS AND YOUTH FRIENDLY SERVICES

H4L will also work with DHOs in selected districts to improve service accessibility of Adolescents and youths under its Objective 6. The RA also explored different aspects of Adolescents and Youth friendly services in the public health facilities of Pyuthan district. Following are the major findings:

9.1 EXISTING SERVICES FOR ADOLESCENT

In Pyuthan, Kalika Bikas Kendra in support of Save the Children and UNFPA has supported to establish the adolescent and youth friendly services corner at HF level. At present, a total 26 HFs has Adolescent Friendly Services (AFS); 13 HFs are supported by UNFPA (Bijuwar, Khalanga, Baraula, Dhubang, Dharmawati, Torbang, Okharkot, Sotre, Raspurkot, Khaira, Pakala, Hanspur, ) and remaining 13 (Bhingri, Swargadwari, Gothibang, Devisthan, , Markabang, Sapdanda, Dhakhaquadi, , Jumrikada, Khabang, Damri, Maranthana) are supported by Save the Children. There is a plan to introduce AFS in 15 more HFs in 2013. Three HWs from each HF have taken two days training on AFS recently. It is found that reporting of AFS from HF to district is weak. Out of the 26 AFS functioning, only 13 are sending reports in the last 3 months.

9.2 ORGANIZATION WORKING FOR ADOLESCENT

Kalika Bikas Kendra/Save the Children: Kalika has been working in AFS. They are forming married adolescent peer group where they share their experiences regarding family planning, early marriage and early pregnancy. They facilitate to participate youths in Quality Improvement team formed at HFs. Kalika is going to conduct a survey on early marriage very soon.

Kapilbastu Integrated Development Service (KIDS): KIDS is providing peer education on HIV/AIDS and STI. KIDS has got grant from the global fund for implementing this program. It has covered 36 out of 49 VDCs of Pyuthan district.

UNFPA: UNFPA has supported DHO to implement AFS in 13 HFs. HFs are trying to provide AFS service from separate room.

9.3 STRENGTH AND OPPORTUNITIES

 Soon 41 out of 49 VDCs will be providing AFS. Fifteen are in process for providing the services  Organizations such as WCO, Kalika Bikas Kendra, and UNFPA are working on adolescents health  Three FMs and four local TV cable networks are available in district

9.4 KEY ISSUES AND CHALLENGES

 Only 13 out of 26 AFS centers are reporting. Reporting from all HFs is important.  ASF service yet to scale up in all peripheral HFs of the district  Adolescent groups hesitate to share their problem; therefore, it is necessary to provide adolescent friendly service to change the behavior.

18 10. GENDER EQUALITY AND SOCIAL INCLUSION

H4L is designed to support the Government of Nepal’s stated commitment and responsibility to ensure that quality health services are accessible to all citizens. As such, it is critically important that sound, ongoing GESI-sensitive analysis and gender integration underpin H4L program interventions. H4L’s GESI Objectives are designed to redress gender and social inequities, and dove-tail with the objectives set forth in the MOHP’s 2009 Health Sector Gender Equality and Social Inclusion Strategy as follows:  Objective 1: Support existing MOHP policies, strategies, plans and programs that create a favorable environment for integrating GESI in Nepal’s health sector;  Objective 2: Support MOHP’s efforts to enhance the capacity of service providers and ensure equitable access and use of health services by the poor, vulnerable and marginalized castes and ethnic groups; and  Objective 3: Improve health-seeking behavior of the poor, vulnerable and marginalized castes and ethnic groups in collaboration with local government partners, community-based organizations (CBOs) and other stakeholders.

The first objective is related to policy while the latter two are directly related to DHO systems.

The RA also included assessment and analysis of the health programs of the DHO Pyuthan from GESI perspective. The major findings were as following:

10.1 FORMATION AND FUNCTIONALITY OF GESI COMMITTEE

(PHI) is responsible for looking after Child Health, Health Education and GESI. GESI committee was formed on 30-01-2013. The committee has 20 members among them 14 are male and six are female and two are from M/DAG. The committee has received orientation on GESI from GESI specialist of NHSSP.

Even GESI focal person and DHO of the DHO Pyuthan have not taken the GESI TOT. GESI focal person is not familiar with GESI and don't know how it should be implemented and what are the agendas for meeting. According to GESI focal person there is no budget even for the refreshment for the GESI meeting. Therefore, till to date GESI working committee has not met and is non- functional. One-Stop Crisis center has not established till now in this district.

10.2 ORGANIZATIONS WORKING ON GESI

Two government organizations (DDC and WCO) are working on GESI. RA team visited these organizations during information collection process. Interaction with the DDC staff revealed that DDC has formed a GESI committee under the chairmanship of LDO. Different organizations in Pyuthan- both government and non-governmental have identified a focal person for GESI. DDC has developed a list of these focal persons. DDC has organized GESI orientation to committee member, focal persons, VDC secretary and social mobilizers.

Women and Child Office has formed GESI network among cooperative groups run by WCO. WCO has organized interaction program on GESI. GESI was integrated in all WCO program activities. WCO has organized Girl Adolescent Development Program.

19 WCO has funds for Gender-Based Violence (GBV). GBV links with Paralegal and Paralegal advocates for the GBV. DDC has updated the name of focal person of other organizations who have selected GESI focal person. There are no other activities accomplished except selecting focal person by other organizations. No any other GESI related intervention/activities are planned and implemented below district level.

10.3 ANALYSIS OF SERVICE UTILIZATION BY CASTE/ETHNICITY

Pyuthan has social inclusion reporting system where service Caste Wise Population Vs Service Utilization on utilization for selected programs is Proportio disaggregated by caste/ethnicity. The adjoining figure shows the proportion of population as well as portion of service utilization among three major castes of Pyuthan district. Surprisingly, Dalits have utilized selected services (FP new acceptor, ANC 1st visit, SBA delivery, Full Immunization of under one year children)most than their proportion in the population in the district than the Janajatis and the Upper caste groups.

(Source: HMIS/SI report)

*****************

20 Annexes

Annex 1: Contact information of DHO Staff Years of Years of service Name Position Cell Phone no. service in district District Health Officer 1

Public Health Officer 4 Months 4 Months Public Health Nurse 27 22 Statistics Assistant 10 7 FP focal person 32 10 DTLO 19 5 EPI Officer 24 18 Cold Chain Assistant 19 16 Computer Operator 3 3 Store Keeper 16 3 Child Health / Health Education 27 21 and GESI focal person Section Officer 15 4

Annex 2: List of RHCC Members SN Name of the organization/ Organization Focused area (technical) of Remarks type intervention 1 District Development Committee 2 District Education Office Education 3 Women and Child Office Women and Child 4 Kalika Bikas Kendra Adolescents Health, 5 Marie Stopes Center Family Planning/ Safe Abortion 6 Tikuri Sakriya Yuba Club RH, Social mobilzation 7 Sworgadwari Life Care Hospital Clinical, FP/SM 8 Nepal Red Cross Society, Pyuthan Disaster, Rescue 9 Kapilvastu Integrated Development Services HIV/AIDS, Adolescent 10 UNFPA RH, Population 11 DHO

21 Annex: 3 List of persons met during RA visit SN Name of individual visited Position Office/Organization 1 CDO District Administration Office 2 LDO District Development Committee 3 DHO District Health Office 4 PO/Social welfare District Development Committee 5 PO /PPME District Development Committee 6 WCO Women and Child Office 7 PM Malla Rani Gramin Bikash Sarokar Kendra 8 PHO District Health Office 9 PHO HFOMC/QI Focal person /District Health Office 10 PHO CH/GESI/HET Focal person/District Health Office 11 Stat. Assistant District Health Office 12 FPSO District Health Office 13 PHN District Health Office 14 Cold Chain Offer District Health Office 15 EPISO District Health Office 16 Store keeper District Health Office 17 DACC coordinator District Health Office 18 ED Kalika Bikas Kendra 19 DO UNFPA 20 PO Kalika Bikas Kendra 21 Chairman Red Cross Society 22 GM Sworgadwari Life Care Hospital 23 ANM Meri e Stops

22 HEALTH FOR LIFE

REPORT ON

RAPID ASSESSMENT

OF DISTRICT HEALTH S YSTEMS 2013 ROLPA

1 A REPORT ONRAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013, PYUTHAN A REPORT ON

RAPID ASSESSMENT

OF DISTRICT HEALTH SYSTEMS 2013

ROLPA

MAY 2013

TEAM MEMBERS

2 TABLE OF CONTENTS

1. ABBREVIATION…………………………………………………………………………………………4

2. KEY FINDINGS FROM RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS..…………….6

3. RAPID ASSESSMENT………………………………………………………………………………..… 8

4. INTRODUCTION OF DISTRICT………………………………………………………………………10

5. DHO STRUCTURE AND SYSTEMS ……………………………………………………………...…12

6. SERVICE STATISTICS ……………………………………………………………………………...…15

7. HEALTH FACILITY MANAGEMENT COMMITTEE AND LOCAL HEALTH GOVERNANCE .19

8. SERVICE DELIVERY/QUALITY IMPROVEMENT …………………………………………………21

9. LOGISTICS MANAGEMENT SYSTEM ……………………………………………………………….23

10. BEHAVIOR CHANGE COMMUNICATION ………………………………………………………….25

11. ADOLESCENTS AND YOUTH FRIENDLY SERVICES … ………………………………………….28

12. GENDER EQUALITY AND SOCIAL INCLUSION …………………………………………………..29

13. ANNEXES………………………………………………………………………………………………..31

Annexes Annex: 1 Contact information of DHO Program focal person………………….31 Annex: 2 List of RHCC Members ……………………………………………………………31 Annex: 3 List of persons met during RA visit………………………………………….32

3 ABBREVIATIONS

ADRA Adventist Development and Relief Agency AFYS Adolescents and Youth Friendly Services AHW Auxiliary Health Worker ANC Antenatal Care ANM Auxiliary Nurse Mid-wife ASF Adolescent Friendly Services BC birthing Center BCC Behavior Change Communication BCG Bacillus Calmatte Gurine BEONC Basic Emergency Obstetric Neonatal Care CB-IMCI Community-Based Integrated Management of Childhood Illness CB-NCP Community-Based Newborn Care Package CEONC Comprehensive Emergency Obstetric and Neonatal Care CNC Chlorhexidine Navi Care CPR Contraceptive Prevalence Rate CRRT Community Rapid Response Team DDC District Development Committee DDRT District Disaster Response Team DHO District Health Office DPT DiptheriaPertusis Tetanus DTOT District Training of Trainers EC European Commission EPI Expanded Program for Immunization FCHV Female Community Health Volunteer FM Frequency Modulation FMC Facility Management Committee FP Family Planning FY Fiscal Year GESI Gender Equality and Social Inclusion H4L Health for Life HA Health Assistant HF Health Facility HMIS Health Management Information System HP Health Post HRH Human Resource for Health IP Infection Prevention IT Information Technology IUCD Intra Uterine Contraceptive Devices IYCF Infant Young Children Feeding LDO Local Development Officer LMIS Logistics Management Information System M/DAG Marginalized/Disadvantaged Group MG Mother Group MNCHN Maternal Neonatal Child Health and Nutrition MO Medical Officer MSC Matri Surakshya Chakki MWDR Mid-western Development Region N Number NFHP Nepal Family Health Program NIP National Immunization Program

4 NRCS Nepal Red Cross Society PHC/ORC Primary Health Care/Out Reach Clinic PHCC Primary Health Care Center PHN Public Health Nurse PHO Public Health Officer PNC Post Natal Care QAWG Quality Assurance Working Group QI Quality Improvement RA Rapid Assessment RHCC Reproductive Health Coordination Committee RRT Rapid Response Team SBA Skilled Birth Attendant SHP Sub Health Post SMN Safe Motherhood Network TV Television UNFPA United Nations Population Fund USAID Unites States Agency for International Development VDC Village Development Committee WCO Women and Child Office WDR Western Development Region

5 KEY FINDINGS FROM RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS

TOTAL POPULATION 224,506 NUMBER OF VDCS 51 DHO STRUCTURE AND Public Health facilities: SYSTEMS  District Hospital-1, PHCCs-2, HPs -15 and SHPs-34  Ayurved Aushadhalaya-2 (Liwang and ) Private Health facilities:  Private hospital-2 Meetings:  IlakaIncharge Monthly meeting at District- No meetings for three years  QAWG- No meeting held for the last one year  RHCC- Meets quarterly Health Workforce:  Most of technical positions at DHO are filled except PHN, EPI supervisor, HET, Computer Technician and FP focal person  Unfilled positions at HFs–MO, SN, ANM, AHW and Lab assistant- 85 (43%) .  HA, SN, AHW, ANM and few Vaccinators are hired on contract basis by RHD, DHO, VDC etc. Eight health workers hired from NPC. Monitoring and Supervision:  Monitoring & Supervision system only exist from district level to HF , but no supervision plan. District supervisors use integrated supervision sometimes only. IT infrastructure at D/PHO:  Desktops-13, Laptops-5, Printers-12  No functional internet, however DHO is trying to establish WYMAX.  No peripheral HFs has computers.  Six District Supervisors have skilled in using MS Word and Excel  VDC wise data entry system exists, but there is no online HMIS entry and reporting system. Rapid Response Team:  Well-functioning at the district and HF level SERVICE STATISTICS  BCG coverage is fluctuated but maintained above in 100%. In the year 2068/69 BCG coverage is 102% and measles coverage is 98 percent.  Percent of Severe pneumonia and Severe dehydration is in fluctuating trend but maintained on below 1%. More children are being treated with antibiotics with respect to Sev/Pneumonia cases. (proportion of sev/Pneumonia and treated with antibiotic is 35% and 53% respectively in 2068/69.  Drop out from ANC first to ANC fourth visits is high and in the FY 2068/69 it was 59 percent and 38 percent respectively.  SBA deliveries are in increasing trend (6 percent in FY 2065/66 to 26 percent in FY 2068/69)  Contraceptive Prevalence Rate (CPR) is also in increasing trend (24 percent in FY 2065/66 to 38 percent in FY 2068/69). HEALTH FACILITY  HFs are not handed over to local bodies. MANAGEMENT  About 35% HFOMCs are functional. COMMITTEE AND  HFOMCs received capacity building trainings, refreshers and technical LOCAL HEALTH support by ADRA/EU Nepal implemented by Safe motherhood Network and

6 GOVERNANCE Vulnerable Community Program (VCP) for improved reproductive health in all VDCs and also training support and follow up visit after 2 years from NFHP II.  Community level groups such as -Forestry Users Group, Mothers’ Group andCooperativesare functional. SERVICE  District hospital and two PHCCs are providing BEONC services regularly. DELIVERY/QUALITY  CB-IMCI, MSC and Chlorhexidine Navi Care program is implemented IMPROVEMENT  Seven HFs provides LAFP methods from 17 satellite clinics  IUCD services in 7 HFs and Implants services in 15 HFs.  37 Birthing centers P  Placenta pits in 10 HFs. LOGISTICS  Most essential Key commodities and drugs are available on the day of visit. MANAGEMENT SYSTEM  Iron and Cotrim P was stock out in the last 12 months.  The drug with most problems of over stock in the last year was Aminophyline tablet.  There are 12 functioning refrigerators, sufficient for maintaining cold chain, and have regular power back up system for the cold chain room.  First Expiry First out (FEFO)- maintained well  No Web-based LMIS reporting system and no data entry person recruited. BEHAVIOR CHANGE  There are three FM stations in district. COMMUNICATION  No I/NGOs engaged in Health BCC activities  No school health program in current FY, no activities were planed and conducted for school health program in last year.

 Village Development Committees (VDCs) that are ranked as being highly concentrated by DAG/M by DDC: Gam, Uwa, Talabang, Pachhabang, , Hwama, Thabang and Jelbang (8).  Ethnic/Caste group deprived from service utilization-Dalits and Janajati,  Villages that still practice early marriage and Early Child Bearing- There are no specific VDCs where early marriage is practiced. All the VDCs and caste use to practice on early marriage so far. The proportion of early marriage is high among illiterate population.  High Migrants VDCs- All the VDCs have some somehow migrants seasonal for job especially in India and within country. ADOLESCENTS AND  AYFS- 13 HFs supported by UNFPA. YOUTH FRIENDLY  DHO conducted Peer education training to 10 schools in the current FY (two SERVICES student, one teacher and HFI of the respective school and HF).  WCO have female adolescent youth clubs to enhance life-skill trainings and give information on RH issues. GENDER EQUALITY  GESI focal person assigned, but GESI committee not formed. AND SOCIAL  GESI focal person assigned. INCLUSION  DDC and WCO have GESI related activities in Rolpa.  At DDC, GESI committee under the chairmanship of LDO was formed, which got orientation on GESI  Most of governmental and non-governmental offices have assigned GESI focal person. DDC has updated list of GESI focal persons of district level offices.

7 1. RAPID ASSESSMENT

1.1 HEALTH FOR LIFE

Health for Life (H4L) is a five-year bilateral agreement between the Ministry of Health and Population (MoHP) and the Unites States Agency for International Development (USAID), which focuses on Systems Strengthening and improving the Maternal Neonatal Child Health and Nutrition/Family Planning (MNCHN/FP) service delivery at district and sub-district levels in 14 districts. 12 of the 14 districts are in the Mid-western Development Region (MWDR) –Banke, Bardiya, Dang, Surkhet, Salyan, Pyuthan, Dailekh, Kalikot, Jumla, Rukum, Jajarkot and Rolpa and two are in the Western development Region (WDR) of Nepal- Arghakhanchi and Kapilbastu. The project will be implemented between 2012 and 2017.

1.2 RAPID ASSESSMENT AND ITS OBJECTIVES

Rapid assessment (RA) is a method of analyzing situation of a district where issues are not well defined and where there is not sufficient time or other resources for in-depth quantitative research. RA uses intensive team interaction in both the collection and analysis of data instead of prolonged fieldwork and iterative data analysis and additional data collection to quickly develop a preliminary understanding of a situation from the insider’s perspective. The main purpose of carrying out the Rapid Assessment was to understand the current situation of the health service delivery system of the Rolpa district so as to help in planning activities at district level.

Specifically, the objectives of the RA included the following:  Understanding the demographic profile of the district  Understanding the existing health care delivery system of the district  Knowing the functionality of the Health Facility Operation and Management Committees  Understanding the status of health indicators  Analyzing the strengths and weakness of the D/PHO systems  Exploring feasibility for the implementation of specific programs for adolescents and youth  Exploring feasibility of using Information Technology in information management

1.3 METHODOLOGY

An introduction meeting of H4L project was organized in DHO Rolpa. The main objective of the meeting was to introduce about the project and its objectives. Participants were from LDO, Program Officers (DDC), Acting DHO and all district supervisors, chief and representatives from government and non-government organizations, Journalists of different media (see participant list in annex 4)

Mixes of both qualitative and quantitative methods were used to execute Rapid Assessment in Rolpa district. These include visit to DHO, District Development Committee (DDC), WCO, and NGOs, interaction with key informants, record reviews and observations. A structured tool was used to collect necessary information, which was supplemented by qualitative tools to interview key informants at different agencies working on different areas of health service delivery and management, Gender Equality and Social Inclusion (GESI), Behavior Change Communication (BCC), Information Technology (IT) in Health and Governance.

8 A team composed of four H4L staff formed for carrying out RA in Rolpa where there was a good skill mix among the members to cover different areas of the RA Involvement of Central, Regional and District office staff was ensured.

Before carrying out of the RA in Rolpa, H4L staff got one and a half day orientation in Hotel Siddhartha, Nepalgunj on 23 and 24 day of April. Director and three senior officials from the Mid- western Regional Health Directorate, Surkhet participated the orientation. They provided inputs in further refining the RA tools.

H4L staff completed RA within ten days (May 12 to 21, 2013). Team members divided to visit in different office and stakeholders for establishing relationships, interactions and information collection. At the end of each day all the members gathered for and shared their experiences. Information collected by the team members verified on the same day and brief notes developed for each thematic area. Report was prepared using the template provided by the H4L central office. A brief power point presentation was also prepared covering the key findings of the RA and shared with DHO, DDC on May 16, 2013.

The interaction processes and the information collection the RA confined only in district-based offices. The RA team did not make field visit to below district level institutions for information collection because of most information including the sub-district level that the RA required were availability at the district offices. It was not mandatory to collect data from peripheral health facilities, interaction with HFOMCs and FCHVs. It was the major limitation of the RA.

1.4 ORGANIZATION OF THE REPORT

RA findings are organized in this report in nine Chapters. Chapter one presents the purpose of carrying out RA and the methodology followed. Chapter two presents the introduction of Rolpa district. Chapter three explains the DHO systems and structures. Fourth and the Fifth chapter present the service statistics and the status of the HFOMCs in Rolpa district. Sixth and the Seventh chapter present the findings on service delivery/quality of care and logistics management system. BCC, AYFS and GESI findings are mentioned in Chapter Eight, Nine and Ten in this report.

9 2. INTRODUCTION OF DISTRICT

2.1 GEO-POLITICAL SITUATION

Rolpa District is situated in Rapti Zone, in the Mid-Western Development Region of Nepal. Liwang is the district headquarter. Rolpa covers an area of 1,879 square km. Rolpa is bordered on the West by Salyan, North by Rukum, South by Dang and East by Pyuthan and Baglung districts. There are 51 Village Development Committees (VDCs) in Rolpa.

2.2DEMOGRAPHIC INFORMATION Table 2.1: Population of Rolpa District Number Percent Table 2.1 presents the total population of Total Population 224,506 - Rolpa district, which are 224,506. The Male 103,100 46 proportion of female is higher than that of Female 121,406 54 male. The district has 43,757 households. Household number 43,757 - Source: Census 2011 The District Population Profile of Rolpa Cast/ethnicity distribution 2012 shows that about one-half of the Chhetri 36 population of Rolpa belongs to Janajati Brahman 1 and 36 percent are Chhetri. Twelve Janajati 49 percent of the population are Dalits and Thakuri 1 one percent each are Thakuri and Dalit 12 Brahmin. Source: District Population profile (DHO) 2012

10 3. DHO STRUCTURE AND SYSTEMS

This chapter presents the findings related to the DHO structure and systems collected during the RA. The findings cover following areas: service delivery points, management system, health workforce, monitoring and evaluation system, information technology and health information management and disaster management system.

3.1 SERVICE DELIVERY POINTS Table 3.1: Number of service delivery points The District Health Office, located in Type of service delivery points Number Reugha, Liwang is the main responsible Government District Hospital 01 institution of the MoHP at Rolpa to PHCC 02 provide preventive, promotive and Health Post 15 curative health services to the people of Sub-health Post 34 Rolpa. There are a total of 51 peripheral Private hospital/Nursing Home 02 health facilities (HFs) (2 PHCCs, 15 HPs BEONC 03 Birthing centers 23 and 34 SHPs) in Rolpa district. There are Functioning birthing centers 38 three BEONC and 37 birthing centers in SBA Sites 00 the district. Based of service statistics PHC Out-Reach Clinic 180 review, the safe motherhood focal person Immunization Clinic 215 reported that 38 out of 40 birthing centers FCHVs (VDCs) 459 (including 3 BEONC sites) are functional NGO clinics (SBA/BEOC/FP) 15 in Rolpa. Medical College 00 Private Hospital 02 There are 180 PHC/ORCs and 215 Source: DHO Rolpa, 2013 Immunization Clinics in the district. There are 459 Female Community Health Table 3.2: Current Status of Program Management Volunteers (FCHVs) in all VDCs of the Team district. There are two private hospitals DHO Team Status /nursing homes in Sulichaur VDC. 1. District Health Officer Filled 2. Public Health Officer Filled(temporary) 3.2 MANAGEMENT SYSTEMS 3. Public Health Nurse vacant 4. Statistics Assistant/Officer Filled 5. FP focal person (FPSO) Filled 3.2.1 PROGRAM MANAGEMENT TEAM 6. Health Education Tech/ Officer Vacant 7. DTLA/Officer Filled Table 3.2 shows the sanctioned positions 8. EPI Supervisor/Officer Vacant at DHO. There are 13 technical staff and 9. Cold Chain Assistant/ Officer Filled managers sanctioned at DHO, Rolpa, out 10. Store Keeper Filled of which four positions- Public Health 11. Child Health focal person Filled Nurse and EPI Supervisor, Health 12. Public health inspector Filled Education Officer, Lab technician and EPI 13.Lab technician Vacant supervisor are vacant. The position of 14. Account Assistant/officer Filled Public Health Officer is temporarily filled- 15. Admin Assistant/officer Filled in.

11 3.2.2 MEETINGS

According to SM focal Person Sarmila Pokhrel and Statistical Officer Bhim Chaudhary, DHO Rolpa holds different types of meeting every month such as Reproductive Health Coordination Committee (RHCC) meeting, Quality Assurance Working Group meeting, and ilaka incharge meeting at district. RHCC meeting is organizing on quarterly basis. (The list of RHCC members is provided in Annex 2). QAWG has been formed at district level but its meeting has not been conducted for a year. The monthly meeting of the Ilaka in-charge has not been organized since the last three years.

3.3 HEALTH WORKFORCE

Table 3.3 presents the current situation of health workforce in Rolpa district. According to , out of the two PHCCs one has Medical Officer position filled-in. Three Staff Nurse (SN)/Sr. ANM in two PHCCs were fulfilled during the time of RA. The sanctioned positions of 50 percent of the ANMs are filled-in at the time of RA.

RHD Surkhet and DHO, Rolpa have contracted and posted 30 ANMs, 14 AHWs and two SN in different HFs. National Planning Commission (NPC) has recruited two ANMs and one Lab Assistant in Rolpa district. In Rolpa, VDCs have hired 21 ANMs, five AHWs and two Lab Assistants for providing services in the peripheral HFs. However, the number of the health workers recruited by these agencies might have been over or under reported in this report as RA the team has not visited HFs to validate it.

Table 3.3: Current status of health workforce Type of human resources Number GoN Number supported from Sanctioned Filled- Temp Cont VDC NPC Other in orary ract a. Medical Officer 5 04 0 2 0 0 0 b. Public Health Officer 1 1 1 0 0 0 0 c. Staff Nurse/Sr. ANM 4 03 0 2** 0 0 0 d. Sr. ANM 0 0 0 0 0 0 0 e. ANM/Padnam Sr. ANM 22 11 7* 23** 21 2 0 f. HA/Sr. AHW 19 05 5* 5** 0 0 0 g. AHW 56 36 6* 8** 5 0 0 h. AHW (Previous MCHWs) 51 25 0 0 0 0 0 i. ANM (Previous VHWs) 34 36 0 0 0 0 0 j. Lab Assistant/Technician 04 02 0 3** 2 1 0 k. Adm. Assistant 03 03 0 0 0 0 0 l. Store Keeper 01 01 0 0 0 0 0 m. Office assistant 22 19 0 0 0 0 0 n. Vaccinator NA 00 0 20** 0 0 0 Source: DHO, Rolpa *From RHD ,* *From DHO,

3.4 MONITORING AND SUPERVISION

DHO Rolpa has not developed any Monitoring and Supervision plan. DHO supervisors make supervision to the peripheral HFs occasionally as per need. And there is no such monitoring and supervision plan developed for Ilaka level HFs to monitor SHPs. During visits to HFs, the district supervisor uses the integrated supervision tool. It was also found that the clinical staff also carries out clinical supervision in Rolpa district.

12 3.5 INFORMATION TECHNOLOGY

The RA also explored the existing Information Technology (IT) infrastructure at DHO. At present the DHO has 13 desktops, five laptops and 12 printers. But there is no internet facility and therefore web-based HMIS and LMIS reporting is hampered. It was reported that none of the peripheral HFs in Rolpa has computers. Six supervisors are skilled on using MS Word and Excel.

3.6 HEALTH INFORMATION MANAGEMENT PROVISION

DHO Rolpa has HF level data entry system in the HMIS software. But because of no internet access there is no online data entry system. DHO has recently managed internet system. It was found that DHO has been organizing Data Validation program every year for improving the data quality, particularly maintaining consistency between registers and reports.

3.7 NATURAL DISASTER RESPONSE MECHANISM

DHO Rolpa has a functioning Rapid Response Team (RRT) formed at the district and HF level. Along with the DHO various organizations like District Administration Office (DAO), District Development committee (DDC), Women and Children Office (WCO), Rural Reconstruction Nepal (RRN) etc. are working in close collaboration to respond to disaster when needed.

STRENGTH AND OPPORTUNITIES

During the discussion with DHO staff the following strength and opportunities of the DHO system were identified.

Strengths  Good coordination between hospital and PHO team.  Technically sound district supervisor's team and cohesion among the team members.  DDC/VDC are supporting on infrastructure and human resources for birthing center. Opportunities:  Existing RHCC committee and its regular meeting.  Rolpa is selected as pilot district for “Planning for district health program”  Existence of different partner organizations in the district (PSI, CRS, UNFPA, NSARC).  New nutrition program (KISAN/USAID) is being launch in Rolpa.

KEY ISSUES AND CHALLENGES

The major challenges and constraints faced by the DHO Rolpa are as following:  No QAWG meeting for one year and no district level Ilaka in-charge monthly meeting for three years  About 43 percent of the technical positions are vacant. Health workers on contract by RHD or DHO and locally hired workforce is providing services in many HFs. Staff turnover is a common problem newly recruited health workers are not trained. This is threatening quality service delivery.  Health services are not regularly provided in hard to reach VDCs (HFs).  There is no plan for integrated supervision and no regular feedback system to HFs.

13 4. SERVICE STATISTICS

The RA also sought information on the service statistics of the following programs: Immunization, Child health, Safe Motherhood and Family Planning. RA team collected the HMIS data of last five years from DHO and analyzed. Data for the years 2065/66 to 2068/69 are for complete reporting period. The FY 2069/70 is still ongoing during the time of RA, therefore data for this year has not been added in the trend analysis. Four year (2065/66 to 2068/69) trend analysis of selected indicators has been presented here.

4.1 IMMUNIZATION Figure 4.1: Trend in Measles coverage The trend in child immunization in Rolpa, especially BCG, DPT and Measles is very encouraging. Figure 4.1 compares Measles coverage of Rolpa with Nepal’s overall coverage. The coverage of Rolpa is higher than that of National statistics in all four years. In the last three years, the coverage is almost 100 percent. Drop out from BCG to Measles is also not much high. The achievements in child immunization found in Rolpa have to be maintained with continuous quality monitoring of the EPI program in the future.

4.2 CB- IMCI

The proportion of new pneumonia cases treated with antibiotic followed increasing trend upto the FY 2067/68 and then declined slightly in the following year (FY 2068/69) in Rolpa. In the most recent year it was 54 percent in Rolpa. The sever pneumonia cases was lowest in Rolpa in the FY 2067/68. The severe cases in Rolpa were always higher than that of Nepal’s aggregate but have been below one percent in the last three years. See Figure 4.2.

Table 4.1 presents data on new diarrhoeal cases treated with ORS and Zinc among under 5 years children in Nepal and in Rolpa. The achievements are maintained at above 95 percent in the last two FYs. The sever pneumonia dehydration cases was lowest in Rolpa in the FY 2067/68. The severe Figure 4.2: Percentage of Severe Figure 4.2: Percentage of Severe Dehydration among new diarrhoeal Cases Pneumonia among new ARI Cases

14 dehydration cases in Rolpa were always lower than that of Nepal’s aggregate and below one percent in all the FYs. See Figure 4.3.

4.3 SAFE MOTHERHOOD

Data on safe motherhood displayed in the Figure 4.4: ANC 1stst and ANCANC 44rtrt visitsvisits as as percent percent of of adjoining bar diagram shows that ANC expected pregnancypregnancy first visit as percent of expected pregnancy is in decreasing trend and was 69 percent in the most recent FY. Pregnant women dropping out from first ANC to the fourth is very high and was 38 percent in the most recent FY. The cover ages for ANC services reported here shows problems in service continuity which could have been determined by 2065/66 2068/69 various factors. It however, also points out to data quality. According to statistical officer, the main cause of decreasing ANC service utilization is because of improvements in recording and reporting. In the recent years, during data verification program has begun in Rolpa which checks over-reporting of data. The data of the most recent years have fewer data quality problems that the preceding years data.

Other information on safe motherhood is presented in Table 4.1. SBA attended deliveries are in increasing trend and in the most recent year a quarter of the expected pregnant women in Rolpa got assistance of SBA during delivery which was just six percent in 2065/66. However, utilization of PNC services has not improved much in Rolpa district.

4.4 FAMILY PLANNING

The graph shows that the CPR (all modern methods) as percentage of MWRA is Figure 4.5: Contraceptive Prevalence Rate as increasing over the time but has nearly percent of MWRA stagnated in the last two years in Rolpa. National CPR is has stagnated since 2065/66.

There are private service centers providing FP services which are yet to be incorporated in HMIS system in DHO. Regular reporting of the services provided from the private sector is essential in analyzing the actual CPR of the district.

15 Table no. 4.1: Trend in service utilization in Rolpa SN Indicators 2065/66 2066/67 2067/68 2068/69 1 BCG coverage 92.2 113.0 106.4 102.58 2 DPT 3 85.16 96.09 114.93 99.20 3 Measles vaccination coverage 85.32 107.78 105.16 98.3 4 TT 2& TT2+ coverage among pregnant women 65.12 52.32 51.69 32.67 5 Proportion of new pneumonia cases treated with 35.95 42.62 57.71 53.77 antibiotics 6 Percentage of severe pneumonia among new cases 1.33 0.80 0.52 0.75 7 Proportion of new diarrheal cases treated with ORS + 85.06 61.94 99.88 97.24 Zinc (under 5 years children) 8 Percentage of severe dehydration among new cases 0.41 0.33 0.09 0.16 9 ANC 1st visit as percent of expected pregnancies 54.05 85.34 79.18 58.64 10 Four ANC visits among as percent of expected 18.67 38.13 42.04 37.7 pregnancies 11 Percent of pregnant mothers receiving iron tablets 50.60 86.10 80.59 61.34

12 Delivery conducted by SBAs (both home and institutions) 5.99 14.21 19.87 25.96 as percent of expected live birth pregnancies 13 PNC First visit as percent of live birth 22.54 38.81 34.27 32.75 14 Percent of postpartum mothers receiving Vitamin A 27.92 44.71 42.84 44.68 within 6 weeks 15 Contraceptive prevalence rate (all methods) as 23.62 31.14 36.66 38.48 percentage of MWRA

4.5 STRENGTH AND OPPORTUNITIES  Severity of severe dehydration is declining and maintained below one percent throughout the four years as well as less than national average.  CB NCP program is going to start from this (2069/70) year.  Private sector is also involved on providing FP service  UNFPA is going to support for Long Acting Family Planning (LAFP) method through satellite clinics in coming fiscal year  Birthing centers are increasing and can integrate with long acting family planning methods  Institutional delivery are in increasing trend  DDC is supporting to build buildings for birthing center in HFs  VDCs are hiring ANMs locally for operating the birthing centers 24 hours.

4.6 KEY ISSUES AND CHALLENGES  Newly recruited health workers and community volunteers are yet to be trained on CB-IMCI  CB-IMCI logistics supply yet to be maintained (lack of resupply job aids)  CB-IMCI supportive supervision from district yet to increase  Severe Pneumonia yet to improve with compare to national average  Nursing staff in SBA yet to be trained in all birthing centers  Delivery bed and other equipment yet to managed in birthing centers  Delivery coverage is yet to low with respect to national coverage and need to raise awareness and equip birthing centers for quality service  Gap between ANC 1st and ANC 4th visit yet reduce  Provide TA to private sector to record FP services and report to HF and DHO regularly  Quality service in Public and private sector yet to ensure  A comprehensive information to all clients on all methods yet to ensure

16 5. HEALTH FACILITY MANAGEMENT COMMITTEE AND LOCAL HEALTH GOVERNANCE

Information on Health Facility Operation and Management Committee (HFOMC) was sought from both DHO and DDC. Both quantitative and qualitative methods were used for collecting information. Information was collected on the following topics: HFOMC functionality, capacity building, presence of different community-based groups at VDC level and their federations at district level. This chapter presents the major findings of the assessment on HFOMC.

5.1 HFOMC FUNCTIONALITY In Rolpa, HFs has not been handed over to the local bodies, i.e. VDCs. DHO chief and the program supervisors were asked to give their opinions on measuring the functionality of HFOMCs and most opined that the functionality of HFOMCs can be measured by their regular meetings, meeting minutes keeping practices, The top five functional HFOMCs: action plan developed during meeting, resource collection 1. Gairigaun SHP, and its use to implement activities planned, and the volume of 2. Korchabang SHP VDC budget used for in health. They also explained that the 3. Bhavang SHP HFOMCs that meet once in every month, i.e, conducts at least 4. Jinabang HP twelve meetings in a year, attendance of at least 51 percent 5. Ghodagaun HP members in the meetings, participation of Dalit and women with agenda/issues, and prepares action plan are the major The bottom five HFOMCs 1. Sirpa SHP indicators for measuring the effectiveness of HFOMC meeting. 2. Jelbang SHP It was also reported that DHO supervisors and EDPs staff 3. Fagam SHP used to ensure effective meeting during their field visit. 4. Liwang HP 5. Nerpa HP The DHO supervisors expressed that about 35 percent HFOMCs of the district are functional. The top five functional HFOMCs as judged by the district supervisors include- Gairigaun SHP, Korchabang, Bhavang SHP, Jinabang HP and Ghodagaun HP. The bottom five HFOMCs in terms of functionality are Sirpa, Jelbang, Fagam, Liwang and Nerpa. There is no reformation of HFOMCs within three year. The non-functionality of the HFOMCs as mentioned by district supervisors are - inability to meet regularly, unable to pull VDC budget and inability to ensure the quality of services provided from local HF. DDC/DHO and EDPs can jointly provide support to re-vitalize the non-functional HFOMCs through capacity building activities. Mr. Bhim Chaudhary, statistical officer is the focal person responsible for looking after HFOMC.

5.2 CAPACITY BUILDING OF HFOMC

All HFOMCs of Rolpa district have received capacity building training in the last three years period. Three days training was provided by DHO in support of NFHP II. In 2009; Safe Motherhood Network Federation (SMNF) (VDC)/ADRA/European Commission provided four days training to all 51 HFOMCs and later on NFHP II provided refresher training to them. In addition, NFHP II project staff used to visit HFOMCs for supporting their activities to enhance the capacity of the committee. Some HFOMCs are not formed as per HFOMC guideline, however focal person is unable to tell neither the exact number of such HFOMCs nor their names. This information can only be collected during visits to HFs.

17 5.3 COMMUNITY GROUPS/FEDERATION/ALLIANCE According to the district supervisors’ different type of community groups exists at VDC level in Rolpa district. These group include-Forestry Users Group, Mothers’ Group, Cooperatives and ward citizen forum (WCF). There are 221 community forestry users group (CFUG) and it has a district alliance forum. Cooperative and Media have also district level alliance forum.

5.4 STRENGTH AND OPPORTUNITIES

 HFOMCs have been formed in all VDCs. All the HFOMC members have received four days basic and three days capacity building training.  UNFPA and other organizations are working in the district to provide support in health sector  CFUG, NGO, Journalists etc. federations/network are at the district level

5.5 KEY ISSUES AND CHALLENGES

 65 percent of the HFOMCs in Rolpa are not functioning  Lack of community ownership towards the HFs  No meaningful participation of DAG/M members in HFOMC meetings  Less supportive visits from DHO/DDC.  Some HFOMCs are not formed as per HFOMC guideline. HFOMCs need to be re-formed according to guideline.  Coordination among other community groups (forestry, cooperative etc.) is not as expected  Joint effort of different sector may be the effective approach to overcome the problems /constraints

18 6. SERVICE DELIVERY/QUALITY IMPROVEMENT

This chapter presents the RA findings related to service delivery and quality of health care. RA team collected information on the quality of infection prevention practices at HFs, implementation of community-based interventions, and the provision of IUCD and Implants services at district level. The major findings of the assessment are below.

6.1 SERVICE DELIVERY

The RA sought information on the availability of FP Satellite clinics, Basic Emergency Obstetric and Neonatal Care (BEONC), long acting family planning (LAFP) methods, and implementation of community-based interventions such as Community-based CB-IMCI, Newborn Care Package (CB- NCP), Matri Surakshya Chakki (MSC) and Chlorhexidinenavi Navi Care (CNC) programs. CB-IMCI, MSC and CNC programs are already implemented in Rolpa, which needs to be maintained. CB-NCP will be implemented in Rolpa from this fiscal year with the support of Save the Children.

The district provides BEONC services on regular basis from the District Hospital and two PHCCs. In Rolpa, Community-based MSC was implemented by DHO in support of NFHP II since 2010/11. CB- IMCI program is also Table 6.1: IUCD and Implants Insertion and Removal Sites of Rolpa implemented by DHO and CB- IUCD BC, Y/N Implants BC, Y/N NCP will be implemented soon. 1. District Hospital Y 1. Garigaun Y With regards to providing LAFP 2. Holeri PHC (Sakhi) Y 2. Holeri (Sakhi) Y methods, it was reported that 3. Sulichaur PHC Y 3. Sulichaur (Mijhing) Y IUCD service is being providing 4. Y 4. Gajul Y from 7 HFs and Implants from 15 5. Ghartigaun Y 5. Ghartigaun Y 6. Jungar Y 6. Jungar Y HFs. (Table 6.1). There are 37 7. Thabang Y 7. Thabang Y Birthing Centers (BC ) in Rolpa. 8. Liwang Y Seven HFs are providing LAFP 9. Masina Y methods (IUCD and Implant) 10. Jhenam Y from 17 satellite clinics. The 11. Y following Table shows the HFs 12. Rank Y 13. Y and sites for LAFP methods in 14. Y Rolpa district. 15. Badachaur Y

Table: Holeri PHC Nerpa HP Gajul HP Liwang HP Kureli HP Ghartigaun HP Rank HP Jaulipokhari Nuwagaun Fagam Mirul Korchabang Jinabang Masina Badagaun Jelbang Hwama (1) (1) Ota Gairigaun (2) Jankot (2) Jhenam (3) (3) Dubidanda (5) Source: FP focal person and SM focal person

In Rolpa, there are 10 health workers trained on SBAs. This number is not sufficient for providing services in a district which has 37 BCs and three BEONC sites. As reported by the program focal person, there are 13 and 15 untrained HWs and FCHVs on CB-IMCI respectively. In addition, there is several health workers hired temporarily or on contract basis needing CB-IMCI training in Rolpa.

19 6.2 INFECTION PREVENTION AND WASTE MANAGEMENT PRACTICES AT HFS

Few questions related to infection prevention and waste management practices followed at HFs of Rolpa were also asked to district supervisors during RA. It was found that out of total 37 birthing centers, 10 have placenta pit for disposal of placenta. Remaining BCs use to bury in the ground.

6.3 STRENGTH AND OPPORTUNITIES

 MSC, Chlorhexidine, and CB-IMCI programs are already implemented in Rolpa. CB-NCP will be implemented in the current FY.  UNFPA is supporting on FP program  Private sector are providing FP services (Injectable, Oral Contraceptives and condom )  DDC /VDCs have provided supported in expansion of birthing centers  LAFP service is integrated in 15 birthing centers

6.4 KEY ISSUES AND CHALLENGES

 There are problems in the infrastructure of some BCs  Problem in staff retention especially ones who are recruited temporarily or on contract basis and hired by VDCs.  Problem in logistic supply (Instruments, and equipments).  Very few (10) SBA trained staff with respect to increasing BEONC (3) and birthing centers (37).  Untrained HWs and FCHVs on CB-IMCI are 13 and 15 respectively. Many health workforce. recruited temporarily and on contract also need the training.  Delay release of budget for training and activities implementation.

20 7. LOGISTICS MANAGEMENT SYSTEM

Logistics management is an important part of district health systems. Efficient logistics management is required to run all the public health programs at district, sub-district and the VDC levels smoothly. The RA also sought information from DHO on the logistics management system. The major findings of the assessment presented below.

7.1 AVAILABILITY OF KEY DRUGS AND COMMODITIES

During RA, the storeroom of the DHO was also visited and the storekeeper was interviewed. The availability of 11 commodities/some essential drugs (Injectable, Oral Contraceptive, Condom, ORS, Vitamin A, Iron Folate Tablets, Cotrim (Ped), Zinc, Oxytocin, Gentamycin and MgSO4) in the district store at the time of visit was checked. All key commodities checked were available in the store during RA visit. According to storekeeper, among 11 key drugs/commodities, Iron and Cotrim P were stocked out at some time in the last 12 months. The RA team members also checked the expiry dates of the drugs/commodities and none of the drug/commodity checked were expired at the time of visit.

Table 7.1: Availability of key drugs/commodities SN Drugs/Commodities Availability at Stock out in Expired drugs in the time of the last 12 stock at the time of visit months visit 1 Injectable Contraceptive Y N N 2 Oral contraceptive Y N N 3 Condom Y N N 4 ORS Y N N 5 Vitamin A Y N N 6 Iron Folate Tablets Y Y N 7 Cotrimoxazole (Ped) Y Y N 8 Zinc Y N N 9 Oxytocin Y N N 10 Gentamycin Y N N 11 MgSO4 Y N N

According to storekeeper, there was no stock out problem in the FY 2069/70. It was also reported that Aminophyline tablet had the most problem with over stock in the FY 2069/70.

7.2 COLD CHAIN AND FEFO MANAGEMENT

DHO Rolpa has 12 functioning refrigerators. The available refrigerators are sufficient to DHO for maintaining cold chain. There is a regular power back up system for the cold chain room. The management of five drugs in the store was checked to see whether First Expiry First out (FEFO) was maintained or not. Storekeeper has maintained FEFO system in the district store at the time of visit.

21 7.3 LMIS REPORTING

DHO is not using web-based LMIS to report to center because of internet problem. However, DHO is going to re-establish internet system soon in the district. There is no data entry person recruited for entering LMIS data.

7.4 STRENGTH AND OPPORTUNITIES

 Timely reporting of LMIS from peripheral level to district; district to region and center  Availability of essential drugs throughout the year  Drugs are purchased at local level by few HFOMCs  PULL system in place for drugs/commodities supply  Sufficient refrigerators with full power guarantee to maintain cold chain.

7.5 KEY ISSUES AND CHALLENGES

 Congested store room at district level.  Timely transportation of drugs below district level is difficult due to vehicle/porter problems as well as budgetary constraints.  Sometimes center and Regional Medical store do not follow the PULL system, which is most difficult to follow below district level.  Difficult on reporting in web-based LMIS system because of internet problems.

22 8. BEHAVIOR CHANGE COMMUNICATION

H4L aims to understand legal, cultural/religious, and policy dimensions of GESI inequities on health service access and use and design interventions to ensure sustainable, high-quality BCC and IEC approaches that respond to local realities, and include groups not commonly targeted, but crucial to meeting Nepal’s health goals.

One of the objectives of the RA was to explore the range of BCC interventions that is being implemented for healthy behaviors. Following are the major findings on BCC:

8.1 EXISTING DHO PROGRAMS ON BCC

DHO Rolpa has been organizing BCC program activities as per the DoHS’s yearly plan provided from the National Health Education Information and Communication Center (NHEICC) such as production and distribution of IEC materials, drama and short massages broadcasting through local FM radios, school health program, orientation to teachers, journalists etc.

8.2 FM STATIONS/CABLE TELEVISION NETWORKS

There are three FM radio stations in Rolpa district. 1. Rolpa FM Liwang, Rolpa 2. Jaljala FM Liwang, Rolpa 3. Sunchhahari FM Holeri, Rolpa

DHO Rolpa has partnered with all the three FM stations for airing radio health programs and Public Service announcements (PSAs) on Janaswastha Sandesh (Every Sunday evening at 7.00 PM Radio Rolpa, Every Tuesday evening 6.30 PM by Radio Jaljala and every Thursday evening at 7.00 PM by Radio Sunchhahari Holeri). DHO produces radio programs such as drama, jingles, news etc. and airs from these local FMs regularly. The Radio program time is 30 minutes in all FMs. The major content covered in such programs are- FP, Safe motherhood, Child Health etc. Information about family planning services and devices, birth spacing and its benefits, ANC/PNC visits and HF delivery, Care of child and neonatal are highlighted in the PSA.

8.3 ORGANIZATIONS WORKING IN IEC/BCC ACTIVITIES

There are no organizations other than DHO that is working directly in health related IEC/BCC activities in Rolpa. However, RUDAS/PSI, Nepal CRS company are airing about their family planning services from local FMs. These organizations do not have community level intervention/social activities.

There is no local cable TV network in the district. There is no BCC activities focused on M/DAG in the district. Furthermore, there is no designated IEC/BCC (HET) focal person. Mr. Ganesh Budha, Public Health Inspector is looking after the IEC/BCC activities in Rolpa district.

H4L plans to use mobile phones to reach target groups with messages on health in selected district. The RA also explored whether any organization has used mobile phones to communicate health messages to target groups or entire district population together with DHO. But RA team didn't find

23 any activities where mobile phones were used to communicate health messages to any groups in the district.

One area of intervention of H4L is to improve the quality of counseling provided by health workers and community-based health workers to clients. It is therefore essential to find out whether there is pool of resources available at district level to improve counseling services. Hence, RA also collected information on the health workers who received training on COFP/C in the last three years. According to training focal person no one is trained on COFP/C in the last three years in Rolpa.

8.4SCHOOL HEALTH PROGRAM

There was no school health program in the current fiscal year. RA team tried to collect information on the school health program conducted in the last FY, however, the RA team could not find the detail information on total schools, numbers of classes and topic covered in the school health program.

The person looking after the IEC/BCC activities in DHO Rolpa was asked what other approach would be effective beside school health program in reaching the health message to the adolescents. He expressed that Radio program with drama and dialogues, peer education and interaction program may be the other effective approach to deliver the key message to adolescents. In hard to reach areas, the language used in such programs may also matter the success of the program in hard to reach areas. In addition, due consideration has to be given to sex, caste, place of residence, geography etc.

8.5 MAPPING OF DAG AND EXPLORING CULTURAL PRACTICES AFFECTING HEALTH

DHO has not mapped M/DAG in the Rolpa district. But information on DAG mapping was available with DDC. DDC is doing M/DAG mapping regularly, once in a year. Following indicators are used to map M/DAG in Rolpa: 1. Own agricultural production is sufficient for only three months or below. 2. Majority of excluded family 3. Status of primary education 4. Situation of health facility 5. Participation of Dalit, Women and Janajati on planning, implementation and decision making. 6. Level of gender discrimination 7. Level of vulnerable family

On the basis of above mentioned indicators, all VDCs are categorized into four categories I, II, II and IV. Category IV is priority one and is highly concentrated with M/DAG. Category I is least priority and had least concentration of M/DAG.

24 Category 4 Category 3 Category 2 Category 1 1. Gam 1. Siuri 16. Bhavang 31. Pang 1. Liwang No VDCs in 2. Uwa 2. Jedbang 17. Jankot 32. Masina this 3. Talabang 3. Dubidanda 18. Sakhi 33. Jaulipokhari category 4. Pachhabang 4. Ota 19. Kareti 34. Gairigaun 5. Mirul 5. Jinabang 20. Jhenam 35. Mijhing 6. Hwama 6. Kotgaun 21. Ghodagaun 36. Pakhapani 7. Thabang 7. 22. Gajul 37. Rangkot 8. Jelbang 8. Ghartigaun 23. Dubring 38. 9. Jungar 24. Nuwagaun 39. Badachaur 10. 25. Fagam 40. Sirpa 11. Seram 26. Rangsi 41. Tebang 12. 27. Rank 42. Gumchal 13. Dhabang 28. Iribang 14. Budhagaun 29. Jaimakasala 15. Kureli 30. Korchabang

STRENGTH AND OPPORTUNITIES

 Three FM stations are covering the whole district population  District Supervisor (CCO Lal Bahadur Thakur and SN SarmilaPokhrel) are developing the Radio program (Radio drama, news, jingles, PSAs etc. and airing regularly from all FMs.  DHO is distributing IEC/BCC materials which are supplied from center and developed locally.

KEY ISSUES AND CHALLENGES

 It is difficult to increase awareness and provide health services among people who have strong traditional and cultural beliefs, practice of early marriage and early child bearing.  Bulk amount of BCC materials supply from center Vs use at local level due to improper distribution at local level.  According to DDC profile, average age for marriage of girl is 18 years and boys is 20 years. There is need to find the VDC and caste specific data.  There is no information regarding hard to reach population on health perspective.

25 9. ADOLESCENTS AND YOUTH FRIENDLY SERVICES

H4L will also work with DHOs in selected districts to improve service accessibility of Adolescents under its Objective 6. The RA also explored different aspects of Adolescents and Youth friendly services in the public HFs of Rolpa district. Following are the major findings:

9.1 EXISTING SERVICES FOR ADOLESCENT

In Rolpa, there is focused program for Adolescents in 13 sites (HFs).The HFs which have Adolescents and Youth Friendly Service (AYFS) sites are: Iribang, Gajul, Ghodagaun, Harjang, Jinabang, Jungar, Liwang, Mijhing, Rangsi, Sakhi, , District Hospital and Ghartigaun. Eight out of thirteen HFs namely Liwang, Gajul, district Hospital, Gartigaun, Mijhing, Sakhi, Ghodagaun, and Rangsi are reporting regularly to DHO..

9.2 ORGANIZATION WORKING FOR ADOLESCENT

In Rolpa, WCO and UNFPA (in selected VDCs) are actively working for adolescent’s health. UNFPA is providing AFS services in 13 HFs. There is no Adolescent club reported in the district.

9.3 STRENGTH AND OPPORTUNITIES

 Thirteen HFs have Adolescent and Youth Friendly Service sites.  UNFPA has provided continuous support on AFS.  DHO has conducted Peer education training to 10 schools in the current FY.  WCO has been providing continue support to girls adolescent groups  DHO is coordinating with three FMs for awareness raising on adolescent health

9.4 KEY ISSUES AND CHALLENGES

 Limited government programs and financial constraints are barriers to expand peer review learning into schools.  Eight out of 13 AFS centers are reporting. Reporting should bre done by 100 percent AYFS sites.  ASF service yet to scale up in all peripheral HFs of the district  Adolescent groups hesitate to share their problem; therefore, it is necessary to provide adolescents friendly service to change their behavior.

26 10. GENDER EQUALITY AND SOCIAL INCLUSION

H4L is designed to support the Government of Nepal’s stated commitment and responsibility to ensure that quality health services are accessible to all citizens. As such, it is critically important that sound, ongoing GESI-sensitive analysis and gender integration under H4L program interventions. H4L’s GESI Objectives are designed to re-address gender and social inequities, and dovetail with the objectives set forth in the MoHP’s 2009 Health Sector Gender Equality and Social Inclusion Strategy as follows:  Objective 1: Support existing MoHP policies, strategies, plans and programs that create a favorable environment for integrating GESI in Nepal’s health sector;  Objective 2: Support MOHP’s efforts to enhance the capacity of service providers and ensure equitable access and use of health services by the poor, vulnerable and marginalized castes and ethnic groups; and  Objective 3: Improve health-seeking behavior of the poor, vulnerable and marginalized castes and ethnic groups in collaboration with local government partners, community-based organizations (CBOs) and other stakeholders.

The first objective is related to policy while the latter two are directly related to DHO systems.

The RA also included assessment and analysis of the health programs of the DHO Rolpa from GESI perspective. The major findings were as following:

10.1 FORMATION AND FUNCTIONALITY OF GESI COMMITTEE

DHO Rolpa has selected GESI focal person. She is Staff Nurse. She is looking after safe motherhood program. About three months before the RA, NHSSP has sensitized the DHO to form GESI committee in the district and helped DHO to assign a focal person to look after GESI activities in the district supervisor just three months back. DHO is planning to form GESI committee soon, and looking for supporting agencies.

10.2 ORGANIZATIONS WORKING ON GESI

Two government organizations (DDC and WCO) are working on GESI. RA team these two organizations during information collection process. Interaction with the staff working on the project revealed that DDC has formed a GESI committee under the chairmanship of LDO. DDC has updated the GESI focal persons list from government and non-government offices. DDC has organized GESI orientation to Committee member, focal persons and VDC secretary and social mobilizers.

Women and Child Office has formed GESI network among cooperative groups run by WCO. WCO has organized interaction program on GESI twice in this year. GESI was integrated in all WCO program activities. WCO has organized Girl Adolescent Development Program in six VDCs of Rolpa district. WCO has allocated funds for mitigating Gender-Based Violence (GBV). GBV links with Paralegal and Paralegal advocates for the GBV. DDC has updated the name of focal person of other organizations who have selected GESI focal person. No more activities except selecting focal person by other organizations has been carried out so far.

27 There are no other non-government organizations working explicitly in GESI. There is no other GESI related intervention/activities below district than those mentioned above.

10.3 SERVICE DATA ON THE PERSPECTIVE OF SOCIAL INCLUSION

Rolpa is not a Social Inclusion reporting district. The DHO does not have reports on disaggregated data on OPD visits. The following table shows Fiscal year 2066/67 2067/68 2068/69 female are getting more service than male in OPD setting. It may be the further more discussion Male % 44 42 45 whether female are being more sick or male are Female % 56 58 55 getting service from out of district.

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28 Annexes

Annex: 1 Contact information of DHO Staff, Rolpa Years of Years of service Cell Phone Name Position service in district no. District Health Officer 16 01 Public Health Officer 5/12 5/12 VACANT Public Health Nurse Statistics Assistant/Officer 15 09 FP focal person 19 09 VACANT Health Education Tech/ Officer DTLA/Officer 17 12 Vacant EPI Supervisor/Officer Cold Chain Assistant/ Officer 18 01 VACANT Computer Operator/Officer Store Keeper 16 01

Child Health focal person 26 01 FCHV Focal Person 19 09 (FPSO) VACANT Medical Recorder Adm. Officer/Na. Su. 10 02 Public Health Inspector 25 10 SN /SM focal person 05 03 DACC coordinator 03 03

Annex: 2 List of RHCC members

Name Position Address District Health Officer DHO Rolpa Program Officer DDC Rolpa Section Officer DEO Rolpa Women and Child Officer Women and Child Office, Rolpa Program officer Nepal Red Cross Society, Rolpa President RUDAS Nepal FP. Officer DHO Rolpa

29 Annex: 3 List of persons met during RA visit SN Name of individual Position Office/Organization visited 1 CDO District Administration Office 2 LDO District Development Committee 3 PO District Development Committee 4 WCO Women and Child Office 5 MO District Hospital 6 PHO District Health Office 7 Stat. Officer District Health Office 8 PHI District Health Office 9 FPSO District Health Office 10 SM focal persn District Health Office 11 Cold Chain Off. District Health Office 12 Store keeper District Health Office 13 DACC Coordinator District Health Office 14 PHI District Health Office 15 Chairman Rural Development and Awareness Society (RUDAS) 16 PC RUDAS 17 Staff Nurse District Hospital 18 PC Red Cross Society

30 HEALTH FOR LIFE

REPORT ON

RAPID ASSESSMENT

OF DISTRICT HEALTH SYSTEMS

2013 RUKUM A REPORT ON

RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013 RUKUM

MAY 2013

TEAM MEMBERS

i TABLE OF CONTENTS

ABBREVIATION…………………………………………………………………………………………………iii

KEY FINDINGS FROM RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS..………………..…….v

1. RAPID ASSESSMENT…………………………………………………………………………………...… 1

2. INTRODUCTION OF DISTRICT………………………………………………………………………..…3

3. DHO STRUCTURE AND SYSTEMS ……………………………………………………………….....…4

4. SERVICE STATISTICS ……………………………………………………………………………...... …8

5. HEALTH FACILITY MANAGEMENT COMMITTEE AND LOCAL HEALTH GOVERNANCE ….10

6. SERVICE DELIVERY/QUALITY IMPROVEMENT …………………………………………….….…12

7. LOGISTICS MANAGEMENT SYSTEM ………………………………………………………….……..14

8. BEHAVIOR CHANGE COMMUNICATION ……………………………………………………..…….16

9. ADOLESCENTS AND YOUTH FRIENDLY SERVICES … …………………………………….….….21

10. GENDER EQUALITY AND SOCIAL INCLUSION ………………………………………………..…..23

Annexes Annex: 1 Contact information of DHO program focal person……………….….25 Annex: 2 List of RHCC Members ………………………………………………………….…25 Annex: 3 List of persons met during RA visit……………………………………….….26

ii ABBREVIATIONS

ANC Antennal Care ADSL Asymmetric Digital Subscriber line AHW Auxiliary Health Worker ANM Auxiliary Nurse Mid-wife BCG Bacilus Calmette Guerin BCC Behavior Change Communication BEONC Basic Emergency Obstetric and Neonatal Care CFLG Child Friendly local Governance CAC Community Awareness Center CBOS Community Based Organizations CFUG Community Forestry Users Groups CRRT Community Rapid Response Team CB-IMCI Community-Based Integrated Management of Childhood Illness CB-NCP Community-Based Newborn Care Package CEOC Comprehensive Emergency Obstetric Care CEONC Comprehensive Emergency Obstetric and Neonatal Care CPR Contraceptive Prevalence Rate DPT Diptheria Pertuesis Tetanus DAG Disadvantage Group DRRC Disaster Risk Reduction Committee DADO District Agriculture Development Office DDC District Development Committee DEO District Education Office DHO District Health Office D/PHO District/ Public Health Office DTLA/O District Tuberculosis and Leprosy Assistant/Officer EPI Expanded Program on Immunization EDPs External Development Partners FMC Facility Management Committee FP Family Planning F/Y Fiscal Year GESI Gender Equality and Social Inclusion HA Health Assistant HF Health Facility H4L Health for Life HMIS Health Management Information System HP Health Post HWF Health Work Force HW Health Worker HH House Hold HR Human Resource IYCF Infant and Young Child Feeding IT Information Technology IUCD Intra Uterine Contraceptive Device LFUG Leasehold Forestry Users Groups LDO Local Development Officer LGCDP Local Governance Community Development Program LTAPs Local Technical Assistance Partners LMIS Logistics Management Committee MCHW Maternal and Child Health Worker

iii MNCHN Maternal Neonatal Child Health and Nutrition MSC Matri Surakha Chakki MO Medical Officer MWDR Mid-western Development Region MG Mother Group MIC Nepal Magar Society Service and Information Center N-PAF Nepal Public Awakening Forum NRCS Nepal Red Cross Society NGOs Non-Governmental Organizations N Number ORS Oral Rehydration Solution PNC Post Natal Care PHCC Primary Health Care Center PHC/ORC Primary Health Care/ Out Reach Clinic PHI Public Health Inspector PHO Public Health Officer QAWG Quality Assurance Working Group QI Quality Improvement RA Rapid assessment RRT Rapid Response Team RHCC Reproductive Health Coordination Committee RSDC Rukumeli Samaj Development Center SC Save the Children SBA Skilled Birth Attendants Sq. KM. Square Kilometer SHP Sub Health Post TT Tetanus Toxoid USG Ultra Sonogram UMN United Mission to Nepal UNFPA United Nations Population Fund USAID Unites States Agency for International Development VHW Village Health Worker VDC Village Development Committee WCF Ward Citizen Forum WUA Water Users Association WDR Western Development Region WCO Women and child Office

iv KEY FINDINGS FROM RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS- RUKUM

TOTAL POPULATION 2,08567 NUMBER OF VDCS 43 DHO STRUCTURE AND Public Health facilities: SYSTEMS  District Hospital-1, Community hospital 1, PHCCs-2, HPs -10 and SHPs-31, Private Health facilities:  Private hospitals 1 Meetings:  Monthly meeting of Ilaka In-charge at District- Not held  QAWG- No QAWG formation  RHCC- Meets ad hoc basis December 2, 2012  Health Workforce:  All technical positions at DHO filled in except DTLA and Medical officer  Unfilled positions at HFs–MO, SN, ANM, and AHW. 2 SN, 13 vaccinators, 33 ANM, 5 AHW, 2 computer operators and 1 lab assistant are hired on contract basis by DHO. 2 ANMs, 1 HA, 4 AHW and 1 LA hired from NPC Monitoring and Supervision:  M&S system and plan exists at district level only. Integrated supervision tools are not in use. IT infrastructure at D/PHO:  Desktops-5, Laptops-3, Printers-6  Established internet facility but unreliable.  One HF has computers.  Supervisors skilled in using MS Word and Excel-4.  No Health Facility level entry in HMIS software. Rapid Response Team: Functioning well at the district and HF level SERVICE STATISTICS  BCG and Measles coverage is in fluctuating trend. In the year FY 2068/69 measles coverage was 88.32 percent.  Severe pneumonia and diarrheal cases shows fluctuating trend. More children are being treated with antibiotics  Drop out from ANC first to ANC fourth visits is high and in the FY 2068/69 it was 90.5 percent and 36.4 percent respectively.  SBA deliveries are in increasing trend (11 percent in FY 2065/66 to 21.59 percent in FY 2068/69)  Contraceptive Prevalence Rate in FY 2068/69 was 23 percent HEALTH FACILITY  No HFs handed over to local bodies. MANAGEMENT COMMITTEE  A few 8 HFOMCs received capacity building trainings, refreshers and AND LOCAL HEALTH technical support visit but 3 years back ADRA supported safer GOVERNANCE motherhood network federation has been provided all HFOMCs training but no follow up and refresher later on by DHO/EDPs.  At community level groups such as -Forestry Users Group, Mothers’ Group, Drinking Water Users Group, Irrigation Users Group, Road Rural Users Group, Cooperatives, Media, Youth clubs, Child clubs and Pregnant Mother group are functioning. SERVICE  Regular 2 CEONCs services provided at district hospital and other in v DELIVERY/QUALITY community hospital in Chaujahari. IMPROVEMENT  Community-based service delivery-MSC  Satellite FP clinics-4 but not functional due to budget constraint  IUCD services- 13 health facilities and Implants- 12 HFs.  Birthing centers-21  Placenta pits-8 LOGISTICS MANAGEMENT  All tracer drugs and commodities available on the day of visit. SYSTEM  Drugs with most problems of stock outs in the year- Implant, Doxycycline, Ciprofloxacin and Hyosine Bromide.  Drugs with most problems of over stock in the last year- MgSO4, and Metacloropropide  Functioning refrigerators-4, sufficient for maintaining cold chain, and have regular power back up system for the cold chain room.  First Expiry First out (FEFO)- poorly maintained  Web-based LMIS reporting system. Data entry person recruited. BEHAVIOR CHANGE  FM stations-3 COMMUNICATION  Several I/NGOs engaged in BCC activities  In the FY 2068/069, total 140 session of school health program on HIV/AIDS, RH, GBV, early marriage etc were organized in 250 school (1700 students benefited). In current FY, no activities were planed and conducted for school health program.

 Villages that were highly populated by DAG- Aathbisdandagaun, Chunwang, , Hukam, Jang, Kakri, Kol, Mahat, Pipal, Purtimkanda, Ranmamaikot, Sisne, Syallakhadi and Takasera

 Ethnic/Caste group deprived from service utilization- Dalits and Magar, Gurung were the deprived castes group.

 Villages that still practice early marriage and Early Child Bearing- In all VDCs

 High Migrants VDCs- Seasonal migration from all VDCs ADOLESCENTS AND YOUTH  AYFS- 19 sites supported by UNFPA and UNICEF FRIENDLY SERVICES  DHO conducted Peer Review training to 10 schools in the current FY.  WCO have female adolescent youth clubs to enhance life-skill trainings and give information on RH issues from FMs and in groups. GENDER EQUALITY AND  GESI working group is not formed. SOCIAL INCLUSION  The committee received partial orientation from the RHD focal person.  GESI focal person assigned to a district supervisor.  DDC, WCO LGCDP, and UNFPA have GESI related activities in Rukum.  At DDC, GESI committee under the chairmanship of LDO was also formed .

vi 1. RAPID ASSESSMENT

1.1 HEALTH FOR LIFE

Health for Life (H4L) is a five-year bilateral agreement between the Ministry of Health and Population (MoHP) and the Unites States Agency for International Development (USAID) which focuses on Systems Strengthening and improving the Maternal Neonatal Child Health and Nutrition/Family Planning (MNCHN/FP) service delivery at district and sub-district levels in 14 districts. 12 of the 14 districts are in the Mid-western Development Region (MWDR) –Rukum, Bardiya, Dang, Surkhet, Salyan, Pyuthan, Dailekh, Kalikot, Jumla, Rukum, Jajarkotand Rolpa and two are in the Western development Region (WDR) of Nepal- Argakhanchi and Kapilbastu. The project will be implemented between 2012 and 2017.

1.2 RAPID ASSESSMENT AND ITS OBJECTIVES

Rapid assessment (RA) is a method of analyzing situation of a district where issues are not well defined and where there is not sufficient time or other resources for in-depth quantitate research. RA uses intensive team interaction in both the collection and analysis of data instead of prolonged field work and iterative data analysis and additional data collection to quickly develop a preliminary understanding of a situation from the insider’s perspective. The main purpose of carrying out the current Rapid Assessment is to understand the current situation of the health service delivery system and other associated systems of the so as to help in planning activities at district level.

Specifically, the objectives of the RA includes  Understanding the demographic profile of the district  Understanding the existing health care delivery system of the district  Knowing the functionality of the Facility Management Committees  Understanding the status of health indicators  Analyze strengths and weakness of the DHO systems  Exploring feasibility for the implementation of specific programs for adolescents and youth  Exploring feasibility of using Information Technology in information management

1.3 METHODOLOGY

A mix of both qualitative and quantitative methods was used to execute Rapid Assessment in Rukum district. These includes  Visit to District/Public Health Offices (D/PHO)  Interaction and interview of key staff  Observation of D/PHO

A structured tool was developed to collect necessary information which was supplemented by qualitative tools to interview key informants at District Development Committee and Local Development Office (LDO), International/Non-Governmental Organizations (I/NGOs) working on different areas of health, Gender Equality and Social Inclusion (GESI), Behavior Change Communication (BCC), Information Technology (IT) in Health, Service delivery, and Governance.

1 A team was composed for carrying out RA which included which included H4L staff and Government counterpart staff. Skill mix was ensured while forming team where staff was skilled/knowledgeable on the following- Governance, service delivery, monitoring and evaluation, GESI and BCC. Involvement of Project Center, regional and district office was ensured.

Before carrying out of the RA, one day orientation on RA objective, methods and tools were organized for H4L staff together with orientation on H4L in Hotel Siddhartha, Nepalgunj. RA in Rukum was completed by 2 Staffs in six days May 12-18, 2013. Information collected was verified on the same day and brief notes were developed for each thematic area for sharing with DHO and other line agencies and also for preparing report. After completing the RA, a half day sharing program was organized that was participated by DHO, and DDC. After the completion of the RA, Workplan Outline for implementation of H4L in Rukum district will be signed later on between H4L and DHO.

1.4 ORGANIZATION OF THE REPORT

The findings of the RA are presented in nine Chapters. Chapter one presents the purpose of carrying out RA and the methodology followed. Chapter two presents the introduction of Rukum district. Chapter three explains the DPHO systems and structures. Fourth and the Fifth chapter present the service statistics and the status of the HFOMCs in Rukum district. Sixth and the Seventh chapter present the findings on service delivery/quality of care and logistics management system. Chapter Eight, Nine and Ten reports the findings on BCC, AYFS and GESI in Rukum district

2 2. INTRODUCTION OF RUKUM DISTRICT

2.1 GEO-POLITICAL SITUATION

Rukum District is situated in Rapti zone, and in the Mid- Western Development Region of Nepal. Musikot Khalanga is the district head quarter. Rukum is bordered on the west by Jajarkot district, on the north by Dolpa, on the east by Myagdi, and Baglung districts and on the south by Rolpa and Salyan districts. Rukum covers an area of 2,877 square km.

2.2 DEMOGRAPHIC INFORMATION

The 2011 Census reports total population of Rukum district as 2, 08,567. The proportion of Females is ten percent point greater than that of males. Table 2.1: Population of Rukum District Table 2.1 shows the Number Percent caste/ethnicity distribution of the Total Population 2,08,567 - population residing in Rukum Male 99,159 47.5 district. The proportion of Female 109408 52.5 Brahmin/Chhetri is greatest in Household number 94,773 41856 Source: Census 2011 Rukum district (69 percent) Caste/Ethnicity distribution followed by Janajatis (23 Brahmin/Chhetri 129,257 69 percent). The proportion of Dalits Janajati 44,141 23 in Rukum is about 7 percent. Dalits 13,069 7 There are few people belonging Other Terai Origin 289 0.15 to Other Terai Origin, advantaged Advantage Janajati 1,354 0.72 Janajati, Muslims and Other Muslims 141 0.07 castes. Others 181 0.09 Source: Census 2001

3 3. DHO STRUCTURE AND SYSTEMS

This chapter presents the findings related to the DHO structure and systems collected from the RA. The findings covers following areas: service delivery points, management system, health workforce, monitoring and evaluation system, IT and health information management and disaster management system.

3.1 SERVICE DELIVERY POINTS

The District Health Office, located in Musikot Table 3.1: Number of service delivery points in Khalanga is the main responsible institution of district the MOHP at Rukum to provide preventive, Type of service delivery points Number promotive and curative health services to the District Hospital 1 people of Rukum. There are a total of 43 PHCC 2 peripheral public health facilities (2 PHCCs, 10 Health Post 10 HPs and 31 SHPs) and a District Hospital in Sub-health Post 31 Rukum district. There are 21 birthing centers out Private hospital 1 of which 19 are functioning during the time of Birthing centers 21 Functioning birthing centers 21 RA. There are 125 PHC/ORCs and 165 PHC Out-Reach Clinic 125 Immunization Clinics. There are 387 Female Immunization Clinic 165 Community Health Volunteers (FCHVs) in the FCHVs 387 district. SBA site 19 CEOC 2 There is one private hospital in Khalanga and one Source: DHO, Rukum, 2013 community hospital in Chaujahari.

3.2 MANAGEMENT SYSTEMS

3.2.1 MEETINGS

D/PHO Rukum holds different meeting. The Reproductive Health Coordination Committee (RHCC) meeting was conducted once in this fiscal year 2069/070. The last RHCC meeting was organized on December 2, 2012. The monthly meetings of the health facility in charge were organized in the last year but now due to lack of budget it has been Table 3.2: Current Status of DHO Team stopped. The Quality Assurance Working Group DPHO Team Status has not been formed in the district. a. District /Public Health Officer Filled 3.2.2 PROGRAM MANAGEMENT TEAM b. Sr./Public Health Officer/ Filled Administrator c. Public Health Nurse Filled The DHO Rukum has all the key positions except d. Statistics Assistant Filled DTLA filled-in at the time of RA. Refer to Table e. FP focal person Filled 3.2. f. DTLA/Officer Vacant g. EPI Supervisor/Officer Filled 3.3 HEALTH WORKFORCE h. Cold Chain Assistant/ Officer Filled i. Typist (Nasu) Filled Table 3.3 presents the current status of health j. Store Keeper Filled workforce in Rukum district. Out of 273 k. Child Health focal person Filled sanctioned positions, only 58 percent were Source: DHO, Rukum 2013

4 filled-in during the time of RA. Medical officer position is not filled-in in both the PHCCs. Out of the total 5 sanctioned positions of staff nurses in the district 4 are filled in. Two staff nurse are contracted by DHO. In total 18 staff were recruited on contract basis by NPC and other agencies.

Table 3.3: Current status of health workforce Type of human resources Number GoN Number supported from Sanctioned Filled-in VDC NPC Other a. Medical Officer 1 1 b. Staff Nurse 5 4 2 c. ANM 20 20 2 `4 d. HA/Sr. AHW 50 13 1 e. AHW 50 54 4 1 f. VHW padnam 40 27 g. MCHW padnam 31 31 h. Lab Assistant 3 3 1 i. Adm. Assistant 4 5 j. Store Keeper 1 1 k. Vaccinators 0 13 l. Office assistant 68 41 7 Source: DHO, Rukum 2013 273 159 (58%) 8 10

3.4 MONITORING AND SUPERVISION

D/PHO Rukum has Monitoring and Supervision System in place where, DHO monitors HFs on ad hoc basis. However, planned periodic annual monitoring and supervision system was not observed during the RA. Systematic annual monitoring and supervision, follow-ups and regular feedback mechanism are inevitable. Integrated supervision and monitoring tools were also not in practice in DHO Rukum.

3.5 INFORMATION TECHNOLOGY

The RA also explored the existing IT infrastructure at DHO. At present the DHO has 5 desktop computers and 3 laptops. There is ADSL internet facility but it does not function well posing serious consequences on timely data entry and reporting. Six functioning printers are available in DHO. One HF has computer for official purpose. Out of 33 staffs in DHO only 5 are skilled in using MS Word and Excel.

3.6 HEALTH INFORMATION MANAGEMENT

DHO Rukum has a system to enter Health Facility level data in HMIS software. HF level data is available for the last four years in HMIS. Recently the Statistics Assistant received two-days training on web-based HMIS reporting and two days orientation training on planning and implementation. HMIS data by HFs will be regularly entered in the web-based HMIS software. For improving data quality, DHO is going to organize an event of Data validation program in the current FY 2069/070.

3.7 NATURAL DISASTER RESPONSE MECHANISM

D/PHO Rukum has Rapid Response Team (RRT) at district level to responds to natural disaster and disease outbreak throughout the district. Furthermore, there are six community rapid response team (CRRT) at cluster level to support to and communicate with HF at the time of natural

5 calamities. Cluster based CRRT and DHO RRT focal person have communication plan regarding the issues and DHO RRT focal person has been reporting to Center on weekly basis.

The District Based Rapid Response Team constitute following individuals: 1. DHO 2. i MO 3. PHO 4. EPI supervisor PHI 6. Sr. AHW 7. Sr. AHW 8. Staff Nurse 9. PHI

Followings are the cluster of Community Rapid Response Team members: 1. Gotamkot, Syallakhadi –Gotamkot cluster 2. , Ghetma and Aathbisdandagaun-Aathbiskot cluster 3. Hukam, Ranmamaikot, Kol, Rangsi, Takasera-Kol cluster 4. Jaang, Sisne, -Jaang cluster 5. , Pokhara, Syallapakha, Kanda- Rukumkot cluster 6. Mahat, Morawang, Chunwang, Kakri– Mahat cluster

Medicines for Response Team are located in Rukumkot and Aathbiskot HFs. In remaining HFs, rapid response team is managed from DHO Rukum itself and Chaujahari hospital.

3.8 STRENGTH AND OPPORTUNITIES

The major strengths of the DHO as observed during the RA are as following: • DHO staff structure sanctioned verses fulfillment positions are good (76%) • One district hospitals and one community hospital in the district • 387 FCHVs at community level, two CEOCs, lab, X-ray, USG, are functioning • Availability of trained SBAs are 33 • Out of 21 Birthing centers; 19 birthing centers have been providing SBA services furthermore, these birthing center have separate room and equipment except Pwang HF. • RHCC formation and organize meeting • Some FCHVs are provided incentives from local bodies (VDCs) and meeting expense like snacks from EDPs (UNFPA, UMN, NGOs) • Monitoring and supervision system from DHO to HFs • Internet facility in DHO from three access points • Computers (5), laptops(3), Fax, Photocopy and printers(6) are functional in the office • Web based HMIS, LMIS, data validation program is implemented • 12 HFs have implant sites These includes District hospital, Aathbiskot, Rukumkot, Syallapakha, Mahat, Bafikot, Musikot, Rugha HPs and Kol PHCC, Gotamkot and Khara SHPs similarly Charujahari community hospital • DAG mapping DDC, Settlement level HHs poverty, deprivation mapping from LGCDP and recently poverty profiling of individual HHs members DDC/Ministry of Poverty and Cooperatives in the District • Rapid Response Team(RRT) district level and Community Rapid Response Team(CRRT) at HFs level are functional and Weekly reporting system from DHO RRT to center

6 3.9 KEY ISSUES AND CHALLENGES

The major challenges and constraints faced by the D/PHO Rukum are as following: » Retain to motivate DHO staffs in their working area, HR placement in inaccessible area is low and district headquarter periphery is high » Regularize and sustain equipment functioning » In HFs implant sites; there are scarce of implants and inadequate skilled workforces » Out of skilled 34 SBAs only 19 SBAs are engaged in 19 birthing centers remaining two birthing center still lack of skilled SBAs » Birthing center infrastructures are poor(Pwang) » RHCC meeting regularity, flooring agenda in discussion, deliberation » QWAG is not formed till date » GESI committee is not formed till date » Reliability Internet connection facilities is very poor » No planned, periodic monitoring and supervision system and no practice of integrated monitoring and supervision tools during monitoring visits » M/DAG mapping in planning process and designing activities in the district is weak » HMIS and LMIS reporting system from most of the peripheral HFs to district is delayed » FCHVs receiving incentives from VDCs are not documented and not sustainable, » Poor coordination of HFs with HFOMCs, VDCs,DDCs even with EDPs » Sustained resource pooling from VDCs to FCHVs incentives, meeting allowances » Initiate and regularize private hospitals into systematic reporting channel

7 4. SERVICE STATISTICS

The RA also sought information on the service statistics of the following programs: Immunization, Child health, Safe Motherhood and Family Planning. HMIS data for the last four years, 2065/66 to 2068/69 were analyzed. The four year trend analysis of the selected indicators is presented in this section. Data for the running FY-2069/70 is not complete; therefore it has not been analyzed in the trend analysis.

4.1 IMMUNIZATION

Figure 4.1; Measles Coverage As shown in above chart, Measles vaccination coverage in the last four year is in increasing trend except in the last year. The coverage in Rukum have been consistently above the Nepal’s aggregate in all four years. The objective of National immunization program is to sustain or achieve more than 90% of coverage of all antigens including measles. There is need to maintain measles coverage in Rukum district.

4.2 CB-IMCI

Figure 4.2 reveals that percentage of severe pneumonia among new case of Rukum district is very high as compared to national data. To address the situation HFs has to develop micro plan and mobilize community, volunteers, health workers for early case detection and treatment at community level. Severe pneumonia cases in Rukum are four folds greater that of Nepal’s in all FY. In the most recent year it was high at 2.2 percent.

Figure 4.3 reveals that in Rukum district the percentage of severe dehydration among total new cases has been declined. However, the proportion is much greater than that of Nepal’s total in all four years.

Figure 4.2: Percentage of severe pneumonia Figure 4.3: Percent of Severe among new cases dehydration among new cases

8 4.3 SAFE MOTHERHOOD Figure 4.4: ANC visit as percentage of expected pregency Figure 4.3 shows that 1stANC visit as percentage of the expected pregnancies is above 90 percent over last three FYs. Further, 4th ANC visit as percentage expected pregnancy is less than one- half of the first ANC visits.

4.4 FAMILY PLANNING

The above chart shows that the contraceptive prevalence rate (CPR) of Figure 4.5: CPR as percentage of MWRA Rukum district is in less than one- quarter in the four consecutive fiscal years. The national CPR is above 40 percent. This shows that there is a wide gap between national and district CPR over the four consecutive FYs. The chart shows that there is significant unmet need of FP method among the users. This data also implies that CPR of Rukum is almost less than one-half of the national CPR.

Table 4.1: Trend in utilization of services SN Indicators 2065/66 2066/67 2067/68 2068/69 1. BCG coverage 87.17 113 100.69 97.31 2. DPT 3 80.23 81.4 104 92.91 3. Measles vaccination coverage 75.08 93.62 97 88.32 4. TT 2 coverage among pregnant women 62.35 68.2 68.05 63.38 5. Percent of postpartum mothers receiving 29.10 42.99 35.52 38.76 Vitamin A within 6 weeks 6. Percent of pregnant mothers receiving iron 60.09 108.25 87.58 65.67 tablets 7. Proportion of new pneumonia cases treated 43.18 39.96 60.19 81.93 with antibiotics 8. Percent of severe pneumonia among new cases 2.07 2.42 1.57 2.21 9. Proportion of new diarrheal cases treated with 20.65 15.23 97.17 86.49 ORS (under 5 years children) 10. Percent of severe dehydration among new cases 2.02 1.54 0.90 0.98

11. ANC 1st visit as percent of expected pregnancies 65.61 98.25 97.33 90.5 12. Four ANC visits among as percent of expected 23 37 33 36.64 pregnancies 13. Delivery conducted by SBAs (both home and 11 18 18.64 21.59 institutions) as percent of expected pregnancies 14. PNC First visit as percent of expected 29 48 29.5 28.38 pregnancies 15. Contraceptive prevalence rate (all methods) as 18.6 23.86 21.67 23.52 percentage of MWRA Source: HMIS Rukum , 2012

9 5. HEALTH FACILITY MANAGEMENT COMMITTEE AND LOCAL HEALTH GOVERNANCE

Information on Health Facility Operation and Management Committee was sought from both DPHO and DDC. Both quantitative and qualitative methods were used for collecting information. Information was collected on the following topics: HFOMC functionality, capacity building, presence of different community-based groups at VDC level and their federations at district level. This chapter presents the major findings of the assessment on HFOMC.

5.1 FUNCTIONING HFOMC

It was found out during the RA that MoHP circulated a letter to DHO to handover the HFs to local bodies some years ago. However, no HFs (PHCCs, HPs and SHPs) were handed over to the local bodies. It was also found out that the DHO has no plan to build capacity and monitor HFOMCs activities in VDCs but there has conducted some supportive program in collaboration with UMN, and UNFPA. The DHO supervisors, external development partners and VDC secretaries were also asked some questions on criteria for measuring HFOMC functioning. They opined following criteria as being key for measuring HFOMC functionality are: » Regular monthly and need-based meeting » Have specific plan action » Local resource utilization Plan of action, Resource SN HFOMCs Meeting follow up utilization HFOMC is formed in all HFs and the DHO 1 Rugha Yes Yes Yes supervisors expressed that about 25 2 Musikot Yes Yes Yes percent of the total HFOMCs of the district 3 Kotjahari Yes Yes yes are functional. The top five functional 4 Pokhara Yes Yes yes HFOMCs as judged by the district 5 Magma Yes Yes yes supervisors include Rugha, Musikot, Kotjahari, Pokhara and Magma. The bottom five HFOMCs in terms functionality 1. Hukam, Similarly, the bottom five HFOMCs in terms 2. Ranmamaikot, functionality are Hukam, Ranmamaikot, 3. Takasera Takasera, Kol and Rangsi. This HFs does 4. Kol not meet regularly and do not have action 5. Rangsi plan. The DHO supervisors rated the HFOMCs based on their supervision visit and to perform annual activities, and not specifically for HFOMC monitoring, therefore these data have to be interpreted with caution.

5.2 CAPACITY BUILDING OF HFOMC

The HFOMCs in district have received capacity building training from Safer Motherhood Network Federation Nepal in support of European Commission and ADRA Nepal. The activities carried out for capacity building were re-formation of HFOMCs and HFOMCs training with coordination and collaboration with DHO Rukum. Due to absence of VDC secretaries at VDC level, and lack of plan to follow up program and refresher trainings provided to HFOMCs, the functioning of HFOMCs is questionable. In the last two years, the HFOMCs training were provided by DHO in support of UMN and UNFPA in 7 and 10 VDCs respectively. UMN has follow up program on effectiveness of the

10 HFOMCs training. None of the organizations and even DHO has follow up program and refresher trainings for HFOMCs.

5.2 COMMUNITY GROUPS/FEDERATION/ALLIANCE According to the district supervisors’ and DDC, different type of community groups exists at VDC level of Rukum district. These groups include- • Forestry Users Group • Mothers’ Group • Drinking Water Users Group • Irrigation Users Group • Road Rural Users Group • Cooperatives • Media 3 FMs and 57 Youth clubs

At district level there are federations as follows- • Community Forestry Users Group(CFUG) • Water Users Group(irrigation, drinking water supply) • Cooperatives ( different types saving and credit union, Digreya Saikumari savi.credit, Samudayik saving and credit) • Youth Clubs (Networking loose forum at DDC) • Journalist federation • NGO federation

5.3 STRENGTH AND OPPORTUNITIES

 Formation of HFOMCs in all HFs, few are chaired by VDC secretaries, and majority chaired by social worker.  Some HFOMCs are functional and trained by DHO in support of UNFPA and UMN  Community-based organizations (CBOs) exists at the community and district  HFOMCs capacity building support from UNICEF, UNFPA, SC and UMN  VDCs and DDC also earmarking promotional fund for HFs, HFOMCs through infrastructure construction, equipment for birthing center and incentives for volunteers, workforce

5.2 KEY ISSUES AND CHALLENGES

 HFOMCs are not handover to local bodies  HFOMCs are not oriented about the roles and responsibility, management and operation system required for HFOMCs except a few HFOMCs  VDCs, DDC and DHO are not fully aware to their responsibilities to monitor and supervise HFOMCs  Low level of interest of general members in HFOMCs except Chair  HFOMCs have limited knowledge on local governance issues i.e. planning cycle, resource pooling, coordinating with VDC secretaries, EDPs on health sector for integration of health issues in annual plan  No focal person designated to look after the HFOMC in DHO  Most of the HFOMCs are chaired by either political or social worker except in few VDC secretaries; In addition, VDC secretaries are reluctant to engage in HFs functions as to monitor, supervise and provide feedback even cross their decisions.

11 6. SERVICE DELIVERY/QUALITY IMPROVEMENT

This chapter presents the RA findings related to service delivery and quality of care. Information on the quality of ANM schools, infection prevention practices at HFs, implementation of community- based interventions, and the provision of IUCD and Implants services were collected at district level. The major finding of the assessment is presented hereunder.

6.1 ANM SCHOOLS

H4L intends to improve the quality of pre-service ANM trainings. As such basic information on the ANM schools of Rukum district were sought from DHO and the ANM schools during RA. In Rukum there are no ANM Schools.

6.2 INFECTION PREVENTION AND WASTE MANAGEMENT PRACTICES AT HFS

Few questions related to infection prevention and waste management practices followed at HFs were also asked to district supervisors during RA. It was found that different HFs practice different type of infection prevention and waste disposal practices. In district hospitals, medical wastes are collected in 3 colourful buckets while sharp instruments and syringe are collected in a safety box for further processing. The collected wastes such as plastics, paper, rubber, cotton and dressing bandages are burnt openly in pits or open fields and sharp instruments are buried in pits. According to nursing staffs working in the hospital, they used to wash their hand with soap-water and use disposable globs usually during nursing procedure, but they do not prefer using apron, masks and boots except in labor room. The hospital wards and surrounding are cleaned once in a week. In the laboratory, the collected specimens such as dried blood, sputum are usually burnt. The floors and surface are disinfected by 5 percent Chlorine. Ten HFs in Jajarkot have placenta pit. Other Birthing centers disposes placenta by burying inside a pit. Quality Assurance Working Group is not formed in the district.

6.3 SERVICE DELIVERY

The RA sought information on the availability of Satellite clinics, CEONCs, long acting FP methods, implementation of community- based interventions such as CB-NCP, MSC, Calcium, and service integration.

In Rukum, 4 HFs have satellite clinics. Due to budget constraint these satellite clinics are not functional at the time of RA. District has two CEONCs services, one is under the Chaurajahari community hospital that provides service on regular basis and one CEONC service has just been established in district hospital. At present the center is providing BEONC services but will soon start providing CEONC services too.

In Rukum, MSC was implemented by DHO in the support of UNICEF in 2067. CB-NCP is not implemented in Rukum. With regards to providing long acting reversible FP methods, IUCD service is being provided from 13 HFs and Implants from 12 HFs. A total of 34 nursing staffs are trained in SBA. It was also found out that 13 HFs are providing services and others are not due to inadequate supply of IUCDs sets and infection prevention measures. According to the service provider, they

12 are not able to provide implant services as per users' demand because of under supply of Implants in the district Table 6.1: IUCD and Implants Insertion and Removal Sites of Rukum IUCD Birthing Center Implants Birthing Center 1. District Hospital Yes 1. District Hospital Yes 2. Chaujahari Yes 2. Yes community hospital Community Hospital 3. Syallapakha HP Yes 3. Aathbiskot HP Yes 4. Rukumkot HP Yes 4. Rukumkot HP Yes 5. Aathbiskot HP Yes 5. Syallapakha HP Yes 6. Bafikot HP Yes 6. Mahat HP Yes 7. Kol PHCC Yes 7. Bafikot HP Yes 8. Jaang HP Yes 8. Musikot HP Yes 9. Khara SHP Yes 9. Kol PHCC Yes 10. Chunwang HP Yes 10. Gotamkot SHP Yes 11. Musikot HP Yes 11. Khara SHP Yes 12. Kotjahari PHCC Yes 12. Simrutu HP Yes 13. Mahat HP Yes Source: DHO, Rukum 2013

It was reported that 111 HWs and 115 FCHVs in Rukum needs CB-IMCI training.

6.4 STRENGTH AND OPPORTUNITIES

 10 birthing centers have placenta pit  4 HPs have satellite clinics  2 CEONCs are functional in the district  13 IUCD sites, 12 Implants sites are functional and there are opportunities to expand IUCD services in all SBA sites, as SBAs are trained on IUCD and Implant service in all the Health Posts. Seven HPs out of 10 HPs and 31 SHPS in 2 SHPs respectively have implant sites.  MSC and IYCF programs are implemented in Rukum  In Rukumkot, Kotjahari and Chunwang HPs, there is provision of providing Rs. 50-100 per cases to FCHVs for referring pregnant women to deliver in birthing center as incentive, managed from the HF management cost.

6.5 KEY ISSUES AND CHALLENGES  Out of 21 birthing centers, 11 birthing center have not placenta pit  111 HWs and 115 FCHVs needs CB-IMCI training  Sustained functioning of CEONCs and birthing centers  QAWG formation and making them functional  Provision of implant training to health workers and supply of IUCD sets and implants  Systematic clinical supervision to HFs by SBA focal person is not in place  On site coaching and supportive feedbacks to health workers  FCHVs are illiterate and inactive  Less public are aware of the range of services available at HFs. Information on time, place and service charge is also not known to people  Retention of skilled staffs and increasing their motivation

13 7. LOGISTICS MANAGEMENT SYSTEM

Logistics management is an important part of district health systems. Efficient logistics management is required to smoothly run all the public health programs at district, sub-district and the VDC levels. The RA also sought information from D/PHO on the logistics management system. The major findings of the assessment are presented below.

7.1 AVAILABILITY OF KEY DRUGS AND COMMODITIES

During RA, the D/PHO store room was also visited and the store keeper was interviewed. The availability of ten tracer drugs/commodities (Injectable, Oral Contraceptive, Condom, ORS, Vitamin A, Iron Folate Tablets, Cotrim (Ped), Zinc, Oxytocin and MgSO4) in the district store at the time of visit was checked. It was found that all tracer drugs/commodities were available. The store keeper was also asked whether the ten drugs/commodities were out of stock anytime in the last 12 months, and it was found that no any tracer drugs were found stock outs during last 12 months. The RA team members also checked the expiry dates of these ten drugs/commodities and it was found that none of the tracer drugs have expired. Table 7.1: Availability of key drugs/commodities and their expiry dates SN Drugs/Commodities Availability at Stock out in Expired drugs in the time of the last 12 stock at the time of visit months visit 1 Injectable Contraceptive Y No No 2 Oral contraceptive Y No No 3 Condom Y No No 4 ORS Y No No 5 Vitamin A Y No No 6 Iron Folate Tablets Y No No 7 Cotrimoxazole (Ped) Y No No 8 Zinc Y No No 9 Oxytocin Y No No 10 Magnesium Sulphate(MgSo4) Y No No Source: DHO Rukum, 2013

The Store keeper was also asked to list the drugs/commodities that have most problems with stock outs in the FY 2069/70. There was no any stock out problems in this fiscal year

7.2 COLD CHAIN AND FEFO MANAGEMENT

D/PHO Rukum has four functioning refrigerators. The available refrigerators are sufficient to D/PHO for maintaining cold chain. The management of five to ten drugs in the store were checked to see whether First Expiry First out (FEFO) was maintained or not. It was found that FEFO system was not maintained properly the warehouse was newly constructed and was in the process of management.

7.3 LMIS REPORTING

D/PHO is using web-based LMIS to report to center. D/PHO has recruited computer operator for data entry.

14 7.4 STRENGTH AND OPPORTUNITIES

 Newly constructed warehouse  Web-based LMIS in place  Sufficient staffs at DHO  Sub district level cold chains in Kotjahari and Rukumkot HFs

7.5 KEY ISSUES AND CHALLENGES

 Unnecessary commodities/ outdated materials (X-ray machine, computers, and refrigerators) need to be cleaned and sorted out  FEFO system not followed due to lack of racks inside the warehouse  Drugs, Recording formats, BCC materials, books and resources were not maintained systematically and were not disseminated to concerned stakeholder on time  Untimely and inadequate supply of logistics from center/regional level to district  No timely follow of logistics cycle

15 8. BEHAVIOR CHANGE COMMUNICATION

H4L aims to understand legal, cultural/religious, and policy dimensions of GESI inequities on health service access and use and design interventions to ensure sustainable, high-quality BCC and IEC approaches that respond to local realities, and include groups not commonly targeted, but crucial to meeting Nepal’s health goals.

One of the objectives of the RA was to explore the range of BCC interventions that is being implemented for healthy behaviors. Following are the major findings on BCC:

8.1 EXISTING DHO PROGRAMS ON BCC

 DHO Rukum has school based peer education program on Adolescent and Sexual Reproductive Health (ASRH).  JANASWOSTHA KARYAKRAM in Sano Bheri FM contents are health related problems/issues and remedial measures  Street drama on Family Planning, Safe Motherhood and Newborn care  Orientation program for pregnant mother and their families  One day orientation programs with teachers, mothers group, watch group formed by child friendly local governance(CFLG) at CFLG VDCs level and FCHVs  Radio program on essential health care services program access and utilization in Kham (local language) and Nepali ( weekly 40-45 episodes)  In equity and access program local hired NGOs conducted Drama at community level for behavior change to seek health facility from hard to reach population segments. Similarly, during interview in FMs with health staffs segment quiz, response answers also incorporated between health work forces (HWFs) and client, innovation share from HWs. Further song, joke, Muktak from audience also included in phone call during program time

8.2 FM STATIONS/CABLE TELEVISION NETWORKS

In Rukum there are 3FM stations. Following are the name and address of the FM stations:

 Sano Bheri 89.2 MHZ and 100.8 MHZ  Sisne FM 93.2 MHZ  Community FM 102.0 MHZ

DHO Rukum has partnered with Sisne FM and Sano Bheri FM stations for airing radio health programs and Public Service Announcements (PSAs) on ASRH, Nutrition, Immunization, HIV AIDS, and essential health care services. There is one Cable TV networks in Rukum but it does not broadcast health programs.

8.3 ORGANIZATIONS WORKING IN IEC/BCC ACTIVITIES

RA identified following organizations working in IEC/BCC activities in Rukum:  UNFPA  UMN

16  Save the children  DDC  WCO

H4L plans to use mobile phones to reach target groups with messages on health in selected district. The RA also explored whether any organization has used mobile phones to communicate health messages to target groups or entire district population together with D/PHO. It was found that none of the organizations were involved in using mobile phones to communicate health message.

8.4 ORGANIZATIONS WORKING IN IEC/BCC ACTIVITIES

One area of intervention of H4L is to improve the quality of counseling provided by health workers and community-based health workers to clients. It is therefore essential to find out whether there is pool of resources available at district level to improve counseling services. Hence, RA also collected information on the district health staff who received training on COFP/C in the last three years. Following are the health workforce resources available to train on COFP/C: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

8.5 SCHOOL HEALTH PROGRAM

Conducting health education classes at schools is one of the important BCC activities of DHO. In the last FY 2068/69, 250 school health sessions were organized in 71 schools sessions are based in need and size of students. A total of 1,700 Students were oriented on the following topics HIV AIDSs, Leprosy, TB, ASRH, personal hygienic, sanitation, nutrition, and immunization.

According to the Population Management Focal person, beside school health education program School-based Peer education program in 10 higher secondary schools focusing ASRH activities will be effective in reaching adolescents with health messages. Ten information centers are established in Rukum in order to provide services to the adolescents in the schools.

In the last year DHO Rukum had implemented IEC/BCC activities under "access and equity" program through local NGOs for increasing M/DAG’s access to service. The activities included street drama, radio program, orientation to pregnant women and their families, mother groups, FCHVs, teachers and HFOMC members. The topics covered were related to maternal health, newborn health, child health and family planning.

17 8.6 MAPPING OF DAG AND EXPLORING CULTURAL PRACTICES AFFECTING HEALTH

During the RA, in-depth information on DAG communities residing in Rukum district was also collected. Though there was no position of Health Education Technician Officer in Rukum, public health inspector and DDC were interviewed for this. The major findings of this assessment are as following:

Following are the list of VDCs that constitute inhabitant of deprived groups that needs more support from development partners and government. These VDCs lie in the 4th category in M/DAG mapping, meaning highly concentrated by DAG.

Table 8.1: VDCs of Rukum highly populated by M/DAG SN Village VDC/Wards that Household Caste groups % Development constitute number committees DAG/Dalit (2011 cen.) concentration 1. Aathbisdandagaun 3,5 1440 Dalits 33%, Janajati 44% 2. Chunwang 1,7,8 609 Dalits 50%, Janajati 16.5% 3. Gotamkot 1,2,6,7 1361 Dalits 32.6%, Janajati 1.7% 4. Hukam 1 475 Dalits 15%, Janajati 80% 5. Jhang 1,2 579 Dalits 25%, Janajati 25% 6. Kakri 9 1008 Dalits 10%, Janajati 90% 7. Kol 1,9 707 Dalits 15%, Janajati 80% 8. Mahat 6,7 937 Dalits 49%, Janajati 37.14% 9. Pipal 7 846 Dalits 23.2%, Janajati 3.5% 10. Purtimkanda 1,2 932 Dalits 24%, Janajati 51% 11. Ranmamaikot 1 to 9 775 Dalits 30%, Janajati 65% 12. Sisne 2,5,7,9 372 Dalits 5%, Janajati 0% 13. Syallakhadi 1,2 852 Dalits 22%, Janajati 22% 14. 1,3,8 904 Dalits 27%, Janajati 73% Source: DDC M/DAG mapping, 2064

Villages that still practice early marriage and Early Child Bearing: Early marriage and early child bearing practice is pervasive in the Rukum district. Due to socio cultural practices to get support for household chores, early marriage is practiced. Particularly early marriage is prevailing most among kami, damai, badi, sharki, janajati (magar) community.

The root cause of early marriage might be poverty, lack of knowledge on the disadvantages and risks of early marriage and pregnancy, and lack of knowledge of existing laws.

UNFPA conducted peer education through District Education Office (DEO). WCO conducted Kishor Kishori Sikshya from FMs (Sisne, Sono Bheri). Similarly Child friendly local governance (CFLG) supported Child club watch group to monitor early marriage practice at community, and preserve the right to health of children.

18 Migration pattern: Economic active age group, specifically the males from almost all parts of Rukum (43 VDCs) migrate to India and urban area of Nepal for work opportunities. Migrations usually in agriculture lean period are common.

According to District Food Security Network based at District Agriculture Development Office, migration pattern of economically active age particularly male, about 15-20% migrated for seasonal job in India and elsewhere for earnings. There is no data available to measure in-country migration and migration abroad.

Table 8.2: Distance and mode of travel to VDC from District Head Quarter SN Ilaka Institutions Distance from Mode of travel Remarks DHQ (in Kosh) 1 Kotjhari PHC 15 On foot&seasonal motorable Kotjhari Khola Gaun SHP 11 On foot & seasonal motorable PHC Nuwakot SHP 8 On foot & seasonal motorable Purtimkada SHP 10 On foot & seasonal motorable Bijeshwari SHP 16 On foot & seasonal motorable 2 Kol PHC 23 On foot & seasonal motorable Ranshi SHP 20 On foot & seasonal motorable Kol PHC Hukaam SHP 37 On foot & seasonal motorable Ranmamaikot SHP 40 On foot & seasonal motorable Takasera SHP 23 On foot & seasonal motorable 3 Mushikot HP 0 DHO Mushi kot Shankh SHP 3 On foot & seasonal motorable HP Chibang SHP 2 On foot & seasonal motorable Arma SHP 5 On foot & seasonal motorable Simli SHP 5 On foot & seasonal motorable Garaila SHP 5 On foot & seasonal motorable 4 Rukumkot HP 10 On foot & seasonal motorable Rukum Sailapakha SHP 5 On foot & seasonal motorable kot HP Pokhara SHP 9 On foot & seasonal motorable Kanda SHP 14 On foot & seasonal motorable 5 Mahat HP 15 On foot & seasonal motorable Mahat HP ChunwangSHP 12 On foot & seasonal motorable Morabang SHP 16 On foot & seasonal motorable Kankre SHP 18 On foot & seasonal motorable 6 Jang HP Jang HP 26 On fooet Sisne SHP 29 On foot Pwang SHP 19 On foot 7 Simrutu HP 5 On foot & seasonal motorable Chaukhabang SHP 5 On foot & seasonal motorable Simrutu Bhalakcha SHP 3 On foot & seasonal motorable HP Peugha SHP 6 On foot & seasonal motorable Khara SHP 5 On foot & seasonal motorable Muru SHP 6 On foot & seasonal motorable 8 Baphikot HP 5 On foot & seasonal motorable Baphi kot Jhula SHP 6 On foot & seasonal motorable HP Pipal SHP 7 On foot & seasonal motorable Magma SHP 6 On foot & seasonal motorable Duli SHP 10 On foot & seasonal motorable 9 Aathbish Kot HP 17 On foot & seasonal motorable Aath bish Gotamkot SHP 29 On foot & seasonal motorable kot HP SyalakhadiSHP 26 On foot Aathbishdadagaun SHP 15 On foot&seasonal motorable Ghetma SHP 14 On foot&seasonal motorable

19 H4L has to develop communication intervention plan so that it would be supportive in meeting the district need. Following activities should be covered:  In some of VDCs communication through mobile messages for communication are to be piloted  Adolescents- whether school going or out of school are to be incorporated in peer education session  School management committees, HFOMCs, mother groups, youth clubs (groups) are to be orientated on ASRH  Youth clubs available in the local level are to be incorporate peer educators list and provide ToT to mobilize in school, community level in ASRH activities. 8.7 STRENGTH AND OPPORTUNITIES

 Government had regular BCC related programs  EDPs like UNFPA, UMN, CFLG, LGCDP, SC, DDC and VDCs and line agencies are working in health related programs  Social organizations, local groups, youth clubs, federations are engaged in community level  Availability of FM stations, mobile phones network, local newspaper, and electricity

8.6 KEY ISSUES AND CHALLENGES  Consistency on messaging the health issues  Harmonization of the different sources on health related/ H4L objectives  DHO leadership and management of BCC activities  Disseminate health message to hard to reach populations and using proper way of communication considering language. Drama, interview, leaflets, and flexes might be useful.

20 9. ADOLESCENTS AND YOUTH FRIENDLY SERVICES

H4L will also work with DHOs in selected districts to improve service accessibility of Adolescents under its Objective 6. The RA also explored different aspects of Adolescents and Youth friendly services in the public health facilities of Rukum district. Following are the major findings:

9.1 EXISTING SERVICES FOR ADOLESCENT

In Rukum, there is focused program for Adolescents from the support of UNFPA, WCO and UNICEF (CFLG). These programs are “choose your future” Adolescent girl development program, and Adolescent girl’s education from FM (on access and utilization of equitable health and nutrition services). DHO with the support of UNFPA and UNICEF has declared 19 HFs in Rukum as adolescent and youth friendly reproductive health service sites.

9.2 ORGANIZATION WORKING FOR ADOLESCENT

UNFPA, UNICEF and WCO are working in Rukum district along with other NGOs, DEO, DDC, and DHO. UNFPA is providing funds to following local body and agencies:  District Education Office,  District Health Office,  District Development Committee. The Main activities covered are as following:  Adolescent sexual and reproductive health right  Adolescent sexual and reproductive health right friendly services, norms and features  Orientation on adolescent support and services available in health facilities  Sensitization on ASRH, FP, gender equality, gender-based violence

The program was focused in two clusters: Aathbiskot and Simrutu in Rugha, where 2 peer educators (boy and girl) each from 12 schools were trained on RH and early marriage. The program covered VDCs were Muru, Peugha, Rugha, Aathbiskot, Kanda, Mahat, Simli, Garayalla, Aathbisdandagaun.

Program coverage and implementation have mixed learning as follows  Approaches through health teacher to educate, sensitize and provide services openly to adolescents (boys and girls) were less effective.  Approaches through peer educators, separately with boys and girls alone; while health teacher as a focal person to solve issues not addressed by educators to different sex group(girl, boys) seems more effective  In health facilities, providing ASRH services at 2 pm or afterwards in separate room is more effective program for adolescent. Dissemination of BCC materials at school premises is also effective.  Debate, quiz, folk songs competition, award is more effective to increase ASRH knowledge.  In addition, learning from the adolescent and youth friendly services program the following points are to be considered in further planning  Interview with Doctor/HWF on FM taking questions and answers, regarding ASRH from adolescents

21  Segment quiz, response, innovation share, debate, songs competition on ASRH issues rewards  Orientation to stakeholders (Parents, HFOMCs, teachers) on ASRH  Staffs orientation (whole in HFs)  Awareness raising in community, parents, school management committee and target groups  In school, availability of adolescent/IEC/BCC materials dissemination seems more effective

9.3 STRENGTH AND OPPORTUNITIES

 19 ASRH service sites are in place  EDPs and NGOs are supporting ASRH activities  DHO leading the ASRH activities with EDPs  WCO also engaged in ASRH activities including prevention of early marriage  Availability of 57 youth clubs and federations, networks in the district  Local bodies budgets are used in ASRH promotional activities

9.4 KEY ISSUES AND CHALLENGES

 Despite 19 AYFS sites in Rukum, AYFS is not available. Reporting systems and monitoring of the ASRH activities is lacking  Improper coordination and harmonization of all programs regarding to ASRH from DHO. Need to encourage one door policy, consistency, reporting, and documentation of progress.  Lack of initiation from Focal persons and weak reactiveness on ASRH reporting system  Need of DHO efficiency on managing, coordinating, collaborating with line agencies, local bodies and EDPs  Need to regularize ASRH programs and government to follow up on the progress made overtime  Need to mobilization of youth clubs in community and targeted populations  In appropriate clinic location and time  Untrained Health Worker on adolescence reproductive health issues  Irregular budgeting and irregularity of service provider  Inappropriate location and time  Lack of public awareness  Age and sex of service provider is a barrier  Social barriers on reproductive health concerns especially for girls

22 10. GENDER EQUALITY AND SOCIAL INCLUSION

H4L is designed to support the Government of Nepal’s stated commitment and responsibility to ensure that quality health services are accessible to all citizens. As such, it is critically important that sound, ongoing GESI-sensitive analysis and gender integration underpin H4L program interventions. H4L’s GESI Objectives are designed to redress gender and social inequities, and dove-tail with the objectives set forth in the MOHP’s 2009 Health Sector Gender Equality and Social Inclusion Strategy as follows:  Objective 1: Support existing MOHP policies, strategies, plans and programs that create a favorable environment for integrating GESI in Nepal’s health sector;  Objective 2: Support MOHP’s efforts to enhance the capacity of service providers and ensure equitable access and use of health services by the poor, vulnerable and marginalized castes and ethnic groups; and  Objective 3: Improve health-seeking behavior of the poor, vulnerable and marginalized castes and ethnic groups in collaboration with local government partners, community-based organizations (CBOs) and other stakeholders.

The first objective is related to policy while the latter two are directly related to DHO systems.

The RA also included assessment and analysis of the health programs of the DHO Rukum from GESI perspective. The major findings were as following: » GESI committee is not formed » DHO staffs are oriented on GESI from health programs view point from RHD Surkhet » DHO focal person participate on District GESI committee DDC Rukum every month where each office reports on GESI progress in their own office.

10.1 FORMATION AND FUNCTIONALITY OF GESI COMMITTEE

In Rukum, is given the responsibility of GESI focal person. GESI technical working group is not formed so far but, the DHO staffs were oriented on GESI integration in programs from regional health directorate in July 19, 2012.

At the DDC level, DHO participate in district GESI committee chair by LDO. WCO is the member secretary of the committee and the district line agencies are members. The committee has mandate to address GESI issues in district level. Further, this GESI committee plans to conduct meeting once a month but the meetings are not conducted as planned to integrate and mainstream GESI in the activities of all respective line agencies within the district. Regarding effectiveness and agendas of the committee, the women development officer viewed that a few offices reported the progress over the time. It was reported that in reality, the committee meets only for formality and is less effective.

DHO staffs are aware of the importance of GESI technical working group to mainstream GESI in DHO programs. They viewed that budget has not been allocated for the technical working group to function. Last year government has sanctioned budget to carry out GESI related activities such as for sensitization on gender-based violence. According to the supervisor and focal person, in this fiscal year there is no budget provision, therefore no activities are conducted. According to them there should be budget for the working group to function.

23 10.2 ORGANIZATIONS WORKING ON GESI

LGCDP is working on GESI and was also visited during RA. Interaction with the staff working on the project revealed that program coverage is in 43 VDCs including program implemented in district through local bodies. Program emphasizes to implement GESI guideline and advocate, follow of GESI integration on DDC programs including line agencies, NGOs and EDPs programs. GESI committee meeting is held on every month in DDC Rukum. This committee not only review progress reports on GESI integration of DDC and WCO solely but from the all line agencies progress and guide cross cutting issues.

Furthermore, in the district women and child office, UNFPA, LGCDP are working on GESI integration and mainstreaming and other line agencies have main component of GESI integration.

Major constraints of GESI working group and ways forward as follows  Budget for GESI mainstreaming meeting is needed and performance rating of program focal persons based on GESI mainstreaming  Every supervisor is to be aware of the GESI integration. Report on the status of their GESI mainstreaming is essential and the progress needs to be discussed in meetings at DHO level  Focal person has to document and monitor progress, solve issues with participation of the DHO staffs and report to district level GESI committee from health perspective.  GESI mainstreaming training for district supervisors. Progress made on GESI integration to be followed up and should be agenda for discussion for Ilaka level as well.

*****************

24 Annex 1: Contact information of D/PHO Staff, Rukum Years of Added Years of Cell Phone D/PHO Team (current) Name service in Responsibility service no. district District /Public Health Officer 1 Public Health Officer 4/12 4/12 Public Health Nurse No responsibility Statistics Assistant/Officer 7/12 7/12 FP focal person FP/FCHV 24 5

Malaria focal person No sanctioned position Health Education Tech/ No sanctioned position Officer DTLA/Officer Vaccant EPI Supervisor/Officer 4 4 Cold Chain Assistant/ Officer 30 11 Computer Operator/Officer No sanctioned position Store Keeper 9 3 Child Health focal person Padnam PHO 28 27 Senior AHW Medical 10 6 record/popul ation Medical Recorder No sanctioned position Staff Nurse 6th level PHN 22 16 PHI BCC/IEC/GES 32 7 I/NHTC PHI Epidemiology 23 18 and disease control

Annex 2: RHCC Members SN Name of the organization/ Organization Focused area (technical) of intervention Remarks type 1 District Health Office, Rukum Overall district health system chairperson

2 District Development Committee, Rukum Child friendly local governance, BCC, GESI, Member Planning officer social section 3 District Education Office, Rukum ASRH, School health program Member DEO 4 Women and Children Office, Rukum GESI, BCC Member

5 Khalanga VDC secretary BCC, GESI Member

6 Nepal Red Cross Society, Rukum DRR, Nutrition, Safer motherhood Invitee President member 7 Nepal Public Equity and Access program, nutrition Invitee Shambhu BC member 8 United Mission Nepal, Rukum HFOMC strengthening, nutrition Invitee member 9 United Nations Population Fund ASRH, IEC/BCC Invitee member 10 FP supervisor FP supervisor Member secretary

25 Annex 3: Name list of Participants interacted during Rapid Assessment in Health for Life Program SN Name of Participants Designation Address Phone no 1. Local Development Officer DDCO Rukum 088530091/53 0120/530213 2. Planning, monitoring and DDCO, Rukum 088530091 Administrative officer 3. Program Coordinator Save the Children 9841300828 4. Chairperson, Rukumeli Samaj 9851162315, Development Center ( 088-530134 RSDC), Rukum 5. ME Supervisor, RSDC Rukum 088-530134 6. LN Coordinator RSDC, Rukum 088-530134 7. Station Manager, Saani Bheri FM, Rukum 9857821507, 088-530056 8. School Inspector; UNFPA District Education Office, 088-680138 Focal person Rukum 9. Resource Person District Education Office, 088-680138 Rukum 10. Technical Assistant District Education Office, 088-680138 Rukum 11. Technical Assistant District Education Office, 088-680138 Rukum 12. Program Coordinator MIC Nepal, Rukum 088-530216 13. Program Officer ( Focal DDCO Rukum 088- person social sector) 530120/53021 3 14. Women and children DWCO, Rukum 088-530022 Development Officer 15. Team Leader UMN, Rukum 088-530, 9748520509 16. Project Officer Red Cross Society Rukum 17. Executive Secretary DDC LDF, Rukum 088-530229 18. Coordinator Balvita Rukum 9857821891 19. Livelihood and Nutrition Save the children, 9805332347 Officer Rukum 20. District coordinator CSP/CARE Rukum 9847852581/9 748006071 21. Chairperson NPAF 9741066734 22. Program Officer UMN, Rukum 088530102 23. District Facilitator/CFLG LGCDP, Rukum 9841888447 focal person

26 HEALTH FOR LIFE

REPORT ON

RAPID ASSESSMENT

OF DISTRICT HEALTH SYSTEMS

2013 SALYAN

1 A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013 SALYAN

JUNE 8, 2013

TEAM MEMBERS

2 TABLE OF CONTENTS

ABBREVIATIONS………………………………………………………………………………………………………………………..……….…………III KEY FINDINGS FROM RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS ...... V

1 RAPID ASSESSMENT ...... 1 1.1 Health for Life ...... 1 1.2 Rapid Assessment and its Objectives ...... 1 1.3 Methodology ...... 1 1.4 Organization of Report ...... 2

2 INTRODUCTION OF SALYAN DISTRICT ...... 3 2.1 Geo-Political Situation ...... 3 2.2 Demographic Information ...... 3

3 DHO STRUCTURE AND SYSTEMS ...... 4 3.1 Service Delivery Points ...... 4 3.2 Management Systems ...... 4 3.3 Health Workforce ...... 6 3.4 Monitoring and Supervision ...... 7 3.5 Information Technology ...... 8 3.6 Health Information Management ...... 8 3.7 Natural Disaster Response Mechanism ...... 8 3.8 Strength and Opportunities ...... 8 3.9 Key Issues and Challenges ...... 9

4 SERVICE STATISTICS ...... 10 4.1 Immunization ...... 10 4.2 CB-IMCI…………………………………………………………………………………………………………………………………....11 4.3 Safe Motherhood ...... 11 4.4 Family Planning ...... 12

5 HEALTH FACILITY OPERATION MANAGEMENT COMMITTEE AND LOCAL HEALTH GOVERNANCE ...... 13 5.1 Functioning HFOMC ...... 13 5.2 Capacity Building of HFOMC ...... 15 5.3 Community Groups/Federation/Alliance ...... 15 5.4 Strength and Opportunities ...... 15 5.5 Key Issues and Challenges ...... 15 5.6 Efforts Required to Overcome Issues & Constraints...... 16

6 SERVICE DELIVERY/QUALITY IMPROVEMENT ...... 17 6.1 ANM Schools ...... 17 6.2 Infection Prevention and Waste Management Practices at HFs ...... 17 6.3 Service Delivery ...... 17 6.4 Strength and Opportunities ...... 18 6.5 Key Issues and Challenges ...... 19

7 LOGISTICS MANAGEMENT SYSTEM ...... 20 7.1 Availability of Key Drugs and Commodities ...... 200 7.2 Cold Chain and FEFO Management ...... 20 7.3 LMIS reporting ...... 20 7.4 Strength and Opportunities ...... 21 7.5 Key Issues and Challenges ...... 21

i 8 BEHAVIOR CHANGE COMMUNICATION ...... 22 8.1 Existing DHO programs on BCC ...... 22 8.2 FM Stations/Cable Television Networks ...... 22 8.3 Organizations working in IEC/BCC activities ...... 22 8.4 School Health Program ...... 23 8.5 Mapping of DAG and Exploring Cultural Practices affecting Health ...... 23 8.6 Strength and Opportunities ...... 24 8.7 Key Issues and Challenges ...... 25 8.8 H4L intervention on BCC ...... 26

9 ADOLESCENTS AND YOUTH FRIENDLY SERVICES...... 27 9.1 Existing Services for Adolescent ...... 27 9.2 Organization working for Adolescent...... 27 9.3 Strength and Opportunities ...... 28 9.4 Key Issues and Challenges ...... 28

10 GENDER EQUALITY AND SOCIAL INCLUSION ...... 29 10.1 Formation and Functionality of GESI Committee ...... 29 10.2 Activities on GESI and Information on Disaggregated Data ...... 29 10.3 Organizations working on GESI...... 30 10.4 Areas of Synergy and Collaboration in GESI ...... 31

Annexes Annex 1: Contact information of DHO Staff, Salyan ...... 32 Annex 2: List of RHCC members and Organizations, DHO/Salyan ...... 32 Annex 3: List of Individuals/Organizations visited during RA/Salyan ...... 33

ii ABBREVIATIONS

AHW Auxiliary Health Worker ANM Auxiliary Nurse Mid-wife ASRH Adolescent and Sexual Reproductive Health BC Birthing centre BCC Behavior Change Communication BEONC Basic Emergency Obstetric and Newborn Care BNMT Britain Nepal Medical Trust CB-IMCI Community-Based Integrated Management of Childhood Illness CB-NCP Community-Based Newborn Care Package CEONC Comprehensive Emergency Obstetric and Neonatal Care CRRT Community Rapid Response Team DAG Disadvantaged Group DDC District Development Committee DHO District Health Office DRR Disaster Risk Reduction FCHV Female Community Health Volunteer FECOFUN Federation of Community Forestry Users of Nepal FEFO First expiry first out FP Family Planning FPAN Family Planning Association of Nepal FY Fiscal Year GESI Gender Equality and Social Inclusion HA Health Assistant H4L Health for Life HF Health Facility HP Health Post HFOMC Health Facility Operation and Management Committee HMIS Health Management Information System I/NGO International/Non-Governmental Organization IT Information Technology INF International Nepal Fellowship IUCD Intra Uterine Contraceptive Device IFPSC Institutionalized Family Planning Service Center LDO Local Development Office LMIS Logistics Management Information System LGCDP Local Governance and Community Development Program MO Medical Officer MNCHN Maternal Neonatal Child Health and Nutrition MgSO4 Magnesium Sulphate MSC Matri Surakshya Chakki MSI Marie Stopes International MWDR Mid-western Development Region N Number NFHP Nepal Family Health Program NHSSP National Health Sector Support Programme NPC National Planning Commission PHCC Primary Health Care Center QI Quality Improvement iii QAWG Quality Assurance Working Group RA Rapid assessment RH Reproductive Health RHCC Reproductive Health Coordination Committee RHD Regional Health Directorate RRT Rapid Response Team SHP Sub Health Post SN Staff Nurse UNFPA United Nations Population Fund USAID Unites States Agency for International Development VDC Village Development Committee WCO Women and Children Office WDR Western Development Region

iv KEY FINDINGS FROM RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS

TOTAL POPULATION 242,444 (Census 2011)—52.17% Female & 47.83% Male NUMBER OF VDCS 47 DHO STRUCTURE AND Public health facilities & outreach service points SYSTEMS  1 District Hospital; 2 PHCCs; 15 HPs & 30 SHPs  34 Birthing Centers; 165 PHC ORC; 227 Immunization Clinic  1 CEOC Site; 2 BEOC Sites; 1 Satellite Clinics  18 SBA Service Sites  423 FCHVs Private health facilities/community hospitals/nursing homes  1 Community Hospitals  2 Private Hospitals Meetings  RHCC & DACC—meetings conducted after a year in May 2013  QAWG—non functional  GESI—only formed, no follow ups then after  RRT & CRRT functional—based on need  Ilaka Monthly Meeting and District Level Ilaka Incharge Meeting— discontinued due to budget constraint.  FCHV Monthly meeting—27-30th of Nepali month—functional Health Workforce:  174 positions fulfilled out of 237 sanctioned positions  1 Medical Officer in temporary position & 2 others supported by Nick Simons Institute  1 Medical Officer and 1 PHO in Temporary position  1 ANM, 31 AHW and 1 Computer Operator in contract.  National Planning Commission supported 1 ANM and 2 Sr. AHW  VDC supported 15 ANMS  2 Medical Officer and 1 Staff Nurse supported by Nick Simons Institute Monitoring and Supervision:  DHO has annual monitoring and supervision plan, but is not effectively practiced  Monitoring and supervision from ilaka level health facilities to SHPs is also very limited.  Use of verbal feedback than written with very few follow ups. IT infrastructure at DHO:  Desktops-7, Laptops-5, Printers-2  Good internet facility.  3 other HFs have computers (Hiwalcha, Lekhpokhara and Darmakot)  Supervisors skilled enough to perform their daily responsibilities  Web-based HMIS and LMIS system reporting system in place and is up-to-date.  Four year service data easily available from FY 2065/66 to 2068/69  No social inclusion reporting so far.  No use of mobile phone, tablets or other devices for recording and v reporting purpose.  No data validation program so far but DHO has plan to conduct one before the end of FY 2069/70, provided the budget can be managed Rapid Response Team:  Formed at district and functional  CRRT formed in all 47 health facilities  No buffer stock maintained so far SERVICE STATISTICS  Decreasing trend of BCG and Measles coverage from 2066/67 to 2068/69 with coverage of more than 90%.  Sharp decrease in DPT3 coverage from 112.9% in 2067/68 to 92.06% in 2068/69  Severe pneumonia case and dehydration case is in decreasing trend which is less than 1%. More children are being treated with antibiotics and ORS/Zinc  TT coverage (both TT2 and TT2+) among pregnant women has increased from 55.97% in 2065/66 to 85.33% in 2066/67, but then decreased to 72.08% in 2067/68 and then to 68.62% in 2068/69.  Drop out from ANC 1st to ANC 4th visits is high which is 77.39% and 35.05% respectively in 2068/69.  PNC 1st visit as percent of expected live births is 32.94% in 2068/69.  SBA deliveries (both home and institution) in increasing trend (7.66% in 2065/66 to 28.68% in 2068/69)  Contraceptive Prevalence Rate 33.07% in FY 2068/69 HEALTH FACILITY  None of the 47 health facilities has been handed over to local bodies MANAGEMENT  Only 29% of HFOMCs in Salyan are active based on random COMMITTEE AND sampling of 28 HFs LOCAL HEALTH  HFOMCs have received orientation and refresher training by NFHP GOVERNANCE II and Safe Motherhood Network Federation Nepal in partnership with ADRA Nepal  At district, there are alliances as NGO Federation, NGO Coordination Committee, Journalist Federation, Federation of Community Forestry Users Nepal (FECOFUN), and District Disable Welfare Association SERVICE  No ANM school in Salyan DELIVERY/QUALITY  34 birthing centers out of which 16 have placenta pits IMPROVEMENT  28 SBAs providing services from 18 sites which include District Hospital, 2 PHCCs, 6 HPs and 9 SHPs.  Hiwalcha HP has Satellite Clinic  1 CEOC site at District Hospital in Khalanga  2 BEOC sites in all and Lekhpokhara PHCCs  IUCD service provided through District Hospital, 2 PHCCs and 4 HPs  Implant service provided through District Hospital, 2 PHCCs , 3 HPs and 1 SHP  Around 40 health workers and 10 FCHVs have not received CB- IMCI training  Safety Wastage Disposal Training provided at District Hospital; no infection prevention training in birthing centers & HFs so far. LOGISTICS  All tracer drugs and commodities available on the day of visit. vi MANAGEMENT SYSTEM  Drugs with most problems of stock outs in the last 12 months- Cotrim (P), Iron, Zinc and MgSO4  Drugs with most problems of over stock in the last year- Metronidazole Syrup, Cotrim (P) 480 mg and Depo  Functioning refrigerators-8 out of which 4 in use and sufficient for maintaining cold chain, and have regular power back up system for the cold chain room.  First Expiry First Out (FEFO) maintained in store  Web-based LMIS reporting system—data entered and updated by Store keeper BEHAVIOR CHANGE  FM stations – 3; DHO BCC programs through all 3 FM stations COMMUNICATION  DHO BCC programs include PSAs, programs on population, RH, CB- IMCI, CB-NCP, immunization & campaigns, health camps, day celebrations, etc.  Although DHO staffs mentioned that except for new staffs, most of them have received COFP counseling training, no information was available on the number.  3 different organizations working in IEC/BCC activities: WCO, Red Cross and PASS-Nepal  Red Cross working in Peer Education Program in 5 VDCs  Western part of Salyan are regarded as hard to reach VDCs because of difficult topography and scattered population  15 VDCs identified as high migrant (to India) VDCs by PASS-Nepal ADOLESCENTS AND  Programs like peer education, adolescent friendly services, and YOUTH FRIENDLY adolescent girl’s information and counseling center are currently SERVICES running in Salyan.  Organizations like WCO, GIZ, Red Cross and PASS-Nepal working on AFS.  GIZ working in 13 HFs, Red Cross working in 5 VDCs and PASS- Nepal working with school adolescents to provide information on FP methods and sexual and RH.  WCO has Information and Counseling Center for adolescent girls in 6 VDCs. GENDER EQUALITY AND  GESI working committee formed but no follow up meetings held SOCIAL INCLUSION then after  Although there are some programs running with GESI concept, focal person and other district supervisors not aware of its importance.  No disaggregated data by age, caste, ethnicity, wealth quintile and region; No DAG mapping done recently  Two different programs with GESI focus at DHO—Equity and Access through PASS-Nepal; and free health services to elderly population (age more than 60 years) in collaboration with WCO.  DDC has recently conducted GESI trainings to different people working on program planning and implementation.

vii RAPID ASSESSMENT

1.1 HEALTH FOR LIFE

Health for Life (H4L) is a five-year bilateral agreement between the Ministry of Health and Population (MoHP) and the Unites States Agency for International Development (USAID) which focuses on systems strengthening and improving the Maternal Neonatal Child Health and Nutrition/Family Planning (MNCHN/FP) service delivery at district and sub-district levels in 14 districts. Two of the 14 districts are in Western Development Region (WDR) of Nepal— Arghakhanchi and Kapilvastu, and the remaining are in Mid-Western Development Region (MWDR) — Dang, Salyan, Pyuthan, Rolpa, Rukum, Banke, Bardiya, Surkhet, Dailekh, Jajarkot, Jumla and Kalikot. The project will be implemented between 2012 and 2017.

1.2 RAPID ASSESSMENT AND ITS OBJECTIVES

Rapid Assessment (RA) is a method of analyzing situation of a district where issues are not well defined or where there is no sufficient time or other resources to conduct in-depth quantitative research. RA uses intensive team interaction in the collection and analysis of data, instead of a prolonged field work, iterative data analysis and additional data collection, to quickly develop a preliminary understanding of situation from an insider’s perspective. The main purpose of carrying out the current Rapid Assessment is to understand the current situation of health service delivery system and other associated systems of Salyan district so as to help in planning activities at district level.

Specifically, the objectives of the RA includes  Understanding the demographic profile of the district  Understanding the existing health care delivery system of the district  Knowing the functionality of Health Facility Operation and Management Committees (HFOMC)  Understanding the status of health indicators  Analyzing strength and weakness of the D/PHO systems  Exploring feasibility for the implementation of specific programs for adolescents and youths  Exploring feasibility for using Information Technology in information management

1.3 METHODOLOGY

A mix of both qualitative and quantitative methods was used to execute Rapid Assessment in Salyan district which includes:  Visits to District Health Office (DHO)  Interviews and interactions with key staffs  Observation at DHO

A structured tool was developed to collect necessary information, which was supplemented by qualitative tools to interview key informants at District Development Committee (DDC) and Local Development Office (LDO), International/Non-Governmental Organizations (I/NGOs) working on different areas of health, Gender Equality and Social Inclusion (GESI), Behavior Change Communication (BCC), Information Technology (IT) in Health, Service delivery, and Governance.

1 A team of H4L staffs was composed for carrying out RA in Salyan. Skill mix was ensured while forming team where staffs were skilled and knowledgeable on the aspects of governance, service delivery, monitoring and evaluation, GESI and BCC. During RA in Salyan, the involvement of regional and district offices was ensured.

Before carrying out of the RA, one day orientation on its objective, methods and tools was organized for H4L staff, along with other orientation on H4L project in Hotel Siddhartha, Nepalgunj. RA in Salyan was completed by 3 members of H4L team—Ambika Prasad Neupane, Manoj Dhakal and Gunjan Dhakal from May 11-22, 2013. The information collected was verified on the same day and brief notes were developed for each thematic area for sharing with DHO and other line agencies and also for preparing report. After the completion of RA, a two-hour sharing program was organized at DHO among district supervisors and other members of DHO.

1.3 ORGANIZATION OF REPORT

The findings of RA are presented in altogether ten chapters. Chapter 1 presents the purpose of carrying out RA and the methodology; chapter 2 presents the introduction of Salyan along with its demographic information; chapter 3 talks about the structure and systems of DHO, and provides detail information on service delivery points, management systems, status of health workforce, the practice of monitoring and supervision, status of information technology and information management as well as mechanism of natural disaster response. Chapter 4 presents the service statistics of district; chapter 5 presents information on health facility operation and management committee (HFOMC) and local health governance. Likewise, chapter 6 discusses on what has been done for quality improvement of health service delivery; chapter 7 presents information on logistics management system of DHO; chapter 8 discusses several windows of IEC/BCC activities conducted by DHO; chapter 9 explains the status of adolescent and youth friendly services in district, and chapter 10 presents information on gender quality and social inclusion (GESI), and whether or not the committees have been formed and are functional. Each chapter discusses the strength and opportunities based on the data collected through RA and explains key issues and challenges to fulfill them.

2 2. INTRODUCTION OF SALYAN DISTRICT

2.1 GEO-POLITICAL SITUATION

Salyan is a hilly district situated in Rapti zone of Mid-Western Development Region of Nepal. It borders 7 other districts: Rolpa towards East, Rukum and Jajarkot towards North, Surkhet towards West, Bardiya towards South West, Dang towards South and Banke towards South-West. Administratively, Salyan has 47 VDCs and is headquartered at Khalanga. There are altogether 11 ilakas in Salyan—Bajhkot (), Chande, Darmakot, Dhajaripipal (Ghajaripipal), Phalawang (Sarikot), Hiwalcha, , Kalimati Kalche, Kotmaula, Lekhpokhara and Tharmare

2.2 DEMOGRAPHIC INFORMATION

The total population of Salyan as per Census 2011 is 242,444 out of which 52 percent is female and 48 percent is male population. The information on caste and ethnicity distribution of Salyan could not be found during RA because a) data of Census 2011 based on caste/ethnicity is yet to be analyzed; and b) data of Census 2001 is incomplete due to the Maoist insurgency which affected data collection. Table 2.2: Population of Salyan District Population Distribution Number Percent Total Population 242,444 - Male 115,969 48 Female 126,475 52 Source: Census 2011

3 3. DHO STRUCTURE AND SYSTEMS

This chapter presents the findings related to the DHO structure and systems of Salyan collected from RA. The findings cover the areas of service delivery points, management system, health workforce, monitoring and evaluation system, IT and health information management and disaster management system.

3.1 SERVICE DELIVERY POINTS Table 3.1: Number of service delivery The District Health Office situated in Khalanga is the points main responsible body of the MoHP at Salyan to Service delivery points Number provide preventive, promotive and curative health Government Hospital 1 (District services to the people living in Salyan. There are a Hospital) total of 48 public health facilities in Salyan, which PHCC 2 includes 1 District Hospital, 2 PHCCs, 15 HPs and 30 Health Post 15 SHPs. The 2 PHCCs in Salyan are located in Sub-health Post 30 Tharmare and Lekhpokhara. There are altogether 34 Private hospital 2 birthing centers in Salyan, some of which are Community Hospital 1 recently approved but functional with at least one Birthing centers 34 (all functional) delivery a month. There are 165 PHC Out Reach SBA Service Sites 18 Clinics and 227 Immunization Clinics. One CEOC site PHC Out-Reach Clinic 165 is located in District Hospital, Khalanga and 2 BEOC Immunization Clinic 227 sites are located in Tharmare and Lekhpokhara FCHVs 423 PHCCs. Similarly, there is one Satellite Clinic located NGO clinics No CEOC Site 1 in Hiwalcha. There are altogether 423 FCHVs in BEOC Site 2 Salyan scattered in all 47 VDCs. There are 2 private Satellite Clinic 1 hospitals and 1 community hospital in Shreenagar of Source: DHO, Salyan Khalanga VDC, but no NGO clinics were found and recorded during RA. There are 18 SBA service sites in Salyan offering secure institutional delivery.

3.2 MANAGEMENT SYSTEMS

3.2.1 COMMITTEES AND MEETINGS

There are several committees formed at DHO Salyan to support health activities and deliver quality health services. The table below (Table 3.2.1) shows the glimpse of different committees and meetings, and their status as recorded during rapid assessment. The information provided is based on interviews with DHO staffs and observation of meeting and meeting minutes. Some of the meetings like Ilaka Level Monthly Meeting and FCHV Monthly Meeting are conducted on fixed date whereas committee meetings are conducted few times a year, without any fixed date.

Reproductive Health Coordination Committee (RHCC) in Salyan remained inactive for a year until a meeting was organized on May 19th 2013 in close coordination with GIZ, who introduced Adolescent and Youth Friendly Service in 13 HFs at the time of RA. Before that, the meeting was organized only once in July 3, 2012 (Asar 19, 2069). The last RHCC meeting emphasized the need for promotion of such interactive forum to discuss issues on health related activities and programs

4 in district. In presence of GIZ and H4L representatives, who are now the members of RHCC, the committee has agreed to conduct meetings regularly.

Table 3.2.1: Status of Existing Committees and Meetings in Salyan Committees Meeting Date Status Reproductive Health Coordination May 19, 2013 Held only once in this FY; to be held 3 times Committee (RHCC) (held after a year) a year Quality Assurance Working Group Aug 24, 2012 Conducted one time so far due to budget (QAWG) constraint Gender Equality and Social Inclusion Jul 20, 2012 Only formed but no follow-up meetings (GESI) District AIDS Coordination May 19, 2013 Irregular Meeting Committee (DACC) (held after 10 months) Rapid Response Team (RRT) --- RRT formed in District and CRRT formed at HF level District Level Ilaka Incharge --- Meeting discontinued due to budget Meeting constraint; Not conducted this FY 2069/70 Ilaka Level Monthly Meeting Every 3rd of Nepali Month Meeting discontinued due to budget constraint/ Not conducted this FY 2069/70 FCHV Monthly Meeting 27-30th of Nepali Month Functional and held at the end of every Nepali month; VDC supports the meeting

Likewise, Quality Assurance Working Group (QAWG) was formed at DHO and the last meeting was held on Aug 24, 2012 (Bhadra 8, 2069). DHO staffs mention that all HF workers received orientation on quality improvement last year but none of the facilities have Quality Improvement Committees. Apart from budget issues, DHO staff expressed that district office did not follow up on with HFs for Quality Improvement Committees, which was necessary for its formation at local level. The QAWG meeting has been held only once in the FY 2069/70 and has been discontinued since then due to budget constraints.

Gender Equality and Social Inclusion (GESI) in DHO was formed on Jul 20, 2012 (Shrawan 5, 2069) and a partial orientation was provided to DHO staffs by representative of Mid Western Regional Health Directorate. However, it was only formed but no follow up meetings have been held since then. As per DHO staffs, apart from budget constraints, the reason for not having GESI meeting is the lack of clear concept to have it integrated in health activities and programs.

GESI orientation was provided to all DHO staffs by representative of Regional Health Directorate and a working committee was also formed. It’s true that GESI is the concept which needs to be integrated in each health programs and activities, but we tend to think that is it a stand-alone program like any others in DHO. This is the reason why we look for agenda to call a meeting and express concerns over not having budget to integrate GESI in our activities. Budget is not the real problem in case of GESI; what is important is we have not been made aware that it needs to be prioritized. -- DHO Staff, Salyan

District AIDS Coordination Committee (DACC) is another committee formed at DHO to manage programs on HIV/AIDS in district and coordinate with other stakeholders working in this area. The last meeting of DACC was called on May 19, 2013 during RA and a Candle Light Day was celebrated at Khalanga Bazar to remember all those who died of AIDS. However, the earlier meeting was held last year on July 3, 2012 (Asar 19, 2069), which means the meeting was held only after ten months.

5 Similarly, Rapid Response Team (RRT) is another committee formed at DHO to respond to disasters that are likely to happen in Salyan throughout the year. The committee comprises of members from District Administration Office, District Development Committee, Women and Children Office, Nepal Army, Nepal Police, Nepal Red Cross Society and any other stakeholders in district. In Salyan, Community Rapid Response Team (CRRT) is formed in each HFs to immediately respond to disasters, but it was mentioned that no buffer stock has been maintained in any of those HFs.

There are three other monthly meetings held in Salyan—District Level Ilaka Incharge Meeting, Ilaka Level Monthly Meeting and FCHV Monthly Meeting. Although these meetings are scheduled on a particular date of every month, no District Level Ilaka Incharge Meeting and Ilaka Level Monthly Meeting have been organized in the FY 2069/70—the reason being budget constraint. These are important forums to share experiences and issues at local level that need to be revitalized as per DHO staffs. Only FCHV Monthly Meeting out of three meetings is held at the end of every Nepali month in each HFs, which is usually supported by respective VDCs.

3.2.2 PROGRAM MANAGEMENT TEAM

Table 3.2.2: Current Status of DHO Team, Salyan DHO Salyan has most of the sanctioned DHO Team Status positions fulfilled while 2 of them still 1. District Health Officer Filled remain vacant. The information in this 2. Public Health Officer Filled 3. Public Health Nurse Filled section was collected during May 11-22, 4. FP Focal Person Filled wherein 2 positions out of 13 were found 5. Malaria Inspector Vacant vacant. As per the information provided by 6. District TB Leprosy Officer Filled DHO administration, positions of Malaria 7. EPI Supervisor/Officer Filled Inspector and Statistics Officer are yet to be 8. Cold Chain Assistant/ Officer Filled filled. However, the work is being shared 9. Computer Operator Filled among existing workforce to provide 10. Store Keeper Filled uninterrupted program management. Table 11. Child Health focal person Filled 3.2.2 below has the list of DHO key positions 12. Lab Technician Filled and their status as found during RA. 13. Statistics Officer Vacant

3.3 HEALTH WORKFORCE

This section presents the current status of health workforce in Salyan district as provided to RA team during May 11-22, 2013. Table 3.3 below mentions the number of sanctioned positions, filled- in, temporary and contract positions; and also the number of positions supported by DDC/VDC, National Planning Commission (NPC) or any other resources. As per the table, out of total 237 sanctioned positions, 174 have been filled. To support district health workforce, many health workers have been hired on temporary and contract positions. Based on the information provided by DHO, there is one Medical Officer and 1 Public Health Officer under temporary position and 1 Staff Nurse, 31 ANMs and 1 Computer Operator under contract. There are 15 ANMs supported by VDC, and 1 ANM and 2 HAs supported by NPC. In Salyan, Nick Simons Institute has supported 2 Medical Officers and 1 Staff Nurse.

6 Table 3.3: Current status of health workforce Number supported Number GoN Type of human from REMARKS resources Sanctione Filled- Contrac Other Temporary VDC NPC d in t s a. MS/Medical Officer 5 3 1 0 0 0 2 NSI* b. Staff Nurse 6 3 0 1 0 0 1 NSI* c. PHN 1 1 0 0 0 0 0 d. FP officer 1 1 0 0 0 0 0 e. PHO 1 0 1 0 0 0 0 f. ANM 21 15 0 31 15 1 0 g. HA/Sr. AHW 20 11 0 0 0 2 0 h. AHW 51 42 0 0 0 0 0 i. PadNam AHW 47 28 0 0 0 0 0 j. PadNam ANM 36 31 0 0 0 0 0 k. Lab Assistant 3 0 0 0 0 0 0 l. Assistant/Officer 2 1 0 0 0 0 0 m. Store Keeper 1 1 0 0 0 0 0 n. Support Staff 36 33 0 0 0 0 0 o. Statistics Officer 1 0 0 0 0 0 0 p. Computer Operator 0 0 0 1 0 0 0 q. Account Officer 1 1 0 0 0 0 0 r. DTLO 1 1 0 0 0 0 0 s. Lab Technician 1 1 0 0 0 0 0 t. EPI 1 1 0 0 0 0 0 Supervisor/officer u. Malaria Inspector 1 0 0 0 0 0 0 TOTAL 237 174 2 33 15 3 3 Source: DHO, Salyan *Nick Simons Institute supported 2 Medical Officers and 1 Staff Nurse in Salyan

3.4 MONITORING AND SUPERVISION DHO Salyan has monitoring and supervision system and has annual supervision plan as per DHO staffs. During the monthly integrated monitoring and supervision, a standard checklist is also used to ensure quality service delivery in HFs. It was however mentioned during RA that the system of monitoring and supervision has not been effective due to budget constraints. Salyan is a large district with 47 VDCs and most of which have seasonal roads (that is hard to access during rainy season), so providing on-site coaching and regular monitoring and supervision from district looks impossible with limited budget. Likewise, the monitoring and supervision from ilaka level HFs to SHPs is also very limited. It was reported that DHO mostly provides verbal feedback to HFs. Written feedback is not much in practice because health workers are usually upset when it is a written feedback. Thus, feedbacks are provided to health workers through telephone or during visits, with limited follow ups.

“Salyan is a big district and each VDC has scattered population. Providing health services to people living in every corner of Salyan is difficult—not only because of the difficult terrain but also due to short-sighted vision of government who treats hilly district the same way as Tarai. The limited budget for monitoring and supervision is not sufficient to cover all 47 VDCs, most of which are impossible to travel in a day. We are doing the best of what we can out of limited resources.” -- DHO Staff, Salyan 7 3.5 INFORMATION TECHNOLOGY

The RA team also explored the existing IT infrastructure at DHO Salyan as per which there are 7 desktop computers, 5 laptops and 2 printers that are functional. The district supervisors are skilled enough to perform their given responsibilities. There is web-based HMIS and LMIS reporting in DHO with dedicated staffs doing the needful—HMIS is taken care by EPI Officer and LMIS by Store Keeper. A good internet facility was experienced during RA in DHO for nearly 12 days.

Based on the conversation with DHO staff, HFs in Hiwalcha, Lekhpokhara and Darmakot have computers supported by respective VDCs. Use of other technologies like mobile phone or tablets is not in practice in Salyan yet. Similarly, there is no social inclusion reporting in district so far which could be one of the important steps in identifying the hard to reach people and analyzing GESI gaps for effective planning and service delivery.

3.6 HEALTH INFORMATION MANAGEMENT

DHO Salyan has been using web-based HMIS to record and report HF level data. The person in charge of statistics has received web-based HMIS reporting training to perform his responsibilities. The service data for last three years was on display at district office, which is worth mentioning. Likewise, DHO staff mentioned that data validation program implemented last year was beneficial for HMIS recording and reporting, so there is plan to organize similar program this year too, provided they can arrange funds.

3.7 NATURAL DISASTER RESPONSE MECHANISM

There is the presence of Rapid Response Team (RRT) at DHO Salyan which is formed to respond to sudden disasters that might happen in district. In order to immediately respond to such disasters at local level, Community Rapid Response Team (CRRT) is formed in all 47 HFs as per DHO. However, they have not maintained any buffer stock to provide assistance immediately.

3.8 STRENGTH AND OPPORTUNITIES

Formation of important committees at DHO. All the important committees like RHCC, GESI working committee, RRT, QAWG and DACC have been formed at DHO under different focal persons. Although all committees were formed with some specific purpose to fulfill and address certain needs, not all of them are active. Some meetings are organized on regular basis, some on need basis, while others were just formed with no follow-ups in the later stage. Regular FCHV Monthly Meeting at Health Facility Level. Although monthly meetings as Ilaka incharge meeting and district level incharge meeting have been discontinued since the beginning of this FY 2069/70, FCHV monthly meeting is regularly being organized in Salyan in each HFs. As per the information provided by Ilaka Incharge during district review meeting, FCHV meeting is held in each HF at the end of Nepali month which is regarded as a forum where their challenges and issues are shared among each other. Functional web-based HMIS and LMIS. DHO Salyan has proper display of 3-year service data and has proper documentation of health facility level information as submitted to district. Although they do not have any recent population profile and DAG mapping, they have functional web-based HMIS and LMIS where they can record and report data collected from health facilities. Most of the key positions fulfilled at DHO. As per the information provided during RA, DHO Salyan has most of the key positions fulfilled in district. Out of 13 key positions, 3 positions of Malaria Inspector, Lab Technician and Statistics Officer are not fulfilled but the work is shared

8 among existing district supervisors to provide uninterrupted service delivery. Based on the information provided to RA team, out of sanctioned 238 positions in Salyan, 173 are fulfilled. To support the existing workforce, 2 positions have been supported temporarily, 15 positions have been supported by VDC, 3 positions by NPC and 3 others by Nick Simons Institute. There are altogether 33 contract staffs in Salyan most of which are ANMs.

3.9 KEY ISSUES AND CHALLENGES

Budget constraints to conduct important DHO meetings. It is unfortunate that important forums like District Level Ilaka Incharge Meeting and Ilaka Level Monthly Meeting have been discontinued in Salyan since the beginning of this FY 2069/70. Both these meetings provided an interactive platform where review of work, HMIS reporting, recording, service delivery as well as any other important issues were raised for wider discussion among health workers. These meetings have been discontinued for last one year due to budget constraints. DHO however managed to conduct District Review Meeting during June 5-7, 2013 which was observed by H4L team.

Continuity of QAWG, RHCC, DACC & GESI meeting. Although important committees have been formed at DHO, nothing much has been done to revitalize them and open them for wider discussion on health issues and quality service delivery. No QAWG and GESI meetings have been held since their formation, whereas RHCC and DACC meetings were held after a year during the time of RA. These meetings should be continued and promoted as important forums to interact with district level stakeholders on health issues and activities, which eventually is vital for quality service delivery.

“GESI working committee was formed in July 2012 in the presence of representatives from NHSSP. District level staffs were provided a partial training on GESI and a working committee was formed the same day. However, we have not held any meetings since its formation nor have we initiated for follow ups. Although GESI is a cross cutting theme that does not require any specific program and activity of its own, we look for agenda to hold meeting. More than budget, DHO staffs—from district to local level—require GESI sensitivity. With GESI approach, we can improve our health indicators and provide services to people who are deprived of health service delivery.” -- GESI Focal Person, DHO Salyan

Inadequate monitoring, supervision and mentoring of health facilities. Salyan is a big district with 47 VDCs that are scattered in remote hills. The 47 HFs are geographically dispersed providing services to people from different corners. District supervisors in DHO expressed their inability to conduct regular monitoring and supervision as planned not only because of the budget constraints limiting their travel to remote HFs, but also the time constraint. However, it was mentioned to RA team that monitoring and mentoring is done whenever district staffs go to any HFs even for some other purpose.

9 4. SERVICE STATISTICS

The RA team also sought information on service statistics of Immunization, Child Health, Safe Motherhood and Family Planning. For this purpose, selected HMIS data for the last four years were collected and analyzed. The selected indicators of HMIS for the FY 2065/66 to 2068/69 are presented in this section with trend analysis to see how things have changed or remained over the last few years.

Table 4 below shows the trend of service utilization in Salyan from 2065/66 to 2068/69. The table has information on immunization, severe cases of pneumonia and dehydration, reproductive health and CPR and provides the glimpse of district performance over the last four years.

Table 4: Trend in utilization of services in Salyan from 2065/66 to 2068/69 in percentage SN Indicators 2065/66 2066/67 2067/68 2068/69 1. BCG coverage 78.01 104.28 96.53 94.54 2. DPT 3 78.04 79.37 112.90 92.06 3. Measles vaccination coverage 70.05 103.35 98.78 90.65 4. TT 2 & TT2+ coverage among pregnant women 55.97 85.33 72.08 68.62 5. Percent of postpartum mothers receiving Vitamin A 43.47 70.48 54.61 63.89 within 6 weeks 6. Percent of pregnant mothers receiving iron tablets 79.51 112.53 90.31 78.66 7. Percent of severe pneumonia among new cases 1.10 0.75 0.88 0.67 8. Proportion of new pneumonia cases treated with 35.55 33.37 42.42 44.79 antibiotics 9. Percent of severe dehydration among new cases 0.24 0.13 0.18 0.12 10. Proportion of new diarrheal cases treated with ORS +Zinc - - 98.67 98.41 (under 5 years children) 11. ANC 1st visit as percent of expected pregnancies 62.76 86.93 78.46 77.39 12. <20 years 19.12 25.11 23.69 25.33 13. Four ANC visits among as percent of expected 16.09 32.92 31.93 35.05 pregnancies 14. Delivery conducted by SBAs (both home and institutions) 7.66 19.44 21.95 28.68 as percent of expected live births 15. PNC First visit as percent of expected live births 26.28 32.11 38.43 32.94 16. Contraceptive prevalence rate (modern methods) as 27.58 34.66 33.28 33.07 percentage of MWRA

4.1 IMMUNIZATION Figure 4.1: Measles Coverage The overall data of four years, from 2065/66 to 2068/69, show decreasing trend of immunization for BCG, DPT3 and Measles coverage. There was an increasing trend of BCG, DPT 3 and Measles coverage from 2065/66 to 2066/67, out of which only DPT 3 increased from 79% to 113% in a year from 2066/67 to 2067/68. The coverage of BCG and Measles declined 10 from 104% and 103% in 2066/67 to 95% and 91% in 2068/69 respectively. However, these indicators are above 90% and all of which meet national indicators.

Figure 4.1 compares the trend in Measles coverage of Salyan over the four year period with that of Nepal’s aggregate. It is observed that despite decline trend, the performance of Salyan has been consistently better than that of Nepal’s in the last three years.

The service utilization data in Table 4 also shows that severe pneumonia case is in decreasing trend and is less than 1% (0.67% in 2068/69). Likewise, severe dehydration case is also in decreasing trend with less than 1% (0.12% in 2068/69). The diarrhea treatment case is 98.41% in 2068/69 for under-five children who have been treated with zinc and ORS for last 3 years. In this district, CB- NCP program has been implemented which has contributed to the reduction of neonatal mortality in district.

4.2 CB-IMCI

Graph 4.2 below shows comparison of severe pneumonia among new cases with national data as per which there is high incidence of pneumonia in Salyan i.e. 0.67% compared to 0.40 (natioanl) in 2068/69. Likewise, Graph 4.3 shows comparison of severe dehydration cases with national data, which shows low incidence of dehydration cases in Salyan i.e. 0.12% compared to 0.26% (national) in 2068/69.

Figure 4.2: Severe Pneumonia among New Figure 4.3: Severe Dehydration among New ­ Cases Cases ­

4.3 SAFE MOTHERHOOD

Table 4.1 also has information on TT coverage (both TT2 and TT2+) among pregnant women. The data shows that the TT coverage among pregnant women increased from 55.97% in 2065/66 to 85.33% in 2066/67, which has then declined to 68.62% in 2068/69. Similarly, the data for postpartum mothers receiving Vitamin A within 6 weeks increased from 43.47% in 2065/66 to 70.48% in 2066/67, which then declined to 54.61% in 2067/68. The data of 2068/69 shows increase in service utilization of Vitamin A to 63.89%. The percent of pregnant mothers receiving iron tablets however is in decreasing trend from 112.53% in 2066/67 to 78.66% in 2068/69. These numbers clearly indicate that there is an increasing need of focused intervention in providing preventive care to pregnant women and postpartum mothers to have healthy mothers and babies. Likewise, ANC 1st visit as percent of expected pregnancies is around 77.39% in 2068/69 which needs to be increased to 100% coverage. The data also shows that an expected pregnancy in less than 20 years of age is 25.33% in 2068/69, which means there is high prevalence of early 11 pregnancy. This might be one of the leading factors for maternal and child mortality in district. Thus, focused program on adolescents and youths should be encouraged and rolled out in district. Despite increasing effort in expanding birthing centers, there has not been significant progress in institutional delivery. The data shows that ANC 4th visit and SBA conducted delivery is still less than 35%. The service statistics puts alarming need to bring pregnant women and postpartum mothers to health facilities to promote safe motherhood. DHO staffs think that focused intervention through FCHVs at local level might be one of the important steps in reaching out people and explaining the important of health facilities and institutional deliveries for safe mother and babies.

Graph 4.4 (adjoining) shows FigureFigure 4.4:4.4: ANC 1st1st Visit and Four ANCANC VisitsVisits asas PercentPercent of of st comparison between ANC 1 Expected Pregnancy Visit and Four ANC visits as percent of expected pregnancies, which clearly illustrates high drop out of expected pregnancies from ANC 1st sisit to four ANC visits. Although four ANC visits have increased from 16.09% in 2065/66 to 35.05% in 2068/69, the data ANC 1st visit clearly shows nearly 65% of deliveries in Salyan are still conducted in home. Post-partum hemorrhage is one of the major causes of maternal mortality, so USAID has supported the implementation of Community Based MSC program in Salyan to fight against maternal death. However, it was brought to RA team’s attention that MSC was out of stock in Salyan for first six months during FY 2069/70. MSC is now available in district store and has been distributed to health facilities, but the supply is still irregular and inadequate to meet the demands as per pull system.

4.4 FAMILY PLANNING

The service statistics data show that FigureFigure 4.5: 4.5: CPR CPR as as Percent Percent of of MWRA MWRA there is no significant change in CPR over the last four years. The CPR of Salyan was 27.58% in 2065/66 which increased to 34.66% in 2066/67, and then decreased to 33.28 and 33.07 in 2067/68 and 2068/69 respectively. During RHCC meeting in Salyan, concern over decreasing CPR was expressed by DHO and the importance of expanding 2065/66 2067/68 2068/69 long term FP method service sites was also put forward. Graph 4.3 below compares CPR of Salyan district with District national data from 2065/66 to 2068/69. The self explanatory graph illustrates that more intervention is required in Salyan to meet the national data which is 43.14% in 2068/69. The district has around 10 point difference in achieving national data i.e. 33.07% vs. 43.14% in 2068/69.

12 5. HEALTH FACILITY OPERATION MANAGEMENT COMMITTEE AND LOCAL HEALTH GOVERNANCE

Information on Health Facility Operation and Management Committee (HFOMC) was sought from both DHO and DDC in Salyan. Both quantitative and qualitative methods were used to collect information on HFOMC functionality, capacity building, presence of different community-based groups at VDC level and their federations at district level. This chapter presents the major findings of the assessment on HFOMC.

5.1 FUNCTIONING HFOMC

None of the HFs in Salyan district is handed over to local bodies. HFOMC focal person in DHO mentioned that the process was started some years ago, but it did not go any further from DDC. As stated above, there has been no devolution of power and authority from existing PHCCs, HPs or SHPs to local bodies in the district. However, there are HFOMCs in each HFs and assigning exact number of HFs with active HFOMCs looks impossible at this time because of the indicators that can possibly tell us under what circumstances are HFOMC active or inactive. While some health workers think having regular meeting in HF makes HFOMC active, some others think they should be involved in VDC level planning and budget allocation to be called active.

In order to find out the number of active HFOMCs in HFs of Salyan without visiting HFs at local level, a small survey was conducted among 11 ilaka incharge who were at DHO during 2nd Quarterly Review Meeting on June 5-7, 2013. The ilaka incharge were asked to categorize HFs under their ilakas as active or inactive based on five different criteria:

a) whether the meeting is conducted once a month and minute is maintained; b) 70% of participation in meeting that includes at least one female member; c) activeness of members during interaction/meeting; d) take ownership and are involved in planning and/or review process; and e) HFOMC members monitoring Mother’s Group meetings.

If any HFs met three of the criteria, they were categorized as active or else inactive. Ilaka incharge of 11 ilaka level HFs categorized 28 different HFs based on the above criteria as per which there are only 8 HFs with active HFOMCs. Based on random sampling method, only 29% of the HFOMCs are active in Salyan. Table 5.1 in the next page shows the HFs categorized by ilaka incharge as active or inactive HFOMCs.

Based on the observation of HFOMC focal person and ilaka incharges, 1 PHCC in Lekhpokhara, 4 HPs in Chande, Bajhkot (Mulkhola), Kajeri and Kotmaula, and 3 SHPs in Marmaparikanda, Devasthal and are some of the HFs with active HFOMCs. In contrary to this, some of the HFs with inactive HFOMCs include Kabhrechaur SHP, Kalimati Kalche HP, Majhkanda SHP, Nigalchula SHP and Kavra SHP.

While RA team provided five different criteria to categorize HFOMCs, DHO mentioned that they usually judge functionality of HFOMCs based on the below three criteria. a) whether regular meeting is held—at least 3 meetings in a year; b) whether meeting minute is kept accordingly; and c) whether HFOMC takes any initiation for budget allocation in VDC. 13 Table 5.1: Random Sampling of HFs with active HFOMCs based on information provided by Ilaka Incharge Active HFOMC? Active HFOMC? SN Name of HF (Y/N) SN Name of HF (Y/N) 1 Chande HP Y 15 Bame SHP N 2 Hiwalcha HP N 16 Devasthal SHP Y 3 Karagithi SHP N 17 Kajeri HP Y 4 Kavra HP N 18 Jhajaripipal HP N 5 Laxmipur SHP N 19 Kubhinde Daha SHP N 6 Marke SHP N 20 Majhkanda SHP N 7 Darmakot HP N 21 Kotmaula HP Y 8 Tharmare PHCC N 22 Sarikot HP N 9 Bajhkanda SHP N 23 Kalimati Kalchhe HP N 10 SHP N 24 Lekhpokhara PHCC Y 11 Siddheswori SHP N 25 Chhayachhetra SHP N 12 Marmaparikanda SHP Y 26 Korbang SHP N 13 Bajhkot HP Y 27 Syanikhal SHP N 14 Suikot SHP N 28 Damachaur SHP Y Subtotal1 3 Subtotal2 5 Total number of active HFOMCs in Salyan out of 28 health facilities: 8

Based on the information provided by HFOMC focal person and ilaka incharges, HFOMCs in Kajeri HP and Lekhpokhara PHCC are seen taking ownership of HFs, who support the health activities in their locality. They are willing to work and actively participate in different campaigns (like Polio, immunization, FP camps), and monitor the activities. Most importantly, HFOMCs who take health issues to Village Council and demand for budget allocation were regarded as active based on the interaction with ilaka incharges in Salyan.

Likewise, some DHO staffs and ilaka incharges also think that the functionality of HFOMC depends on HF incharge, who if active can promote HFOMC’s activities and lead them to VDC for resource allocation. What also matters is whether the incharge belongs to the same locality. For example, in case of Hiwalcha HP the incharge belongs to the same place and is aware of overall VDC level activities. Even when HFOMC in this HF is regarded inactive, he has taken health agendas at the Village Council through HFOMC and have budget allocated every year. This is the HF with good infrastructure (observed) along with computer facility (not observed). Thus, having incharge from the same locality matters because of the ownership and “control” over VDC activities, providing ample opportunities to expand health services.

One of the important issues was raised during interaction with ilaka incharges in review meeting— having VDC secretary as Chairperson in HFOMC has led most of the committees to remain inactive. VDC secretary in most of the remote VDCs prefer to stay back at district headquarter in Khalanga who visit their respective VDCs once in a while. Their absence in VDC has not only affected the service receivers of VDC but also the activities of HFOMCs. Some of the health facility incharges mentioned that the meeting minute is carried all the way from HF to district headquarter just to have it signed by HFOMC Chairperson—the VDC secretary. In such cases, they expressed that the provision of giving “power of attorney” to local person should be emphasized so that the services can be carried forward in absence of VDC secretary.

14 It was also brought to RA team’s attention that some of the HFs have practiced handing over Chairman’s “power of attorney” to local person in case of unavailability. Although this is an exception to HFOMC guidelines, this seems to be working in Lekhpokhara PHCC where DHO has handed over the responsibility to local person citing his inability to attend every meetings and activities. Lekhpokhara has active HFOMC who take lead in health activities, take health demands to Village Council and have some budget allocated every year. During interaction, it was also expressed that many HFOMCs are functional only at the time of Village Council so that budget can be allocated for health facility, especially for infrastructure and human resource.

5.2 CAPACITY BUILDING OF HFOMC

The HFOMCs in Salyan have received capacity building training during NFHP II, which provided orientation and refresher training. Capacity building training was also provided by Safe Motherhood Network Federation Nepal in partnership with ADRA Nepal during 2008 to 2010. But apart from that no training, review meeting or monitoring visits have been supported by any of the organizations lately. However, DHO staffs look for HFOMC functionality during their visits to HFs for some other purpose.

5.3 COMMUNITY GROUPS/FEDERATION/ALLIANCE

According to the DHO staffs, there are different community groups at local level and district level alliances and networks in Salyan. While the presence of community groups varies from VDC to VDC as per the need, there are community forestry user groups, mother’s groups, drinking water user groups, and cooperatives in common. At district level, there are alliances like Federation of Community Forestry Users Nepal (FECOFUN), Media Federation, NGO Federation and District Disable Welfare Association. However, there are no health sector specific network and alliances, like FCHV Network, Health Professional’s Network in Salyan district.

5.4 STRENGTH AND OPPORTUNITIES

HFOMCs formed as per the guidelines, and orientation and refresher training provided. Although none of the HFs have been handed over the local bodies in Salyan, HFOMCs have been formed as per the guideline. Except for two PHCCs in Lekhpokhara and Tharmare, where the authority of Chairperson has been handed over to local person, health facilities have VDC secretary as Chairperson with other members as directed in the HFOMC formation guideline. The HFOMCs were also provided orientation followed by refresher training by NFHP II and Safe Motherhood Network Federation Nepal in partnership with ADRA Nepal. Support from DDC/VDC if demands are collected through HFOMCs. Based on the information provided during RA and review meeting, majority of HFs have been supported by their respective VDCs in either expansion of infrastructure or hiring local staff. It was clearly expressed that if health demand is presented at Village Council through HFOMC, it is more likely to be fulfilled. HFOMC is a legitimate formal body representing HFs so the health needs are more likely to be met if HFOMC is active and thus leads health sector in VDC.

5.5 KEY ISSUES AND CHALLENGES

Lack of regular monitoring, supervision and mentoring of HFOMC. Although HFOMC have been formed at HFs, orientation and refresher training have been provided, most of them are inactive. One of the issues raised during interaction with ilaka incharge and district supervisors was the lack of regular monitoring, supervision and monitoring of HFOMC, either from district or from ilaka. It

15 was mentioned that HFOMC is just formed but no follow up is done by district to check whether they have been functioning and working to address the local health needs. No meaningful participation of members in HFOMC meeting. HFOMC is formed as per the guidelines in Salyan but the participation is not meaningful as expected during its formation. It was explained that HFOMC members in some health facilities ensure their demands are presented in Village Council for budget allocation through active participation while HFOMCs in many other HFs are inactive. Ensuring active participation of HFOMC members and helping them have ownership of health facilities in their locality is a challenge to DHO and H4L team. Health demands through proper channel. Except for some HFs that raise health issues at Village Council and have budget allocated, many of them are not active enough to put forth local health needs in a formal way. Although DDC/VDCs have been supporting in expansion of health services by allocating budget for birthing centers, hiring staffs and building infrastructures, what looks important is having demands received and sent through proper channel—mainly from HFOMCs to VDCs. Bypassing HFOMC during health related planning and resource allocation can bring isolation in HFs, limiting the exercise of management committee.

5.6 EFFORTS REQUIRED TO OVERCOME ISSUES AND CONSTRAINTS

Orientation to newly formed HFOMCs with clear explanation of roles and responsibilities. Although orientation and refresher training was provided to HFOMCs earlier, these committees have been reformed after the expiry of 3 years tenure. As per DHO staffs, even when new committees were formed as per the guidelines, most of the current (new) members are unaware of HFOMC guidelines, and their roles and responsibilities. Thus, providing orientation to the members of newly formed HFOMCs and explaining and assigning them the roles and responsibilities look important to revitalize HFOMCs in HFs. DHO to regularly monitor, supervise and mentor HFOMCs. Based on the information received from different district level DHO staffs, apart from formation of HFOMCs and orientation/refresher trainings, it is essential to regularly monitor and mentor them. As the committee is voluntary, it needs extra focus on how to regularly engage members and make their participation valuable. Thus, DHO should visit HFs, take part in HFOMC meetings, and mentor them to collect health needs and take it forward to the planning process. Participatory planning and health demands through proper channel. Participatory planning is one of the main components of local development and this applies to health facilities too. Considering the fact that HFOMC members represent different caste, ethnicity, marginalized and disadvantaged groups of people, their involvement in planning process looks crucial. Their engagement in demand collection, issues identification and program planning is as important as placing these demands at the Village Council to have them addressed.

16 6. SERVICE DELIVERY/QUALITY IMPROVEMENT

This chapter presents the RA findings related to service delivery and quality of care. Information on the quality of ANM schools, infection prevention practices at HFs, implementation of community- based interventions, and the provision of IUCD and Implants services were collected at district level. The major finding of the assessment is presented hereunder.

6.1 ANM SCHOOLS There are no ANM Schools in Salyan.

6.2 INFECTION PREVENTION AND WASTE MANAGEMENT PRACTICES AT HFS Some questions related to infection prevention and waste management practices at HFs were also asked to district supervisors during RA and the detail information was received during the RA sharing meeting. It was found that Infection Prevention (IP) training called Safety Wastage Disposal Training was provided at district hospital. DHO mentions that IP training at birthing center is very important and there is also high demand of this training at HFs, which has not been provided as of now. Proper disposal of waste materials esp. hospital materials still look important in district hospital as per the observation of RA team.

There are altogether 34 birthing centers in Salyan out of which only 16 have placenta pits. When asked about the reason for not having placenta pit in all birthing centers, DHO staff mentioned that the funds for two birthing center is received every year and thus placenta pit is built at the pace of 2 per year. However, the number of birthing center is high because of its expansion through support from DDC/VDC every year.

6.3 SERVICE DELIVERY The RA sought information on the availability of Satellite clinics, BEONCs, CEONCs, long term FP methods, implementation of community- based interventions such as CB-NCP, MSC, Calcium and service integration. It also sought information on the number of health workers and FCHVs who have not received CB-IMCI training in the district; also seeking information on provision of clinical supervision in HFs.

In Salyan, only one health post in Hiwalcha has satellite clinic that provides family planning services to people in certain days. There is one CEONC site at district hospital in Khalanga, and two BEONC sites in Tharmare and Lekhpokhara PHCCs. In order to provide long term reversible family planning methods Table 6.3(a): IUCD and Implants Insertion and Removal Sites in Salyan there are IUCD and IUCD Birthing Implants Birthing implant service sites Center? Center? that are provided 1. District Hospital Yes 1. District Hospital Yes through different HFs 2. Tharmare PHCC Yes 2. Tharmare PHCC Yes as shown in Table 3. Lekhpokhara PHCC Yes 3. Lekhpokhara PHCC Yes 6.3(a) below. As per 4. Darmakot HP Yes 4. Darmakot HP Yes 5. Phalabang (Sarikot) HP Yes 5. Phalabang (Sarikot) HP Yes the table, there are 7 6. Chande HP Yes 6. Mulkhola (Bajhkot) HP Yes IUCD and 7 Implant 7. Kajeri HP Yes 7. Kavrechaur SHP Yes sites in Salyan.

17 Programs like CB-NCP and MSC have been implemented in Salyan. With regards to CB-IMCI training in district, around 40 health workers and 10 FCHVs in district have not received the training. DHO staffs also mentioned that clinical supervision is done sometimes only, that too during visits to HF for a different purpose.

In Salyan, there are altogether 28 SBAs providing services through 18 HFs. As per the information provided by PHN and other DHO staffs, SBA service is provided through District Hospital, 2 PHCCs, 6 HPs and 9 SHPs, which is illustrated in Table 6.3 (b) below. All these 21 HFs are birthing centers.

Table 6.3 (b): SBA Sites and their Numbers in Salyan Health Facility Birthing No. of SBA Health Facility Birthing No. of SBA Center Center (Yes/No) (Yes/No) 1. District Hospital Yes 6 1. Bafukhola SHP Yes 1 2. Tharmare PHCC Yes 3 2. Sibaratha SHP Yes 1 3. Lekhpokhara PHCC Yes 2 3. Triveni SHP Yes 1 4. Bajhkot/Mulkhola HP Yes 1 4. Kalagaun SHP Yes 1 5. Kalimati Rampur 5. Kajeri HP Yes 1 SHP Yes 1 6. Hiwalcha HP Yes 2 6. Rim SHP Yes 2 7. Darmakot HP Yes 1 7. Siddeshwori SHP Yes 1 8. Phalabang/Sarikot 8. Marmaparikanda HP Yes 1 SHP Yes 1 9. Chande HP Yes 1 9. Bame SHP Yes 1 Subtotal 1 18 Subtotal 2 10 Total number of SBAs in 18 Health Facilities: 28

6.4 STRENGTH AND OPPORTUNITIES

Functional Birthing Centers with Placenta Pit. In Salyan, there are altogether 34 birthing centers offering free institutional delivery services. Out of 34 birthing centers, 16 have placenta pits for infection prevention and waste disposal. Having birthing centers in HFs is expected to increase institutional delivery, helping reduce maternal and neonatal deaths by bringing delivery cases in front of skilled health workers. Presence of CEOC & BEOC Sites. In order to provide emergency care services to new born, there is One CEOC site at district hospital and 2 BEOC sites in Tharmare and Lekhpokhara PHCCs. All these sites have been offering services to improve the status of new born in district, particularly in decreasing the neonatal deaths. With CEOC and BEOC sites, referrals and emergency cases of new born can be promptly taken care in district. 28 SBAs providing services through 18 health facilities. Considering the fact that birthing centers are being expanded in district, having trained SBAs in birthing center is an asset. There are altogether 28 SBAs in 18 HFs of Salyan providing continuous support to improve institutional delivery and decrease in numbers of maternal and child mortality rate. Free ambulance by DHO to support referral delivery cases. DHO Salyan has provisioned free ambulance for women who are referred by health in-charge of respective birthing centers in case of complicated delivery cases. The cost of ambulance for this purpose is usually NRs 5,000 which is waived by DHO in case of referral. Salyan is geographically remote district with service receivers scattered all around, thus having an ambulance free of cost in case of delivery emergency should be regarded as an important step by DHO.

18 Satellite clinic and long term FP services sites. Out of 47 HFs, 9 of them are providing IUCD and implant services in districts. As per the information provided by FP focal person, there is high unmet need of IUCD/implant service in district which has not been met due to limited service sites and limited trained staffs. To address this issue, several camps were organized this FY 2069/70 providing services to people in need. CB-IMCI & CB-NCP programs implemented. In Salyan, both CB-IMCI and CB-NCP programs have been implemented for last few years. Both these programs have been in district to improve the status of newborn and child health. Infection Prevention Whole-site Prevention Training at District Hospital. During the RA sharing meeting, it was mentioned that safety wastage disposal training was provided at district hospital for infection prevention last year. Despite high demand to provide infection prevention training to birthing centers, nothing as such has been provided so far.

6.5 KEY ISSUES AND CHALLENGES

Increasing the number of Institutional Delivery. Despite increase in number of birthing centers in Salyan over the four years, more focused intervention is required to bring deliveries to health institutions. The data of 2068/69 clearly shows the sharp decline from ANC 1st visit (77%) to ANC 4th visit (35%). Likewise, PNC 1st visit during the same year is 33%. Irrespective of social, cultural, religious and economic barriers, increasing institutional delivery is a great challenge to DHO. Integration of service data from private/NGO Clinics. Apart from government services, there are some private clinics providing long term FP services in Salyan—one of the recent program is supported by PASS-Nepal. These private clinics are providing the same services as offered by DHO but the statistics of which is not incorporated in district recording and reporting. Thus, there is a need of integration of service statistics of such private/NGO clinics in HMIS reporting. Low number of trained health workers for IUCD/Implant Services. One of the biggest challenges in Salyan is the low number of skilled and trained health workers who can provide IUCD services to people. Like in Dang, there is a very limited number of trained health workers who if transferred or retired or expire will lead to the closure of service. There is a need to train more health workers to provide IUCD/implant services. Health Workers and FCHVs without CB-IMCI Training. DHO district supervisor mentioned that there are many health workers and FCHVs who have not received CB-IMCI training in district. CB- IMCI is an important component of community health, so is typically more important for FCHVs who have direct access to community level information on mother and child. In Salyan, nearly 40 health workers and 10 FCHVs from 47 health facilities are yet to receive CB-IMCI training.

19 7. LOGISTICS MANAGEMENT SYSTEM

Logistics management is an important part of district health systems. Efficient logistics management is required to smoothly run all the public health programs in district, sub-district and the VDC levels. The RA also sought information from DHO on logistics management system. The major findings of the assessment are presented below.

7.1 AVAILABILITY OF KEY DRUGS AND COMMODITIES

As a part of RA, the store room of DHO was visited and store keeper was interviewed to confirm the status of key drugs and commodities. The availability of ten tracer drugs/commodities—Injectable, Oral Contraceptive, Condom, ORS, Vitamin A, Iron Folate Tablets, Cotrim (Ped), Zinc, Magnesium Sulphate and Oxytocin in the district store was checked. It was found that all these drugs and commodities were available at the time of RA. The store keeper was also asked whether the ten drugs/commodities as listed in Table 7.1 were out of stock anytime in the last 12 months, and it was found that he had issues maintaining the stock of Iron, Zinc, Cotrim (Ped) and MgSO4 because of the under supply by LMD/RMS but did not run out of stock at DHO. The RA team members also checked the expiry dates of the ten drugs/commodities and it was found that all the items were intact with no expired ones in store. Table 7.1: Availability of key drugs/commodities and their expiry dates in Salyan SN Drugs/Commodities Availability at the Stock out in the last Expired drugs in stock time of visit 12 months at the time of visit 1 Injectable Contraceptive Y N N 2 Oral contraceptive Y N N 3 Condom Y N N 4 ORS Y N N 5 Vitamin A Y N N 6 Iron Folate Tablets Y N N 7 Cotrimoxazole (Ped) Y N N 8 Zinc Y N N 9. MgSO4 Y N N 10. Oxytocin Y N N

The Store keeper was also asked to list the drugs that have most problems with over stock for the last 12 months. As per the information, there has been over stock of Cotrim (P) 480 mg, Metro Syrup 100 gm and Depo in district store.

7.2 COLD CHAIN AND FEFO MANAGEMENT Out of 8 functioning refrigerators in DHO Salyan, 4 refrigerators are in use which is sufficient enough to maintain the cold chain. There is alternative power supply to these refrigerators in case of need which is provided through generator. The management of five to ten drugs in the store was checked to see whether First Expiry First Out (FEFO) was maintained. Although there was huge supply of drugs and commodities during RA, it was found that FEFO system was maintained properly.

7.3 LMIS REPORTING DHO Salyan is using web-based LMIS system that was in function during rapid assessment. Through LMIS, RA team checked the availability of stock, status of key drugs and commodities, recent supply through LMD/RMS and the report of third quarter. It was observed that the store keeper has 20 managed to record and update LMIS regularly which helped the RA team get required information easily. DHO has however not recruited any data entry person to enter LMIS data into the system; this is being done by the store keeper who has been handling the position for last 6 months.

7.4 STRENGTH AND OPPORTUNITIES Well managed and updated web-based LMIS. The recording at web-based LMIS looks updated in DHO Salyan. Information like quarterly reports, availability of drugs in store, and the recent inflow of drugs can easily be seen in LMIS. Maintenance of Cold Chain and FEFO, and alternative power supply. DHO Salyan has eight functioning refrigerators out of which only 4 are in use and sufficient enough to maintain cold chain. Generator and solar is used as alternate to power supply for cold chain maintenance. Likewise, the store has maintained FEFO system for effective supply and management of drugs and commodities. No stock out of key drugs and commodities at DHO store for last 12 months. Despite regular follow ups with LMD and RMS for supply of Iron, Cotrim (P), Zinc and MgSO4, there was issue in supply throughout the country. However, the store keeper mentioned that there was no stock out of key drugs and commodities at DHO store for last 12 months. Re-arrangement of DHO store for proper management of drugs and commodities. Although FEFO system is maintained and expired drugs are segregated, rearrangement of store looks important for proper management of drugs and commodities in DHO Salyan. With rearrangement, the store could accommodate more drugs and commodities (some of which were seen outside the store during RA), for easy access and management.

7.5 KEY ISSUES AND CHALLENGES Inadequate supply of Cotrim (P) and Iron. Although DHO manages to keep stock of essential drugs and commodities, it is difficult to adequately supply these to all HFs. Less supply of Iron, Cotrim(P), Zinc and MgSO4 this year caused supply issues to HFs. DHO usually sends request orders to respective supply centers, and if not supplied, they purchase it before running out of stock. But the tender process for purchasing drugs and commodities usually takes around 3 months so this option is usually not taken forward. On the other hand, during district review, some of the ilaka incharges mentioned that they were not sufficiently provided with iron which affected the distribution. It means less supply of key drugs and commodities hampered the distribution at HFs. High cost of transportation affecting the supply of drugs and commodities in health facilities. The cost of transporting drugs and commodities from DHO store to HFs seems to have created recurring issues at DHO store. Although there are road tracks opened to reach most of the VDCs in Salyan, most of them are seasonal with very limited access to vehicles. As per the information provided to us, the cost of transportation is usually very high, due to poor road and high labor cost, causing budget issues every year. Proper management and disposal of expired drugs and commodities, and unused equipments and instruments. During interaction with DHO store keeper, he mentioned that proper management and disposal of expired drugs and commodities is a challenge. Although FEFO system is maintained and expired drugs are segregated, he is not much aware of proper disposal procedures. There are also unused equipments and instruments stored in a room of DHO which needs to be cleaned up. Delay in budget release causing difficulty in logistic management. As per DHO Store keeper, the budget is released at the very end of FY which makes it difficult to manage logistics. There is a huge cost involved in store maintenance, vehicle cost and labor cost for supply to HFss, which they have to arrange on their own until the budget is received. Normally, the fund is internally managed within different programs and once the budget is released, it is settled.

21 8. BEHAVIOR CHANGE COMMUNICATION

H4L aims to understand legal, cultural/religious, and policy dimensions of GESI inequities on health service access and use and design interventions to ensure sustainable, high-quality BCC and IEC approaches that respond to local realities, and include groups not commonly targeted, but crucial to meeting Nepal’s health goals by mobilizing LTAPs. One of the objectives of the RA was to explore the range of BCC interventions that is being implemented for healthy behaviors. Following are the major findings on BCC.

8.1 EXISTING DHO PROGRAMS ON BCC

There are several health related programs and public service announcements (PSAs) that are aired through existing three FM stations in Salyan. DHO Salyan has partnership with all the three FM stations with most of the programs focused at population program, reproductive health, CB-IMCI, CB-NCP, immunization campaigns, polio campaign, health camps, day celebrations or any other program organized by DHO. It was also observed during RA that the health messages, notices and announcements are delivered to public via local newspapers.

8.2 FM STATIONS/CABLE TELEVISION NETWORKS

There are altogether 3 FM stations in Salyan—Sharada FM, Rapti FM and Kapurkot FM. Sharada FM and Rapti FM are located in Khalanga whereas Table 8.2: FM Stations in Salyan Kapurkot FM is in Kapurkot of Dhanabang. DHO Name of FM Station Address Salyan partners with all the three FM stations in 1. Sharada FM Khalanga district to provide information on health activities 2. Rapti FM Khalanga and issues. It was mentioned during RA that the total 3. Kapurkot FM Dhanabang coverage of these FMs is up to Rukum, Rolpa, Dang, Banke, Surkhet and Jajarkot, which makes the use of FM more important. Thus, FM stations are vital means of information dissemination for DHO to provide health information and activities to larger population in and out of district.

There is also a cable TV network in Salyan that broadcasts district-based health programs in TV. The RA team watched few public service announcements and programs on nutrition week while at Salyan. DHO Salyan mentions that similar other programs are broadcasted through cable TV during weekly celebrations and immunization camps. RA team tried to gather information on whether IEC/BCC activities have been implemented for M/DAGs to increase access to service in the last FY 2068/69, but no information was received.

8.3 ORGANIZATIONS WORKING IN IEC/BCC ACTIVITIES

As per the information provided by BCC Focal Person (also CH Focal Person) in DHO, there are three different organizations working in IEC/BCC activities in Salyan as listed below:

1. Women and Child Office (gender-based violence, reproductive health, peer education) 2. Red Cross (RH, peer education, HIV/AIDS, social discrimination, human trafficking, ASRH, WASH) 3. PASS-Nepal (RH, FP services, equity and access, health awareness, pregnancy, ASRH) These organizations work on different areas of health and support IEC/BCC programs but none of them work in coordination with DHO. All their programs and activities are stand alone with very 22 less input and consultation with DHO. The major topic covered by these organizations are reproductive health, family planning services, HIV/AIDS, adolescent and sexual reproductive health (ASRH), water sanitation and hygiene (WASH), pregnancy and delivery through public service announcements in radio, health awareness programs, street drama and peer education.

H4L plans to use mobile phones to reach target groups with messages on health in selected district. The RA also explored whether any organization has used mobile phones to communicate health messages to target groups or entire district population together with DHO. It was found that there has been no intervention as such in Salyan i.e. neither mobile phones nor tablets or any other devices as such have been used to disseminate information to larger public.

One other area of intervention of H4L is to improve the quality of counseling provided by health workers and community-based health workers to clients. It is therefore essential to find out whether there is pool of resources available at district level to improve counseling services. Hence, RA tried to collect information on the district health staff who received training on COFP counseling in the last three years, but no data/list was found. However, as per the information provided by BCC focal person, most of the DHO staffs have received COFP counseling training except for new staffs.

8.4 SCHOOL HEALTH PROGRAM

Through school health program, topics like reproductive health, family planning, adolescent health, communicable diseases, TB, leprosy, and gender based violence are covered. But based on the information provided by BCC focal person, not much of activities have been conducted under school health program this year. No information was available to RA team under this topic. DHO focal person thinks that street dramas, health exhibitions, wall paintings, radio dramas could be effective in reaching adolescents. And more importantly, health messages and BCC activities in relation to early marriage would be very effective considering the fact that one-quarter of expected pregnancy in district pertains to women less than 20 years of age.

Red Cross Salyan has been working on peer education program in 10 schools of 5 VDCs—Kubhinde Daha, Majhkanda, Dhajaripipal, Devsthal and Mulkhola. In this program, 3-day training is provided to 1 male student and 1 female student from 10 different schools on reproductive health, HIV/AIDS, human trafficking, early marriage, etc. Through peer learning techniques, these trainee upon completion of 3-day training talk and discuss about the issues in their respective class and group. Last year, there was Peer Education program targeted to youths with more focus on health education and awareness, but due to budget constraint, the program has not been held this year. According to the HETO, besides school health education program, activities like street dramas, radio dramas and wall painting can be effective in reaching adolescents with health messages.

8.5 MAPPING OF DAG AND EXPLORING CULTURAL PRACTICES AFFECTING HEALTH

During the RA, in-depth information on DAG Table 8.5(a): Villages and ethnic communities communities residing in Salyan was also collected deprived of service utilization in Salyan from DHO staffs. Based on the information 1. Majhkanda 2. Kabhrechaur provided, the western part of Salyan—especially 3. Kubhinde Daha 4. Bafukhola the bordering VDCs to Surkhet and Jajarkot have 5. Nigalchuli 6. Marmaparikanda difficult topography with scattered population. 7. Chande 8. Dhajaripipal Below are the major findings of the assessment. 9. Bafukhola 10. Bame

23 Villages/communities that still practice Early marriage and Early Child Bearing There is no specific caste, ethnicity, village or community practicing early marriage in Salyan i.e. it is a wide problem among most of the communities and villages. Early marriage as a problem seems to have been identified by most of the stakeholders in Salyan, who brought the issues during our conversations, meetings and group interactions. It was mentioned to us that most of the early marriages in district happen at the age of 15-18 years, and around 80% of students are married by the time they reach class 10. DHO staffs think, early marriage has developed as a culture in Salyan which has been exacerbated by lack of awareness and focused intervention. Even when there is outcry on issues brought by early marriage and early child bearing, no program to address these issues has been introduced in the district so far, as per DHO staffs.

Migration pattern There is a trend of migration Table 8.5(b): VDCs with highest number of to India for economic opportunities in Salyan, migration with very few to Malaysia and Gulf countries. 1. Khalanga 2. Marmaparikanda Staffs at PASS-Nepal, who have been working to 3. Triveni 4. Tharmare provide counseling to migrants on HIV/AIDS and 5. Jhimpe 6. Pipalneta STDs, mentioned that there is no particular caste 7. Kubhinde Daha 8. Jhimali or ethnicity migrating for economic opportunities 9. Kajeri 10. Kotmala from Salyan. There are basically people from all 11. Siddheshwori 12. Bafukhola caste and ethnicity going to India after harvesting 13. Bajhkada 14. Kotbara and returning back during farming season. 15. Sivarath -

Based on the information, Table 8.5(b) shows the VDCs with highest number of migration in district. PASS-Nepal staff also mentioned that they are working on data compilation of migrants going to India from 15 VDCs, as listed in Table 8.5(b), the preliminary report of which shows the number as 1,800.

8.6 STRENGTH AND OPPORTUNITIES

Use of FM stations for PSAs and information dissemination. DHO Salyan has been using all three FM stations to disseminate health information to larger audience. Although there are only three FM stations in district, their coverage is huge reaching the PSAs and programs at Rolpa, Rukum, Dang, Banke, Surkhet and Jajarkot. Sharada FM in Salyan mentions having coverage in more than 10 districts. There are several PSAs and health messages aired through FM stations on daily basis.

Use of local cable TVs and local newspapers for health message dissemination. There is also a cable TV network in Salyan that broadcasts district-based health programs in TV. A couple of public service announcements and programs on nutrition week was observed by RA team while at Salyan. Other information on weekly celebrations, immunization camps, awareness programs are also broadcasted through cable TV as per BCC focal person.

IEC/BCC activities conducted by different organizations. Along with DHO, there are many IEC/BCC activities being conducted by different organizations in Salyan. Organizations like WCO, Red Cross and PASS-Nepal have been working on different health issues and awareness raising programs. These three organizations have been working to create awareness on different health issues covering their respective areas of gender based violence, reproductive health, peer education, HIV/AIDS, social discrimination, human trafficking, ASRH, WASH, etc. However, most of these programs are running without any coordination with DHO. If these organizations can

24 collaborate with DHO to reach different target groups, there are opportunities to have long term effect on behavior change.

Newly established BCC corner at DHO. A BCC corner has recently been established at DHO, Salyan with posters, books, pamphlets and brochures on display. Whoever wants more information can easily approach at reception and get the required materials. As this has recently been established, having a person who can provide counseling services would help the information seeker.

8.7 KEY ISSUES AND CHALLENGES

Inadequate IEC/BCC materials on early marriage, adolescent health, RH, HIV/AIDS and sanitation. After visiting BCC corner at DHO and other organizations working on IEC/BCC, it was observed and noted that there are inadequate IEC/BCC materials on early marriage, adolescent and sexual health, reproductive health, HIV/AIDS and sanitation. If DHO could develop and print district specific materials on these issues, it is likely to have more impact on larger population.

Use of BCC to address the issues raised by early marriage and early pregnancy. Early marriage is one of the major problems in Salyan and the HMIS data shows that 25.33% of ANC 1st visit is done by women less than 20 years. Use of BCC materials and at the same time respecting cultural and traditional practices in locality is quite a challenge in Salyan. Through proper use of BCC materials and programs, awareness can be raised to prevent early marriage and early pregnancy in district and at the same time awareness raising on RH and FP/MNCH can help mitigate the possible risk that can be caused by early pregnancies.

“There are quite a few innovative ideas to work on BCC in district but everything gets stuck and piled up because of budget. We have discussed an idea to address early marriage and early pregnancy in Salyan which can be effective if it gets room for implementation. The plan is to mobilize FCHVs, who will visit newly married couple in their respective wards and gift them an attractive envelope that contains complete information on family planning, informed choice, pregnancy, birth spacing, complications of early pregnancy, information on reproductive health, etc. Along with the counseling, FCHVs will also provide condoms and pills to the newly married couple and ask them to consult her or any health workers in their locality in case of any queries. This way we can reach many newly married people, provide counseling and information on informed choice, and at the same time make them aware of complications that might arise in future due to early pregnancy, low birth spacing, etc.” -- FP Focal Person, DHO Salyan

Coordination among different organizations working on IEC/BCC activities. Including DHO, there are four different organizations working on IEC/BCC activities in Salyan but with no or very less coordination among each other. There are rooms for collaboration among these organizations that can utilize and adopt each other’s IEC/BCC materials, ideas, concepts, etc. This will not only create synergy among different organizations but also help in cost reduction and development of focused intervention. No system of recording information of Health Workers who have received training. During the rapid assessment, it was identified that there is no provision of keeping records of health workers who have received important trainings through center, region, district or any others organizations. If DHO could maintain a record of health workers who have received SBA training, COFP counseling training, IUCD training, etc, it could help DHO nominate staffs based on the coverage and need.

25 8.8 H4L INTERVENTION ON BCC

Collaborate with district level stakeholders to design focused BCC programs/materials on early marriage and early pregnancy. As mentioned in earlier sections, early marriage and early child bearing are two important issues that are interlinked in Salyan. These issues have been identified by many district level stakeholders who have committed to work against it. H4L can collaborate with these identified district level stakeholders and design focused BCC program or material jointly, so that it can have wider and long term effect on people. Coordinate with organizations working on IEC/BCC, and utilize and adopt different materials, ideas and concepts used so far. There are several programs and ideas being implemented on IEC/BCC under different themes within and out of district. Different materials, ideas and concepts developed and used by other organizations can be utilized and adopted in close coordination with them. H4L can coordinate with these organizations, which will not only help share innovative concepts and ideas but also help in cost reduction, avoiding duplication and joint planning. Support DHO and other stakeholders in developing locally relevant BCC materials. Most of the IEC/BCC materials in DHO are supplied by central level, which covers general topics that are applicable to any other parts of the country. But these materials might not necessarily address the issues of Salyan, for example: stigmas attached to disability, HIV/AIDS, early marriage, early pregnancy, sanitation, nutrition, water-borne diseases, and adolescent health, so having district specific BCC materials is important to provide information to people and bring change in their behavior. H4L can support DHO and other stakeholders working in district to develop locally relevant BCC materials to have wider and long term effect on behavior change. Ensure that RHCC and QAWG meetings are held so that IEC/BCC programs and activities can be discussed. H4L should ensure that RHCC and QAWG meetings are conducted on regular basis. These meetings can be developed and used as forums to share information on different activities and programs being conducted by different district level stakeholders and other organizations under different topics. These forums can also be used for joint planning of BCC programs/activities for cost effectiveness, as well as replication of effective communication and materials to reach more people.

26 9. ADOLESCENTS AND YOUTH FRIENDLY SERVICES

H4L will also work with DHOs in selected districts to improve service accessibility of adolescents under its Objective 6. The RA also explored different aspects of Adolescents and Youth Friendly Services in the public health facilities of Salyan district. Following are the major findings under this section:

9.1 EXISTING SERVICES FOR ADOLESCENT There are several programs running for adolescents in Salyan and some organizations have been supporting to promote the services as youth friendly. Programs like school health, adolescent and youth friendly services, peer education, adolescent girl’s information and counseling center and awareness raising programs are currently running in Salyan with support from WCO, GIZ, PASS- Nepal and Nepal Red Cross Society (NRCS). DHO/GIZ launched adolescent and youth friendly services in 13 HFs of Salyan at the time of RA. The program has just been introduced in the district with 2 days training to three health workers each from 13 HFs. Although RA team tried gathering information on adolescents and youth clubs located in district, no such information was available. There are adolescent groups and committees formed by different organizations like WCO and NRCS, but nothing specific as district level adolescent clubs, youth clubs or social groups were found during rapid assessment.

9.2 ORGANIZATION WORKING FOR ADOLESCENT Women and Children Office (WCO) has been closely working with adolescent girls in 6 VDCs of Salyan—Damachaur, Phalabang, Syanikhal, Pipalneta, Bajhkada and Siddeshwori, and providing them livelihood trainings. They work with girls who are 10-19 years of age and who are in or out of schools through committee formation. At VDC level, 7 committees comprising of these adolescent girls have been formed and life skill training is being provided with information on RH, adolescent health, menstruation cycle, early marriage, gender-based violence, etc. In the next phase, they are given skillful training for income generation. Likewise, WCO has also established Information and Counseling Center for adolescent girls in working VDCs. WCO has been working closely with adolescent girls to provide them access to information, skillful training, counseling and awareness. The RA team observed one of the trainings in WCO Hall where adolescent girls were being trained on briquette making for income generation. GIZ in collaboration with DHO has recently launched Adolescent and Youth Friendly Services in selected HFs of Salyan. The program was introduced during RA and the RA team was invited in the event. As per the information provided, the program is being implemented in 13 HFs of Salyan— District Hospital in Khalanga, 2 PHCCs in Tharmare and Lekhpokhara, 8 Ilaka level health posts (Sarikot, Hiwalcha, Kalche, Mulkhola, Darmakot, Kajeri, Chande, Kotmala) and 2 SHPs in Damachaur and Marke. Through these health facilities, youth friendly services are provided to adolescents, with more focus on adolescent sexual and reproductive health. Nepal Red Cross Society in Salyan has been working on peer education program in 10 schools of 5 VDCs—Kubhinde Daha, Majhkanda, Dhajaripipal, Devsthal and Mulkhola. Through this program, 1 male student and 1 female student from 10 different schools are provided 3-day training on reproductive health, HIV/AIDS, human trafficking, early marriage, etc. Through peer learning techniques, the knowledge is shared among other school students, friends and their circles and groups. PASS-Nepal has limited adolescent friendly program in Salyan with focus on information and awareness raising among school students. As PASS-Nepal has been working on expanding FP 27 services through private clinics and medical stores, they are also targeting adolescents in schools to make them aware of services offered and provide information on FP methods, sexual and reproductive health.

9.3 STRENGTH AND OPPORTUNITIES Different organizations working on adolescent and youth friendly services. There are four different organizations working on adolescent friendly services in Salyan. Organizations like WCO, GIZ, NRCS and PASS-Nepal have been working in this sector to provide adolescent and youth friendly services through trainings and programs on awareness raising, school health program and peer education. Information and Counseling Center for adolescent girls in 6 VDCs (WCO). WCO has been working on 6 VDCs of Salyan providing them livelihood trainings. They work with girls who are 10- 19 years of age and who are in or out of schools. Through committees, they provide livelihood trainings to these groups of girls as income generation activities. Apart from that, WCO has also established Information and Counseling Center for adolescent girls in these 6 VDCs.

9.4 KEY ISSUES AND CHALLENGES Early marriage a major issue—need of focused intervention. Like in Dang, early marriage is a serious issue in Salyan having direct effect on health of women and children. Early marriage is also a major barrier in improving health indicators, especially on RH and FP/MNCH. It is very essential to come up with awareness raising programs among parents and youths/adolescents such that issues can be widely discussed to prevent early marriage. Besides that, programs with focus on RH and FP/MNCH need to be focused at young girls and boys who are married at the young age to mitigate the possible risks that can be caused by early pregnancy. Many organizations working in AFS but limited to few VDCs. Although there are adolescent and youth friendly services in different VDCs and HFs of Salyan, its expansion in all VDCs and HFs is a challenge. Although four organizations are working to provide AFS, expanding their coverage and providing regular and sustainable services are key issues. The coverage of such services has to be expanded in all VDCs to ensure that no youths are deprived of health services. Lack of BCC materials on adolescent related aspects. As mentioned in IEC/BCC section, there is a lack of adolescent focused BCC materials in Salyan. In a district where there is high prevalence of early marriage and early pregnancy, developing innovative and attractive BCC materials on adolescent and RH can have positive impact on behavior change. Different organizations working on AFS can collaborate and come up with a common but impressive material and programs to reach adolescents. Bringing adolescent and youths to health facilities. It is a challenge to health workers to bring adolescent and youths to HFs. Considering student’s engagement in schools during HF working hour, a special hour can be dedicated to provide services. Apart from that, tracking and bringing out-of-school adolescents to HFs is another big challenge, which needs focused intervention from DHO and other organizations working in health sector. Involving youths in decision making process. Although youth and adolescent targeted programs are launched in Salyan, having their representation in different local and district level meetings is vital. Their participation should be ensured by different stakeholders, providing them friendly forum where they can discuss on their issues and raise their demands. Based on the interaction with district level stakeholders during RHCC meeting, involving youths and adolescents in decision making process is important for which focused intervention is needed from DHO and other organizations working in the district.

28 10. GENDER EQUALITY AND SOCIAL INCLUSION

H4L is designed to support the Government of Nepal’s stated commitment and responsibility to ensure that quality health services are accessible to all citizens. As such, it is critically important that sound, ongoing GESI-sensitive analysis and gender integration underpin H4L program interventions. H4L’s GESI Objectives are designed to redress gender and social inequities, and dove-tail with the objectives set forth in the MOHP’s 2009 Health Sector Gender Equality and Social Inclusion Strategy as follows:

Objective 1: Support existing MOHP policies, strategies, plans and programs that create a favorable environment for integrating GESI in Nepal’s health sector; Objective 2: Support MOHP’s efforts to enhance the capacity of service providers and ensure equitable access and use of health services by the poor, vulnerable and marginalized castes and ethnic groups; and Objective 3: Improve health-seeking behavior of the poor, vulnerable and marginalized castes and ethnic groups in collaboration with local government partners, community- based organizations (CBOs) and other stakeholders.

The first objective is related to policy while the latter two are directly related to D/PHO systems. The RA also included assessment and analysis of the health programs of the DHO Salyan from GESI perspective. The major findings were as following:

10.1 FORMATION AND FUNCTIONALITY OF GESI COMMITTEE

In DHO Salyan, GESI committee was formed on July 20, 2012 in accordance with the GESI institutional guidelines guided by central level, with 17 male and 6 female members. Out of 23 members in the committee, there is 1 Dalit female, 1 Muslim male and 1 Janajati female and 3 Janajati male. The committee also formed a GESI working committee the same day with members from District Hospital, DHO, DDC, WCO, District Ayurvedic Office, DEO and other stakeholders working in health sector.

NHSSP supported the formation of GESI committee and NHSSP GESI specialist based in Regional Health Directorate provided a partial orientation of 3 hours to all the stakeholders. The committee thus formed agreed to meet in every four months, but no meeting or follow ups has been held since its formation. As per the information provided by GESI Focal Person at DHO Salyan, some of the programs have been initiated with GESI sensitivity but no meetings have been held to discuss about them. She mentioned that the committee was formed as per the guidelines but the orientation provided during the formation is not sufficient to understand the main thrust of GESI. It was mentioned that MOHP GESI Strategy and Operational guidelines have not been provided to district team. District staffs at DHO also mentioned that they are not aware of the importance of GESI in program and activities, and that the committee was formed to fulfill the mandate. Once they are sensitized enough, they think they would not require any meeting agenda or a separate budget allocation to integrate GESI—instead each programs and activities at DHO would be GESI focused.

10.2 ACTIVITIES ON GESI AND INFORMATION ON DISAGGREGATED DATA

To integrate GESI in programs and activities, DHO currently has Equity and Access program implemented through PASS-Nepal that provides information and awareness to deprived group of 29 people living in 5 VDCs of Salyan—Kabhrechaur, Kavra, Dhakadam, Majhkanda and Chande. Likewise, initiation has been taken by WCO and DHO to provide free health services to elderly people (above 60 years of age) from district hospital. Under this initiation, DHO provides free health check up and medicines while the cost of extra care (x-ray, lab tests, extra medicines, etc) is provided by WCO.

DHO Salyan does not have any disaggregated data by age, caste, ethnicity, wealth quintile and region, nor do they have any recent DAG mapping. The availability of such data and its analysis would help initiate programs to address GESI gaps. Likewise, the district also lacks GESI sensitive process indicators to measure utilization and health care services and disparities between different caste and ethnicities.

10.3 ORGANIZATIONS WORKING ON GESI

Apart from DHO, the RA team came across three organizations working on GESI in Salyan—DDC, WCO and PASS-Nepal and visited all of them, seeking information on what kind of activities are they conducting, who are the beneficiaries, level of sensitivity, their programs and coverage.

District Development Committee (DDC). The RA team met LDO and sought information on GESI integration on DDC programs and activities. Although mainstreaming and H4L support to DDC, Salyan on GESI orientation: integrating GESI into programs has Post RA support been mandated by the government, the lack of proper training to district and It was identified during RA that DDC Salyan due to lack of local level leaders and staffs acted as a budget was struggling to find a proper resource person to barrier. train different groups of people on GESI. Realizing the importance of the training in Salyan, H4L supported DDC Women and Children Office (WCO). by providing its GESI Advisor from as a GESI has been an integral part of WCO, resource person to train the targeted people in the district. Three-days training was provided to the head of but with more focus on women and offices in district, political party representatives, women adolescent girls. They have been leaders, members of target groups (Dalit Network, Jajajati working on group formation at tole group, women’s network, disabled network, child club, level, committee formation at ward etc.), and representatives from district level stakeholders. level and cooperative formation at VDC The training was successfully conducted during June 2-5, level, which involves women above 20 2013 to the group of around 50 people. Apart from that, years who are out of school and are DDC also arranged for other round of GESI training to all economically backward. These groups VDC secretaries, social mobilizers under LGCDP and are usually led by FCHVs who provide village facilitators under WCO. awareness on RH, HIV/AIDS, GBV, The main purpose of these orientations was to inform and women and reproductive rights, etc. sensitize different layers of local level leaders on GESI. Likewise, WCO also works with Also these are the same group of people who are involved adolescent girls between 10-19 years of in district level planning and budget allocation. Thus, the age form ward level committee training is expected to sensitize them on GESI issues so comprising of 25-30 adolescent girls in that it can be integrated in district and local level planning or out of school. At present, WCO has and implementation. Along with several district level formed 7 committees of adolescent girls stakeholders, this training was also attended by DHO who in 6 VDCs—Damachaur, Phalabang, actively participated in interaction and group activities, Syanikhal, Pipalneta, Bajhkada and and committed to focus on GESI perspective in upcoming Siddheswori, and provided awareness programs and activities in health sector. on issues like RH, early marriage,

30 adolescent sexual and reproductive health, GBV, HIV/AIDS, etc. Apart from awareness raising, WCO also provides livelihood trainings to support income generation activities. One of the groups of adolescent girls was taking briquette-making training at WCO at Khalanga at the time of RA, which was observed by RA team.

PASS-Nepal. Although GESI is not a main focus of PASS-Nepal, they are working with DHO on Equity and Access program offering information and awareness raising programs to people of hard to reach areas of 5 remote VDCs of Salyan—Kabhrechaur, Kavra, Dhakadam, Majhkanda and Chande. Through Equity and Access program, women, esp. pregnant and new mothers are given support and health awareness is provided through different BCC activities like street drama. Although there are few programs with GESI focus in district, H4L can collaborate with them to deepen GESI understanding among different stakeholders and support them to identify M/DAGs, hard to reach areas, deprived group of people, and work together to extend quality health services.

10.4 AREAS OF SYNERGY AND COLLABORATION IN GESI

The different level of trainings provided by DDC in collaboration with WCO recently has supported a level of sensitization on GESI. As these trainings were attended by many district level stakeholders and line agencies, it is more likely that the upcoming programs and planning will have some level of GESI sensitivity. There are areas of synergy and collaboration with DHO, DDC, WCO, GIZ and other stakeholders in identification of hard to reach areas, deprived population (elderly, disabled, children, women, people living with HIV/AIDs, etc), marginalized and disadvantaged group of people, and provide quality services to them.

======END OF REPORT======

31 Annexes Annex 1: Contact information of DHO Staff, Salyan Years of Added Years of Cell Phone DHO Team (current) Name service in Responsibility service no. district District /Public Health DHO 17 1 Officer Public Health Officer PHO 5 mnths 5 mnths CB-IMCI/CB-NCP Focal CH, BCC 28 19 person Public Health Nurse RH, MNH 25 10 FP focal person FP, FCHV 18 11 DTLA/Officer TB, Leprosy 19 6 EPI Supervisor/Officer EPI officer, 19 17 HMIS Cold Chain Officer EPI supervisor, 19 17 HFOMC Store Keeper Store 3 1 Nutrition Focal Person PHO 18 11

Annex 2: List of RHCC members and Organizations, DHO Salyan SN Member/Representative Organization Designation 1. Medical Officer District Hospital Member 2. Medical Recorder District Hospital Member 3. Nursing Incharge District Hospital Member 4. District Health Inspectors District Health Office Member 5. Social Development Officer District Development Committee Member 6. Women Development Officer Women & Children Office Member 7. Head District Ayurvedic Office Member 8. GESI Focal Person District Education Office Member 9. Representative GIZ Member 10. Representative Health for Life Member 11. Representative Nepal Red Cross Society Member 12. Representative Pass-Nepal Member 13. FP Focal Person District Health Office Member Secretary

32 Annex 3: List of Individuals/Organizations visited during RA in Salyan SN Name Designation/Department Organization Contact No. 1. Local Development Officer DDC 2. Women Development Officer Women & Child Office 3. District Health Officer District Health Office 4. Public Health Officer District Health Office

5. EPI Officer District Hospital 6. EPI Supervisor/HFOMC District Health Office 7. FP Supervisor District Health Office 8. PHN/ GESI Focal Person District Health Office 9. Na.Su/Admin Section District Health Office 10. Store Keeper District Health Office 11. TB/Leprosy Supervisor District Health Office 12. Health Assistant, BCC District Health Office 13. Public Health Officer District Health Office 14. ANM District Hospital 15. Chairperson PASS Nepal 16. District Coordinator PSA-PASS Nepal 17. District Coordinator AMDA-PASS Nepal 18. Information & District Development Office Communication 19. Field Coordinator Nepal Red Cross Society -

33 HEALTH FOR LIFE REPORT ON RAPID ASSESSMENT

OF DISTRICT HEALTH SYSTEMS

2013 SURKHET

1 A REPORT ON RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 2013

SURKHET

MAY 2013

TEAM MEMBERS

HALL 401, OASIS COMPLEX

PATANDHOKA

2 TABLE OF CONTENTS

ABBREVIATIONS 4

KEY FINDINGS FROM RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS 5

RAPID ASSESSMENT 8

Introduction Of Surkhet District 10

DPHO Structure and Systems 12

Service Statistics 16

Health Facility Management Committee and Local Health Governance 20

Service Delivery/Quality Improvement 22

Logistics Management System 24

Behavior Change Communication 26

Adolescents and Youth Friendly Services 28

Gender Equality and Social Inclusion 32

Annexes -----1 36 Annexes ------2 37 Annexes------3 38

3 ABBREVIATIONS

AHW Auxiliary Health Worker ANM Auxiliary Nurse Mid-wife BCC Behavior Change Communication CB-IMCI Community-Based Integrated Management of Childhood Illness CB-NCP Community-Based Newborn Care Package CDO Chief District Officer CEONC Comprehensive Essential Obstetric and Neonatal Care BEONC Basic emergency Obstetric and Neonatal Care DAO District Administrative Office DDMC District Disaster Management Committee EMC Emergency Management Committee HFOMC Health Facility Operation and Management Committee FP Family Planning GESI Gender Equality and Social Inclusion H4L Health for Life HA Health Assistant HF Health Facility HMIS Health Management Information System HP Health Post IT Information Technology LMIS Logistics Management Committee MNCHN Maternal Neonatal Child Health and Nutrition MO Medical Officer MWDR Mid-western Development Region N Number PHCC Primary Health Care Center QAWG Quality Assurance Working Group QI Quality Improvement RA Rapid assessment RHCC Reproductive Health Coordination Committee SHP Sub Health Post SN Staff Nurse USAID Unites States Agency for International Development VDC Village Development Committee WDR Western Development Region FEDO Feminist Dalit Organization FECOFUN

4 KEY FINDINGS FROM RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS

TOTAL POPULATION 350804 TOTAL MALE 169421 TOTAL FEMALE 181383 NUMBER OF VDCS 50 MUNICIPALITY 1 ILAKA 11 ELECTED AREA 3 DPHO STRUCTURE AND Public Health facilities: SYSTEMS  Zonal Hospital-1,hospital -1 PHCCs-3, HPs -24 and SHPs-23, urban health clinic -4, Zonal Ayurved-1 and Ayurved Aushadhalay-1 Private Health facilities:  Private hospitals and nursing homes-3, Eye clinic-1, Dental clinic-1 Meetings:  Monthly meeting of Ilaka In-charge at District- 7th of every month  QAWG- No meeting held in the last 6 month  RHCC- Meeting quarterly and last meeting was organized Falgun 2069 (Need basis only) Health Workforce:  All technical positions of DHO filled in but in the peripheral level health facility following situation was found during RA Out of the 3 PHCCs; Medical Officer Position is vacant in all. Out of the total 3 sanctioned positions of Staff Nurse in the district, one position is field and 2 are vacant in the PHC.  Out of 48 ANM only 37 position full field, out of 50 HA./S.AHW 35 only full field, out of 45 AHW 42 AHW field. Out of 35 padnam AHW 34 only field , like wise out 23 padnam ANM 21 field in, out of 3 Lab Assistant 2 field in , out of 42 support staff 39 position field in the district and peripheral level health facility.  Only four health workers hired from NPC and 36 staff has hired by DHO in contract and 5 staff has been hired from local recourses (VDC)

 Irregularities of assigned staff in hard to reach VDCs (HFs) has been faced several times.  Population based human resource need according to DAG mapping  Some of supervisor has given additional responsibly

Monitoring and Supervision:  DHO has monitoring and supervision system in place to monitor HPs and SHPs.  Ilaka HPs do supervision to SHPs too  Use integrated monitoring and supervision tools and gives feedback.  Does have integrated check list but occasionally used (DHO & HP) IT infrastructure at D/PHO:  Desktops-12, Laptops-5, Printers-10 all are functioning.  DHO has internet facility with functioning.  Four HFs have computer and they are practicing on the same.  Among the district supervisors 7 are skilled on MS words and excel  Web- based HMIS and LMIS reporting system exists in DHO  No data validation plan in this fiscal year  Well established internet facility.

5  Four HFs has computers.  Supervisors skilled in using MS Word and Excel-.  Social Inclusion reporting system practiced.  Data are being reported but not analyzed at district  Collection of disaggregated data in place which need further analysis  Recently DHO has been implementing IT related intervention in the district that is phone SMS with the support of WHO. Rapid Response Team:  Rapid Response Team (RRT) formed in DPHO and Focal Person assigned.  They have been organizing meeting in the district in quarterly basis and if needed call the meeting immediately.

SERVICE STATISTICS  Percentage of reports received from FCHVs found good that is 90%.  BCG and Measles coverage is in increasing trend. In the FY year 2068/69 BCC coverage was 100 % and measles coverage was 90 %. This is 4% less than previous year.  Severe pneumonia and diarrhea cases show fluctuating trend. More children are being treated with antibiotics.  Percent of severe dehydration among new cases is constant or slightly decreasing in trend.ANC first visit (under, 20 years) as of expected pregnancy is comparatively low 31.7 % in 2068/69 than previous FY. Which is good in the sense of number of under 20 years women are decreasing it shows effect of HE in the entire community people and as well as impact of communication intervention program. But district data still shows that more than national. Likewise ANC four visits appeared to be low in comparison of ANC first visit in last 4 years at the same time period. At previous it counts any four visit but according to our government rule following visit only counted as a antenatal check up fist at 4th month, second at 6th month, third at 8th month and fourth at 9th month of pregnancy at least four ANC visit within the specified interval which effect on the parentage of 4 ANC visit according to DHO by the way data of 4 ANC visit of this district is more than nation coverage. Data shows that the pregnant women attending at least 4 ANC visits, irrespective of the timing of visit, as percentage of the first ANC visit.  Delivery conducted by SBAs (both home and institutions) as percent of expected live birth is also in increasing trends the data shows that percentage of expected pregnancy and institutional delivery is going improve.It is significant to message that delivery by SBA has increased over the last couple of years. It has increased from 26.74 percent in 2065/66 to 43.39 percent in 2066/67 and 52.65 percent in 2067/68 and 58.72 % in 2068/69 (percent of deliveries conducted by SBA (in both home and institution). There has been an increase in institutional delivery in the last three years in district which is one of positive massage.

 Percentage of mother who are received postnatal care at the health facility among the expected live birth has increased from 63.94 to 74 (2065/66 to 2068/69)  pregnancies is in increasing trends 58.7 in 2068/69 (this also does not give any meaning. Please write both the bullet meaningfully)  CPR (all modern methods) as percentage of MWRA of Surkhet district is almost decreasing /constant for last 4 years (in between 50.9 to 53.8).  PNC 1st visit as a percentage of live birth is in increasing trend. It was 53.94 in

6 2065/66 and 74.34 in 68/69  Most of post partum mother receiving vitamin “A” is good (that is 80.5 in FY 2068/69)

HEALTH FACILITY  All together out of 50 HF 38 HF has been handed to VDC. (HP 15, SHP 23) MANAGEMENT COMMITTEE and remaining HF hand over to VDC and DDC are PHCC-3, HP 9. AND LOCAL HEALTH  All HFOMCs received capacity building trainings and refreshers training with GOVERNANCE the support of NFHP II.  HFOMC were formed as per the guidelines and majority (80%) are functioning (meeting at least once in a month). But only organizing onetime meeting is not sufficient so need to improve.  At community level following groups are existing in the district such as - Forestry Users Group, Mothers’ Group, Drinking Water Users Group, Irrigation Users Group, Road Rural Users Group, Cooperatives, Media and Pregnant Mother group are functioning. SERVICE DELIVERY/QUALITY  There are 36 functional birthing centers all are functioning well. IMPROVEMENT  34 Birthing centers have placenta pits  Out of 50 health facilities, 8 HF has been providing long term FP services by government, Regional hospital has been also providing long term family planning services and 4 private institution have been providing long term FP services in the district  One CEONC service center is functioning– Regional hospital.  Programs like CB-IMCI, MSC and IMAM, IYCF have been already implemented. And need CB-IMCI training for newly joined FCHVs LOGISTICS MANAGEMENT  No stock-out rate of health commodities in the health facilities is SYSTEM attributed to the scale-up of Pull System in the districts, monitoring of LMIS and inventory management, sub district level logistics orientation, and other capacity building activities in logistics management at various level .Most of key drugs are in stock but Cot- rim P, ORS, and Iron were stock-out for few times only in last 12 months. During RA condom have most problem with over stock during FY 2069/70.  Webb-based LMIS system is in place in DPHO, and is being reported regularly  FEFO and LIFO system found maintained in the district accordingly and systematic way. Even though they had followed the system to make it more systematic further more strong system needs to be maintained as per the guideline and manual. According store in charge it would be better if one more human resources were recruited to maintain LMIS reporting system. And training for us.  There are 7 refrigerators that are functioning well for cold chain maintenance. There is alternate to power-cut in place. BEHAVIOR CHANGE  DHO has partnership with all 4 FM stations and radio Nepal (regional COMMUNICATION broadcasting) at Surkhet  Swasthya Sarokar and MankoSansar Programs, FP and population and nutrition like jingles was lunched through DPHO (need to air other radio program all over the year )  Organizations like INF, CAED/WRRP have been working on BCC programs  No BCC services target to M/DAGS.  Dalit, Chherty/Muslims are deprived to get health services  At present DHO has been developing health related massage according to need basis but not target audience and target people demand so must to practice according to target audience nature.  Need to Organize School health program in different school

7 ADOLESCENTS AND YOUTH  In Surkhet, there are many focused programs on Adolescents and Youths. FRIENDLY SERVICES Adolescents and Youths Friendly Services (AYFS) are established with the support from various INGOs/NGOs and CBOs. DHO with the support of GIZ has implemented Adolescents Friendly Health Services (AFHS) in 13 VDC  SAC, WRRP/caed, ISS has been working in the district which works in women and adolescent health & advocating delay marriage, sexual reproductive health, FP, HIV, hygiene & sanitation program in the community.  Organize cultural and awareness campaign in the working area (who does it?) GENDER EQUALITY AND  GESI committee is formed in 2068 in the district but need to practice as per SOCIAL INCLUSION guideline.  Received GESI orientation from NHSSP/RHD.

8 1. RAPID ASSESSMENT OF DISTRICT HEALTH SYSTEMS

1.1 HEALTH FOR LIFE

Health for Life (H4L) is a five-year bilateral agreement between the Ministry of Health and Population (MoHP) and the Unites States Agency for International Development (USAID) which focuses on Systems Strengthening and improving the Maternal Neonatal Child Health and Nutrition/Family Planning (MNCHN/FP) service delivery at district and sub-district levels in 14 districts. 12 of the 14 districts are in the Mid-western Development Region (MWDR) –Banke, Bardiya, Dang, Surkhet, Salyan, Pyuthan, Dailekh, Kalikot, Jumla, Rukum, Jajarkot and Rolpa and two are in the Western development Region (WDR) of Nepal- Argakhanchi and Kapilbastu. The project will be implemented between 2012 and 2017.

1.2 RAPID ASSESSMENT AND ITS OBJECTIVES

Rapid assessment (RA) is a method of analyzing situation of a district where issues are not well defined and where there is not sufficient time or other resources for in-depth quantitative research. RA uses intensive team interaction in both the collection and analysis of data instead of prolonged field work and iterative data analysis and additional data collection to quickly develop a preliminary understanding of a situation from the insider’s perspective. The main purpose of carrying out the current Rapid Assessment is to understand the current situation of the health service delivery system and other associated systems of the Surkhet district so as to help in planning activities at district level.

Specifically, the objectives of the RA includes  Understanding the demographic profile of the district  Understanding the existing health care delivery system of the district  Knowing the functionality of the Facility Management Committees  Understanding the status of health indicators  Analyze strengths and weakness of the DHO systems  Exploring feasibility for the implementation of specific programs for adolescents and youth  Exploring feasibility of using Information Technology in information management

1.3 METHODOLOGY

A mix of both qualitative and quantitative methods was used to execute Rapid Assessment in Surkhet district. These includes visit to DHO, District Development Committee (DDC), WCDO, and I/NGOs, interaction with key informants, record reviews and observations. A structured tool was developed to collect necessary information which was supplemented by qualitative tools to interview key informants at different agencies working on different areas of health service delivery and management, Gender Equality and Social Inclusion (GESI), Behavior Change Communication (BCC), Information Technology (IT) in Health and Governance.

A team composed of 4 H4L staff was formed for carrying out RA in Surkhet where there was a good skill mix among the members to cover different areas of the RA Involvement of Central, Regional and District office staff was ensured.

9 Before carrying out of the RA in Surkhet, one and a half day orientation on RA objective, methods and tools were organized for H4L staff together with orientation on H4L project in Hotel Siddhartha, Nepalgunj on 23 and 24 day of April. Director and three senior officials from the Mid- western Regional Health Directorate, Surkhet they provided inputs in further refining the RA tools.

RA in Surkhet was completed by H4L Staff in seven days beginning May 2 to May 8, 2013. Small groups were formed within the team where the members divided their responsibilities and visited DPHO and other stakeholders for establishing relationships, interactions and information collection. At the end of each day all the members gathered for about an hour and shared their experiences. Information collected by the team members was verified on the same day and brief notes were developed for each thematic area. Report was prepared using the template provided by the H4L central office. A brief PowerPoint presentation was also prepared covering the key findings of the RA which was shared with DHO on May 8, 2013.

The interaction processes and the information collection during the RA were confined to district- based offices. The RA team did not make field trips to below district level institutions for information collect because of most information including the sub-district level that the RA required were availability at the district offices. Visiting peripheral health facilities and interaction with HFOMCs and FCHVs would have enriched the RA but this was not done. This can be considered as the major limitation of the RA.

1.4 ORGANIZATION OF THE REPORT

The findings of the RA are presented in nine Chapters. Chapter one presents the purpose of carrying out RA and the methodology followed. Chapter two presents the introduction of Surkhet district. Chapter three explains the DHO systems and structures. Fourth and the Fifth chapter present the service statistics and the status of the HFOMCs in Surkhet district. Sixth and the Seventh chapter present the findings on service delivery/quality of care and logistics management system. Chapter Eight and Nine present current scenario, findings and coordination aspect on Behavior change communication (BCC) and Adolescents Youth Friendly Services (AYFS) and Chapter ten express current situation, findings and understanding on GESI in Surkhet district.

10 2. INTRODUCTION OF SURKHET DISTRICT

2.1 GEO-POLITICAL SITUATION

Surkhet District is located in the Mid –Western Development Region (MWDR) of Nepal. Surkhet district is a part of Bheri Zone. is its district head quarter as well as the regional headquarter of the MWDR. Surkhet covers area of 2,451 square km.

The district neighbors Kailali, Banke and Bardia districts to the south, and Doti and Achham districts to the west. It shares its North boarder with Achham, and Dailekh and East boarders with Jajarkot and Salyan. There are 50 Village Development Committees (VDCs) and one municipality- Birendranager in Surkhet. It has 11 Ilaka and three electoral constituencies.

2.2DEMOGRAPHIC INFORMATION Table 2.1: Population of Surkhet District The 2011 Census reports total population Number Percent of Surkhet district as 350,804. The Total Population 350,804 - proportion of Female is greater than that Male 169,421 48 of male in Surkhet. Female 181,383 52 Household number 83,176 - Table 2.1 shows the caste/ethnicity Source: Census 2011 distribution of the population residing in Caste/Ethnicity distribution Surkhet District as reported in the Chetri/Brahman 41 District Development Committee (DDC) Thakuri 5 annual report 2069/2070. Out of all the Janjati (Tharu, Gurung ,Magar) 24 caste/ethnicity groups, the proportion of Dalit (kami, Damay Sharki) 21 Chhetri/Brahmin is greatest (41%) Sanyasi 2 followed by Janajati which includes Others 8 Tharu, Magar and Gurung) (24%) and Source: DDC profile 2069/70 Dalit which includes Kami Damay And Sarki (21%). There are some and few Sanyasis in Surkhet. Eight percent of the population to other different caste/ethnicity groups.

11 3. DHO STRUCTURE AND SYSTEM

This chapter presents the findings related to the DHO structure and systems collected from the RA. The findings covers following areas: service delivery points, management system, health workforce, monitoring and evaluation system, IT and health information management and disaster management system.

3.1 SERVICE DELIVERY POINTS

The District Health Office located in Birendragnagar Table 3.1: Number of service delivery points in Surkhet district is the main responsible institution of MoHP at Type of service delivery points Number Surkhet to provide preventive, promotive and Government Hospital Regional 1 curative health services to the people of Surkhet. Government Hospital 1 There are a total of 50 peripheral public health Zonal Ayurved 1 facilities (3 PHCCs, 24 HPs and 23 SHPs) and a one Ayurved Ausadhalay 2 Regional Hospital in Surkhet district. There is PHCC 3 another hospital- Melkuna hospital in the district. Health Post 24 There are one zonal Ayurved hospital and two Sub-health Post 23 Ayurved Ausadhalays. There are 36 birthing centers Private hospital 2 and all birthing center have been functioning and Urban health center 4 providing health services. There are 160 PHC/ORC Birthing centers 36 Functioning birthing centers 36 clinics and 188 Immunization Clinics running in the PHC Out-Reach Clinic 160 district. There are 995 Female Community Health Immunization Clinic 188 Volunteers (FCHVs) in the VDCs and in the FCHVs 995 municipality of Surkhet district. NGO/Clinics 2 Source :DHO profile and DDC profile 2069/70 There are two private hospitals/nursing homes, four urban health clinics and two NGO clinics namely run by Family Planning Association of Nepal (FPAN) and Merie Stopes International (MSI).

3.2 MANAGEMENT SYSTEMS

3.2.1 MEETINGS

DHO Surkhet has formed different type of committees and groups at district level for overseeing the delivery of quality health services in the district. In order to give continuity to program activities, it also conducts different types meetings in the district. Following two committees and working groups exist in the DHO- Reproductive Health Coordination Committee (RHCC) and the Quality Assurance Working Group (QAWG). RHCC is organized on quarterly basis or half-yearly basis but if needed is organized monthly too. The last meeting was held on Falgun 2069. On the other hand, QAWG meetings are conducted on quarterly basis and sometimes more frequently. The monthly meeting of the Ilaka charge at district is organized on 7th of every month.

In Surkhet, FCHVs of about 25 percent VDCs receive allowances from VDCs. In Surkhet, monthly meetings of FCHV are conducted in all HFs and collect monthly report from them.

12 3.2.2 PROGRAM MANAGEMENT TEAM Table 3.2: Current Status of DHO Team The DHO Surkhet has all the key positions at DHO Team Status the DHO filled-in at the time of RA. Refer to i. Sr. Public Health Administrator Filled Table 3.2. shows that program management ii. Public Health Nurse Filled team of DHO Surkhet. iii. Statistics Assistant/Officer Filled iv. FP focal person Filled v. Malaria focal person Filled vi. Health Education Tech/ Officer Filled 3.3 HEALTH WORKFORCE vii. DTLA/Officer Filled viii. EPI Supervisor/Officer Filled Table 3.3 ix. Cold Chain Assistant/ Officer Filled All technical positions and program x. Computer Operator/Officer Filled management team of DHO filled in but in xi. Store Keeper Filled xii. Child Health focal person Filled the peripheral level health facility following xiii. Urban health center (Municipality) Filled situation was found during RA Out of the 3 PHCCs; Medical Officer Position is vacant in all. Out of the total 3 sanctioned positions of Staff Nurse in the district, one position is field and 2 are vacant in the PHC. Out of 48 ANM only 37 position full field, out of 50 HA./S.AHW 35 only full field, out of 45 AHW 42 AHW field. Out of 35 padnam AHW 34 only field , like wise out 23 padnam ANM 21 field in, out of 3 Lab Assistant 2 field in , out of 42 support staff 39 position field in the district and peripheral level health facility. Only four health workers hired from NPC and 36 staff has hired by DHO in contract and 5 staff has been hired from local recourses (VDC).

Table 3.3: Current status of health workforce Type of human Number GoN Number supported resources from Sanctioned Filled- Tem Contract VDC NPC Other in pora (DHO) ry a. Medical Officer 3 0 0 0 0 0 0 b. Staff Nurse 3 01 0 0 0 0 0 c. Sr. ANM 00 00 0 0 0 0 0 d. ANM 48 37 0 21 0 1 0 e. HA/Sr. AHW 50 35 0 1 0 1 0 f. AHW 45 42 0 5 0 2 0 g. AHW (padnam AHW) 35 34 0 0 0 0 0 h. ANM (Padnam ANM) 23 21 0 8 4 0 0 i. Lab Assistant 03 02 0 1 1 0 0 j. Adm. Assistant 03 03 0 0 0 0 0 k. Store Keeper 00 00 0 0 0 0 0 l. Office Support staff 42 39 0 0 0 0 0

Source: DHO, SURKHET, Stat. section (Data only shows PHC. HP, and SHP)

13 3.4 MONITORING AND SUPERVISION

DHO Surkhet has Monitoring and Supervision System place in the district. The same channel is practiced in DHO to supervise peripheral level institution, where DHO monitors Ilaka level HFs and Ilaka level supervise SHP according to the Monitoring and Supervision plan.

When asked to show the monitoring and supervision plan of FY 2069/70, the DHO supervisors could not show it. It was explained to the RA team that even though district have developed supervision and monitoring plan to monitor all level of HFs for ensuring effective delivery of services as well as to enhance capacity of health workers, it could not be translated into action effectively due to the lack of budget and inadequate coordination between different agencies.

“Development of proper supervision and monitoring plan in integrated way, may be effective in implementing district level activities, they contribute in bringing positive results in health indicators of Surkhet district” - A District Supervisor 3.5 INFORMATION TECHNOLOGY

The RA team explored the existing IT infrastructure at DHO. DHO has a good functioning internet and email facility. At present the DHO has 12 desktop and 5 laptop computers and 10 printers, all of which are functioning properly. When asked about district supervisors who are familiar with using email internet as well as Microsoft office package, it was reported that most are familiar with it. DHO has system of web-based HMIS and LMIS reporting in the district.

It was also found that four HFs in Surkhet have computer, which they have been using for web- based reporting. In the FY 2069/70, there was no data validation program implemented in Surkhet. DHO has well maintained the target population for different programs such as women of reproductive age group, under one year children, under five year children, expected pregnant women, adolescent’s etc. of the current FY 2069/70.

Even though DHO has above mention facility and human resources to fulfill district demand on data need for program activities, there was lack of data on M/DAG mapping practice and data validation activities. In order to know more of DAG mapping in Surkhet the RA team also visited DDC. It is observed from the discussion that there is need of DAG mapping and identification of the neediest groups and their locations in the VDCs so that health services can be made more accessible to them. Information on migration is also important. What is even important is to have a good functioning HFOMC that is aware of such issues in the VDCs.

3.6 HEALTH INFORMATION MANAGEMENT

DHO Surkhet has a system to enter HF level data in HMIS software. HF level data is available for the last five years. Surkhet has social inclusion reporting system piloted for some years. DHO Surkhet has been reporting data by caste/ethnicity; however, at present DHO has not been able to compile the data.

Recently Statistics Officer has received four days training on web-based HMIS reporting. From this FY, HMIS data that has been received from HFs are entered in the web-based HMIS software. DHO did not have an event of data validation program implemented in the current FY.

3.7 NATURAL DISASTER RESPONSE MECHANISM

14 DHO Surkhet has a Rapid Response Team (RRT) formed at district to respond to epidemics, under the leadership of District Disaster Management Committee (DDMC) which is chaired by Chief District Officer (CDO) of District Administration Office (DAO). Ilaka level Disaster Team (IDRT) team also available in the district to response natural Disaster in the district for that DHO has been calling meeting in the DHO. Following organizations are involved in DDMC - DDRT DHO, DDC, District Water and sanitation office (DWSO) Nepal Red Cross Society (NRCS) and other non-government organizations.

Similarly, there is also Emergency Management Committee (EMC) in the district, which is functioning well in addressing natural disasters. It is supported by NRCS and is chaired by president of NRCS. This committee also works under the supervision of DDMC.

3.8 STRENGTH AND OPPORTUNITIES

The major strengths of the DHO as observed during the RA are as following;

System and Structure  District level monthly meeting with Ilaka Health Post In-charge are conducted regularly on the 7th of every month  In the district Ilaka level meeting is being conducted regularly at different fixed dates for different Ilaka. But, data analysis and feedback system is not effectively reported. Integrated supervision which is not followed up as per annual plan.

 Focal person assigned for the all program and they are working according to responsibility in the district.  Regarding system and structure, the major challenges and constraints are,  No human resources according to population based  Lack of technology and upgrading training for capacity enhancement of staff  District level QAWG committee is formed, no meeting has held yet. RHCC mostly meets quarterly. Last meeting was held on Falgun 2069  QAWG has been formed but meeting has not been conducted since Aswin 2069 due to lack of budget and proper guidelines and follow-up.  Provision of allowance for FCHVs in some VDCs. FCHV monthly meetings are conducted in all HFs;  Developed annual supervision plan.

3.9 KEY ISSUES AND CHALLENGES

The major challenges and constraints faced by the DHO Surkhet are as following:

 Even though we have all infrastructures but lack of services consumer due to unaware about provides service and communication we could not serve according to our targate.  Lack of Proper time for reporting system not followed.  Attitude of government human recourses and political issue.

15  Lack of policy and confusion type of government decision e.g. Padnam AHW who use to work as immunization supervisor now he/she is working as padnam AHW and left to work as an immunization supervisor in the community. For that VDC and DHO recruited temporary staff in the community but He or she works for fixe time period till organization paid for them but when they discontinue to paid at that time workers also left job and it brings another problem in the district.  Sufficient counseling during service providing period which is another challenging part to develop proper counseling system.  Community people less aware about provided services.  Population based human resources supply is also major challenge in the district.  Lack of supervision and monitoring of programs, specially the integrated supervision.  Integrated supervision checklist is available but it is occasionally used.  Geographical difficulty which brings difficulty in material distribution and service delivery and outreach clinic mobilization and conduction.  To conduct awareness program and development of IEC material in the district according to target basis  Not proper Working environment in the district  Lack of sufficient Human resources and technology in the district which need to improve according to time and situation.  Conduction training in the district on new technology and not access of proper technology and communication media.  Budgeting system and implementation of pull system in the district in a systematic way.  To conduct awareness program in the district in a massive way by targeting M/DAG group of different community and area  Surkhet is the headquarter of the MWDR. The RHD of the MWDR is located in Brendranagar. This is an advantage for DHO, Surkhet.

According to DHO we can overcome from the mentioned challenges are given below

 Establishing punishment and reward system in the district  Giving full accountability and authority of human recourses.  Organizing proper training and workshop and adequate supply of human resources, by making proper working environment and adequate supply of logistic material as well as commodity and proper management of budget and incentives for the staff.  Proper management of existing human recourses and demand for vacant post and full fill the post which brings easy to conduct job task.

16 4. SERVICE STATISTICS

The RA also explored information on the service statistics of the following programs: Immunization, Child health, Safe Motherhood and Family Planning. HMIS data for the last four years, 2065/66 to 2068/69 were analyzed. The four-year trend analysis of the selected indicators is presented in this section. Data was also collected for the current FY 2069/70 but as data was not complete for the year it has not been analyzed here.

4.1 IMMUNIZATION Figure 4.1: Trend in Measles coverage

In the last three years, BCG coverage has been achieved 100 percent and measles coverage above 90 percent. It is important to note that indicators for almost all the programs analyzed has decline from the FY 2067/68. If compared with national figure, measles coverage in Surkhet district is above national coverage in all the years of comparisons.

4.2 CB-IMCI

Acute Respiratory Infections are one of the most common causes of death in children under 5 years of age. It is also a major public health problem and control of ARI is an integral part of primary health care.

In Surkhet, the proportion of pneumonia cases treated with antibiotics has stayed at around 30 percent in the last four-year period. The trend in severe pneumonia cases is not uniform in the district. In 2067/68 it was lowest at 0.06 percent which increased to 0.41 percent in the following year. At national level sever pneumonia cases showed declining trend but stayed constant at 0.4 percent in the most recent year.

Figure 4.3: Percent of severe dehydration among new cases In the last three year, the proportion of new diarrhea cases treated by ORS and Zinc has stayed almost constant at around 90 percent. Figure 4.3, compares the proportion of severe dehydration cases among the new cases of Nepal’s overall with that of Surkhet. It is found that the trends are not

Figure 4.2: Percent of severe pneumonia among new Figure 4.3: Percent of severe dehydration among new cases cases

17 uniform for Nepal as well as for Surkhet district. In the year 2067/68, the severe cases were greater in Surkhet than in overall Nepal while in the remaining it was lower than that of overall Nepal. The proportion of sever pneumonia and severe dehydration cases are lower than one percent in Surkhet, is an outcome of CB-IMCI.

4.3 SAFE MOTHERHOOD Figure 4.4: ANC first and four ANC visits as percent of expected pregnancy In Surkhet, almost all the pregnant women received ANC first and four times ANC services in all the four years of comparisons (Figure 4.4). Drop out from ANC first to ANC fourth is very low and this is a very interesting finding which contrasts with pattern seen in other districts and at national level where dropping out from ANC first to ANC four are large.

Trend in receiving iron tablets by pregnant women show that the achievement is maintained at 90 percent in all four years, though in the most recent year it declined from 99 percent coverage to 91 percent. Iron tab consumption trend looks consistent with ANC checkups. SBA attended deliveries are also increasing in the district and is 59 percent in the most recent year. Data on safe motherhood program of Surkhet is very encouraging.

4.4 FAMILY PLANNING Figure 4.4: CPR as percentage of MWRA

Overall, Figure 4.5 shows that the Contraceptive Prevalence Rate (CPR) as percent of Married Women of Reproductive Age (MWRA) of Surkhet district is more than the National CPR. CPR in Surkhet has increased gradually over the last four-year period and was 54 percent in the FY 2068/69.

There are few organizations and I/NGOs providing support to the public sector in providing FP services. Regular reporting of the services provided from the private sector is essential in analyzing the actual CPR of Surkhet district.

18 Table 4.1: Trend in utilization of services SN Indicators 2065/66 2066/67 2067/68 2068/69 2069/70* 1 BCG coverage 84 .9 105.2 101. 2 100 92. 1 2 DPT 3 82. 8 90.2 103.7 94.4 86.7 3 Measles vaccination coverage 83.1 97.6 96 90 81.8 4 TT 2 & TT2+ coverage among pregnant women 90. 5 93.8 82.2 72.7 64.7 5 Proportion of new pneumonia cases treated 38.1 32.5 31.64 29.2 31.7 with antibiotics 6 Percentage of severe pneumonia among new 0.3 0.4 0.6 0.4 0.3 cases 7 Proportion of new diarrheal cases treated with 94.6 98 92 89.9 87.9 ORS + Zinc (under 5 years children) 8 Percentage of severe dehydration among Data 0.2 0.8 0.12 new cases missing 9 ANC 1st visit as percent of expected 99.3 111.4 98.5 95.9 73.7 pregnancies 10 Four ANC visits among as percent of expected 54.7 67.3 63.75 65.29 53.64 pregnancies 11 Percent of pregnant mothers receiving iron 97.2 119 99.1 90.8 71.6 tablets 12 Delivery conducted by SBAs (both home and 26.7 43.3 52.6 58.7 54.7 institutions) as percent of expected live birth pregnancies 13 PNC First visit as percent of live birth 53.9 70.5 69.9 74.3 60.3 14 Percent of postpartum mothers receiving 78.6 92 82.8 80.5 48 Vitamin A within 6 weeks 15 Contraceptive prevalence rate (all methods) as 50.9 51.3 53 53,8 49 percentage of MWRA

19 5. HEALTH FACILITY MANAGEMENT COMMITTEE AND LOCAL HEALTH GOVERNANCE

Information on Health Facility Operation and Management Committee (HFOMC) was sought from both DPHO and DDC. Both quantitative and qualitative methods were used for collecting information. Information was collected on the following topics: HFOMC functionality, capacity building, presence of different community-based groups at VDC level and their federations at district level. This chapter presents the major findings of the assessment on HFOMC.

5.1 FUNCTIONING HFOMC

In Surkhet, 38 SHPs are handed over to the local bodies in FY 2057/58 and remaining HFs are not handed over to local bodies. The RA team also asked the DHO and the program focal person about any plan of handing over the remaining HFs to local bodies. They explained that they have been trying to hand over the remaining HFs as well but due to lack of budget, it has not been possible. They mentioned that they have also been coordinating on this with DDC.

Furthermore, question on criteria for measuring HFOMC functionality was asked to the HFOMC focal person and other district supervisors and they opined that following as criteria for measuring HFOMC functionality.

1. Regular motherly meeting 2. Work in the Planning schedule 3. Discussion on previously point ousted issue 4. Outreach clinic observation by HFOMC member 5. Problem solving mechanism by member.

According to program focal person, as well as other DHO supervisors, 80 present of HFs is working properly according to the above criteria. Even though the DHO supervisors rated that the majority of the HFOMCs are functioning based on the above criteria, the actual situation of the HFOMCs might be different and is likely that many of them are non-functioning.

The top five functional HFOMCs as marked by the district The top five functional HFOMCs; supervisors and focal person are : PHC, LekGau HP, 1. Salkot PHC Dashrathpur PHC, Sanilec HP, and Chinchu HP. Similarly, the 2. LekGau HP bottom five HFOMCs are- Ghoretar SHP, Chapre SHP, 3. Dashrathpur PHC Taranga SHP, Neta SHP, and Hariyarpur HP. 4. Sanilec HP 5. Chinchu HP In Surkhet, NFHP II project had worked in capacity building of The bottom five HFOMCs; HFOMCs. Most of the DHO staff, HF staff and the HFOMC 1. Ghoretar SHP members have received training on the same. NFHP II also 2. Chapre SHP 3. Taranga SHP supported for organizing meetings and workshop. The project 4. Neta SHP also hired staffs at district to support HFOMC program. This 5. Hariyarpur HP suggests that the foundation for HFOMC strengthening activities has already been laid in Surkhet. What is required at present is energizing support to the district and HFOMCs so that the HFOMCs functions better.

20 5.2 CAPACITY BUILDING OF HFOMC

It was found that HFOMCs had received capacity building training: basic and refreshers. They were also involved in different meetings. These trainings were provided by D/PHO in support of NFHP-II. The project staff also used to visit HFOMCs for assessing their status and onsite capacity building.

5.3 COMMUNITY GROUPS/FEDERATION

According to district supervisors’ different type of community groups exists at VDC and district level in Surkhet. It also has different types federation /alliance /networks at the district level. Some of these groups are:  NGO federation  FECOFAN (Federation of community forestry users Nepal)  Women alliance group  FEDO (feminist and dalit organization)  Women awareness forum  National health association  Press and Media at district level

5.4 STRENGTH AND OPPORTUNITIES

HFOMC have been formed in all VDCs, and all HFOMCs have received capacity building training from DHO/DDC and NFHP. Most of the HFOMCs in Surkhet are reported as being functional.

 Total 38 health facilities have been handed over to VDC.  Most of HFOMC functioning well in the sense conduction meeting according to DHO but we have to work beyond that and one step deeper for proper functioning of HFOMC.  HFOMC focal person is available in the district and he is taking responsibility of HFOMC  Capacity building activities for HFOMC is carried out since three years.  Most of district stakeholders involved in RHHC meeting at that time we can communicate with them regarding M/DAG service utilization further more please follow the annex

5.5 KEY ISSUES AND CHALLENGE  Absence of electoral body in the VDC.  Political instability.  Lack of budget.

Challenges  Community people are less aware about the services provided from the local HF  Gap between program planning and follow up (Law should be strict )  Need to regularize the meeting in HFs and update its status.  Need to improve coordination between stakeholders-DHO and DDC  One VDC secretary has to manage more than one VDC, which hampers management in several ways.

21 6. SERVICE DELIVERY/QUALITY IMPROVEMENT

This chapter presents the RA findings related to service delivery and quality of health care. Information on the quality of ANM schools, infection prevention practices at HFs, implementation of community-based interventions, and the provision of IUCD and Implants services were collected at district level. The major finding of the assessment is presented below.

6.1 SERVICE DELIVERY

The RA sought information on the availability of Satellite Clinics, CEONCs and BEONCs, long term FP methods service sites and implementation of community-based interventions such as CB-NCP, MSC, and Calcium.

In Surkhet two HFs are providing satellite clinics namely, Banyachaur and Chinchu. CEONC service is provided in regional hospital and BEONC service is provided in 36 HFs, which are Birthing Centers. Eight HFs in Surkhet were providing IUCD and Implants service during the time of RA. Refer to Table 6.1. In Surkhet, MSC, CB-IMCI and program are implemented in Surkhet by DHO in support of NFHP II.

Table 6.1: IUCD and Implants Insertion and Removal Sites of Surkhet Birthing Birthing IUCD Implants Center? Center? 1. Awalching PHC Y 1. Awalching Y 2. Birendranagar Municipality Y 2. Birendranagar Municipality Y 3. PHC Y 3. Dasarathpur Y 4. Lekhfarsha PHC Y 4. Lekhfarsha Y 5. Lekhgaun HP Y 5. Y 6. Y 6. Mehelkuna Y 7. Salkot PHC Y 7. Salkot Y 8. Garpani Y 8. Garpani Y

According to DHO, there are untrained HWs and FCHVs for CB-IMCI progeam. Abou 10-12 health workers and 10-11 FCHVs needs CB-IMCI training. Nepal Red Cross Society, FPAN and SAC, CAED, are also working in the sector of FP and RH in the district. NRCS is providing awareness session to the adolescents regarding FP and STI including HIV and AIDS through its VDC level network. In the same way CAED is providing uterine prolapse, FP, and RH services in Surkhet.

6.2 INFECTION PREVENTION AND WASTE MANAGEMENT PRACTICES AT HFS

Few questions related to infection prevention and waste management practices followed at HFs were also asked to district supervisors during RA. It was found that different HFs practice different type of infection prevention and waste disposal practices. Thirty-four out of the 36 birthing centers have placenta pit. The IP practice observed during RA at district is poor. Infection control is crucial for the safety of health care workers, patients and individuals in the community who are receiving health care. Therefore, The DHO staff recommended that peons are trained on Infection Control, using low-tech approaches that are practical and simple to improve safety for individuals, patients and the community at large.

22 6.3 STRENGTH AND OPPORTUNITIES

There are 36 functional birthing centers in Surkhet and all of them are functioning. 34 Birthing centers have placenta pits. Out of 50 HFs, eight are providing long term FP methods. Regional hospital is providing CEONC service. Programs like CB-IMCI, MSC and IMAM, IYCF have been already implemented. However, there is a need to refresh the knowledge and skills of the health workers on it.

6.4 KEY ISSUES AND CHALLENGES

A. Key issues  Inadequate clinical supervision to ensure that services are provided as per guidelines and clinical protocol  Need of regular planning of program activities  Need to coordinate with DHO as well  MNH update and RH review for HFs human resource..

B. Challenge  Expansion of satellite clinics in other areas of the district is a challenge. There is lack of human resources and budget.  To Fulfillment of vacant sanction post of district.  Frequent transfer of HWs  Regularizing timely clinical supervision by DHO and other stakeholders  Building infrastructure in remaining birthing centers.  Population-based human resource recruitment in the district.

23 7 LOGISTICS MANAGEMENT SYSTEM

Logistics management is an important part of district health systems. Efficient logistics management is required to smoothly run all the public health programs at district, sub-district and the VDC levels. The RA also sought information from DHO on the logistics management system. The major findings of the assessment are presented below.

7.1 AVAILABILITY OF KEY DRUGS AND COMMODITIES

During RA, the D/PHO store room was also visited and the store keeper was interviewed. The availability of eight tracer drugs/commodities (Injectable, Oral Contraceptive, Condom, ORS, Vitamin A, Iron Folate Tablets, Cotrim (Ped), and Zinc) in the district store at the time of visit was checked. It was found that all were available in the store during the day of visit to the store. The store keeper was also asked whether the eight drugs/commodities were out of stock anytime in the last 12 months, and it was found that ORS and Cotrimoxazole (P) were out of stock at any point in the last 12 months. The RA team members also checked the expiry dates of the eight drugs/commodities and it was found that none of them were expired.

Table 7.1: Availability of key drugs/commodities and their expiry dates SN Drugs/Commodities Availability at Stock out in Expired drugs in the time of the last 12 stock at the time of visit months visit 1 Injectable Contraceptive Y N N 2 Oral contraceptive Y N N 3 Condom Y N N 4 ORS Y N N 5 Vitamin A Y N N 6 Iron Folate Tablets Y Y N 7 Cotrimoxazole (Ped) Y N N 8 Zinc Y N N

The Store keeper was also asked to list the drugs/commodities that have most problems with stock outs in the FY 2069/70. The store keeper reported that Vitamin A, ORS, and Iron had most problems with stock outs in the year. However, there was no drug that was over-stocked in the last FY as reported by the store-keeper.

7.2 COLD CHAIN AND FEFO MANAGEMENT

DHO Surkhet has seven functioning refrigerators with proper power back up. The available refrigerators are sufficient to DHO for maintaining cold chain. DHO has assigned one focal person to look after store. When the store room was check to see the management of drugs according to FEFO, it was found that FEFO was not maintained properly in Surkhet.

7.3 LMIS REPORTING

DHO Surkhet has web-based LMIS system to report on Logistics. The system was functional during the time of RA.

24 7.4 STRENGTH AND OPPORTUNITIES

Most of key drugs are in stock but Cotrim (P), ORS, Vitamin A and Iron were stock-out for few times in the last 12 months. Web-based LMIS system is in place in DPHO, and is being reported regularly. There are 7 well-functioning refrigerators in DHO Surkhet.

KEY ISSUES AND CHALLENGES A. KEY ISSUES  FEFO system is not well maintained. Need more one staff for logistic management and need to organize refresher training on logistics  Not sufficient supply of medicine  Only focused on managing medicine but poster and pamphlets and not managed  There is limited space for storage. Lack of sufficient boxes for proper storage.  Pull system is not practiced in district  Re-arrangement of drugs and segregation of expired drugs has to be done.

B. Challenges  Human resource is not adequate for logistics management.  Frequent change of staff in district.  Space management for drugs within the available space;  Supplying drugs/commodities down to health facilities it is difficult.  Channelization of inventory mechanism from district to periphery and allocation of budget for the same.

25 8 BEHAVIOR CHANGE COMMUNICATION

H4L aims to understand legal, cultural/religious, and policy dimensions of GESI inequities on health service access and use and design interventions to ensure sustainable, high-quality BCC and IEC approaches that respond to local realities, and include groups not commonly targeted, but crucial to meeting Nepal’s health goals.

One of the objectives of the RA was to explore the range of BCC interventions that is being implemented for healthy behaviors. Following are the major findings on BCC:

8.1 EXISTING DHO PROGRAMS ON BCC

DHO Surkhet has been organizing BCC program activities as per the DHO yearly plan provided from the National Health Education Information and Communication Center (NHEICC) such as production and distribution of IEC materials, short massages broadcasting through local FM radio, school health program, day celebration etc.

8.2 FM STATIONS/CABLE TELEVISION NETWORKS

In Surkhet, there are four FM stations. Following are the name and address of the FM stations registered in Surkhet district.  Radio Bheri, Birendranager -6,  Bulbule FM,  Jagran FM Radio Surkhet  Radio Nepal

DHO Surkhet has partnered with all the four FMs and radio Nepal for airing of health related matter. DH also telecasts drama through TV network by coordinating with existing station. Different types of radio program are aired in Surkhet such as Sawasth Sarokar, Mankoansar, and different health related Jingles covering topics such as FP, nutrition, Filariasis, and Vitamin A.

There is one Cable TV network in Surkhet, which has been broadcasting district-based health programs on safe motherhood and FP, named Mitho Satya only once time.

8.3 ORGANIZATIONS WORKING IN IEC/BCC ACTIVITIES

In Surkhet, organizations like International Nepal Fellowship (INF), CAED/WRRP, FPAN have been working on BCC programs in coordination with DHO. However, there are no specific BCC activities targeted to M/DAGS.

As H4L plans to use mobile phones to reach target groups such as M/DAG and adolescents with messages on health in selected district, the RA also explored whether any organization has used mobile phones to communicate health messages to target groups or general population together with DHO. It was found that DHO has not collaborated and coordinate with any external agency to use mobile phones in disseminating health messages to any target groups in the district.

26 Challenges

Providing health services and changing behavior of people who have strong traditional and cultural beliefs is a challenge. As in many other parts of Nepal, early marriage is a problem in Surkhet as well. Many organizations are working in Surkhet in this area but proper coordination between the organizations and proper documentation of the learning is a challenging task.

8.4 COUNSELING SERVICE

The RA also asked question to find out the number of staff who received training on FP counseling. The Family planning focal person of the DHO and the Public Health Nurse reported that most of the health workers in Surkhet had taken COPE training, which they are using in their working areas.

8.5 SCHOOL HEALTH PROGRAM

School health program is one of the important and potentially effective programs of the DHO. This approach is effecting in reaching huge mass of adolescents with health messages throughout the district in a cost effective way. In the current FY 2069/070, school health sessions were organized in more than 135 classes for about 2000 students. Different topics were covered and were carried out in five schools. In Surkhet, the topics mostly covered during the School Health Education are given below.  Awareness on sanitation  Nutrition  Malaria, TB, and HIV/AIDS  Safe motherhood  Measles.  RH/Family planning  Adolescent health  Uterus prolapse

According to the focal person of DHO, beside school health education program, activities such as exposure visit, observe think and act (OTA and Focused Group Discussion helps in group mobilization. Activities such as street drama, folk songs and day celebrations are also effective means of delivering massage to community people.

8.6 STRENGTH AND OPPORTUNITIES

 Health education massage aired through FM in different topics.  Partnership with FM station  Other NGO/INGO working in the district.

27 9 ADOLESCENTS AND YOUTH FRIENDLY SERVICES

H4L will also work with D/PHOs in selected districts to improve service accessibility of Adolescents under its Objective 6. The RA also explored different aspects of Adolescents and Youth friendly services in the public health facilities of Surkhet district. Following are the major findings:

9.1 EXISTING SERVICES FOR ADOLESCENT

In Surkhet, there are many focused programs on Adolescents and Youths. Adolescents and Youths Friendly Services (AYFS) are established with the support from various INGOs/NGOs and CBOs. DHO with the support of GIZ has implemented AYFS in 13 VDCs (See Table 9.1). These AYFS centers has been providing services to youth and adolescents on different issues like sexual and reproductive health, family planning, menstruation, safe birthing, hygiene and sanitation. DHO has also been supporting capacity building of school teachers and students. Table 9.1: AYFS centers in Surkhet Thereby disseminating healthy S.N Name of AYFS/HF S.N Name of AYFS/HF messages and practices to other 1. Awalching 6 /Sanilekh students and peer groups. In-terms of 2. Babyachaur 7. reporting mechanism, the HFs has 3. Katkuwa/Birendranager 8. Lekhfarea been sending report to DHO in municipality monthly basis. Beside the AYFS 4. Chinchu 9. Lekhghau 5. Dasarathpur 10. Matela centers in the HFs, there are few other 11. Mehelkuna local organization in Surkhet that are 12. Rakam actively involved in educating 13. Salkot adolescents and youth on the issues related to early marriage, sexual reproductive health, contraceptives use and girl’s empowerment.

9.2 ORGANIZATION WORKING FOR ADOLESCENT AND YOUTH

9.2.1 Social Awareness Center

Social Awareness Center (SAC) has been working in this district since long time particularly focusing on advocacy and awareness raising issues. SAC basically works for adolescents, youth, children and women through establishing children/adolescents network and women group in the district. SAC is also one of the local implementing partner of the USAID funded Saath Saath Project. So, it is working for family planning and HIV prevention in Surkhet. Some key activities of SAC that might be of interest to H4L are as following:

 Formation of 355 child network and 70 women group in VDCs and Municipality,  Formation of youth groups (Yuwa Sasaktikaran Manch, NauloBihani)  Formation of Community support group, Nagarik sachetana kendra.  Agenda-Surkhet to be announced as child marriage free area.  Provide materials to support health post.  Formed Social Inclusion group and organized awareness program, literacy program for school drop-out youth, income generation activities for women in selected community.  Address seasonal migration problem.  Provide family planning service cluster wise- divided in to 3 clusters.

28  Formation of District AIDS Group Committee (legal committee).

SAC is working in following nine VDCs for HIV and FP integration under the Saath-Saath project: Tatapani, Ghatgau, Bijhaura, Gutu, Taranga, Bidhayapur, BabyeaChaur, Salkot, and Bartichaur

SAC is working closely with DHO's DACC for HIV and AIDS prevention and care program. They have chosen three clusters to provide family planning including counseling service by adopting USAID Family Planning Compliance training and materials. But they don't have mechanism to track the result about whether people are following family planning methods or not. At present they just counsel and refer clients to VCD counseling center for HIV/AIDS in the possible high risk areas.

9.2.2 GIZ

GIZ does not implement the program directly in the district but implements program through DHO. GiZ provides technical support to AYFS in 13 VDCs. They focus on topics such as - sexual and reproductive health and rights, menstruation, early marriage and its consequences, and decision making skills. They also work on capacity enhancement of HFOMCs, and supporting on providing leadership and ownership of HFOMCs for quality management of HFs.

9.2.3 Women and Children Development Office (WCDO)

The district women and children development committee is working in some of the H4L interest key areas. RA team visited Ms. Bishow Mani Joshi, Section chief of WCDO. WCDO have exclusive Girls Adolescents Group (Kishori Shamuha) in 10 VDCs of Surkhet. WCDO provide life skills base training to the group and through this training they empower girls and enhance their capacity on decision-making skills for delay marriage, family planning and economic empowerment and counseling services. There are cooperative/micro-credit groups in VDCs. The micro finance women group at the ward level identifies needy areas in ward level, choose the adolescent girls and recommended them for the training.

Most of these girls are from M/DAG community, school dropout students, and illiterate girls, hence, have social inclusive perspective in the programming. The groups functions with minimum coordination with other organizations. Some key activities accomplished by WCDO are as follows:

 Girls (adolescents) group in 10 VDCs.  Program for addressing Gender Based Violence (GBV) in15 VDCs  Micro credit group established and tied up with Adolescent girls/groups

9.2.4 Family Planning Association of Nepal (FPAN)

Family Planning Association of Nepal provides overall family planning services and contraceptive distributions in 13 VDCs. The RA team visited Section Chief of FPAN who briefly introduced about FPAN services in the district. In the district level they work with a structure of one branch in municipality and three community clinics in , Jahara, VDCs. In community health clinic s they've formed ‘Out-of-school’ and ‘In-school’ groups. In this group, school teachers also supports in organizing different activities for students belonging to grade five to ten. FPAN is also prioritizing gender equality and social inclusion issues by focusing on socially excluded groups in their community health clinics.

29 Following are the services provided by FPAN in Surkhet district:  Safe abortion with proper counseling that provides FP method choices and voluntary decision.  Family health clinic: immunization, safe delivery, contraceptive distribution.  Youth information center in one community health clinic in Jarbuta health post where they discuss about FP, contraceptive distribution and sexual and reproductive health issues.  Weekly Outreach Clinic for family planning in 13 VDC  Adolescents program mainly focused on family planning

9.3 STRENGTH AND OPPORTUNITIES

The district received support to adolescent’s health program from numbers of local organizations. The local organization has also been trying to build capacity of health worker and FCHVs on adolescent’s health. DHO has been running AYFS in 13 HFs. FPAN is also working for youth and adolescents, and WCDO is also working for adolescents focused program in the district. Here some key strength and opportunities in the Surkhet district:  Receiving AYFS monthly reports regularly from 13 VDCs  Child Network , social inclusion group, women group and informal youth club formed at VDC and Municipality level by SAC  Focused program on delay marriage, sexual reproductive health, FP, HIV, hygiene & sanitation  Provided material support to HFs like equipment for family planning service, IEC/BCC materials and other technical support.

9.4 KEY ISSUES AND CHALLENGES

 Health worker who works in AYFS are not updated on counseling skills  Regular feedback sharing mechanism is not in place.  No regular coordination between DHO and NGOs/CBOs.  Need of AYFS expansion to other hard to reach VDCs.  Need to follow up and update the data and check the service quality in AYFS site.  Organize advocacy program to raise awareness about AYFS.  Need of regular monitoring and supervision plan; and feedback and sharing mechanism.  Quality monitoring mechanism should be introduced.  Need to have separate place to maintain privacy for counseling and check –up in service sites.  Need to regular follow-up and encourage health workers who work in AYFS sites.

30 10. GENDER EQUALITY AND SOCIAL INCLUSION

H4L is designed to support the Government of Nepal’s stated commitment and responsibility to ensure that quality health services are accessible to all citizens. As such, it is critically important that sound, ongoing GESI-sensitive analysis and gender integration underpin H4L program interventions. H4L’s GESI Objectives are designed to redress gender and social inequities, and dove-tail with the objectives set forth in the MOHP’s 2009 Health Sector Gender Equality and Social Inclusion Strategy as follows:  Objective 1: Support existing MOHP policies, strategies, plans and programs that create a favorable environment for integrating GESI in Nepal’s health sector;  Objective 2: Support MOHP’s efforts to enhance the capacity of service providers and ensure equitable access and use of health services by the poor, vulnerable and marginalized castes and ethnic groups; and  Objective 3: Improve health-seeking behavior of the poor, vulnerable and marginalized castes and ethnic groups in collaboration with local government partners, community-based organizations (CBOs) and other stakeholders.

The first objective is related to policy while the latter two are directly related to D/PHO systems.

The RA also included assessment and analysis of the health programs of the DHO Surkhet from GESI perspective. The major findings are as following:

10. 1 Existing scenario on GESI

 With the support of NHSSP, DHO a brief orientation was provided to the GESI Focal Person- Senior Public health Nurse) and a in 2068 Falgun GESI committee was formed as per the guidelines. There are 15 members from NGOs, CBOs and DHO and socially excluded members from the society in the committee. Despite this, it was found that the focal person is not aware of the GESI roles and responsibilities. After the formation of GESI committee, two meetings have been conducted but activities on GESI has not been identified and discussed in the district. RA team reviewed the GESI meeting minutes and the materials provided by the RHD to the committee. The focal person and DHO assumed that GESI concept is integrated in DHO annual plan, and monitoring and supervision plan but no evidence was identify during the assessment GESI committee formed as per the guidelines.  GESI committee received orientation from NHSSP/RHD.  To till date GESI Technical Working Group (TWG) meeting has been organized in one year.  GESI Approaches and concepts are clear in DHO but are not reflected in activities.  GESI concept is integrated in Annual Plan, monitoring and Supervision plan as well.

10.2 FORMATION AND FUNCTIONALITY OF GESI COMMITTEE

After formation of the GESI committee, only two meeting has been conducted in Surkhet district. The last meeting was held on 22 Jestha 2069 (May 2012). The meetings decided to orient all DHO and other organizations staff on GESI concept. They also discussed about how to integrate GESI in health system and DHO annual plan. They also decided to incorporate GESI on monitoring and supervision activities in HFs. The focal person expressed that without regular follow up from NHSSP, it was not possible to organize the meeting because she was not guided clearly about the

31 process and not informed about the priorities. During the RA, the RA team members conducted group discussion with female staff from DHO. Most of the female staffs from DHO expressed their dissatisfaction about the role and responsibility given by senior staffs and DHO. The female staff highlighted that they have not been asked to participate in decision-making meetings. They were further unhappy that they are exploited in-terms of providing duties . They stressed that GESI should be integrate in DHO structure and plans.

The RA found following gaps in GESI in Surkhet:  No coordination with DHO and other staffs about the GESI and its importance.  Not much clear understanding on the guideline and integrating approach in DHO system.  No regular coordination with other I/NGOs, CBOs and HFs (VDC &Ilaka level).  No program to address early marriage, Gender-based Violence.  Doesn't have clear idea about GESI integration in health system and service.

10.4 ORGANIZATIONS WORKING ON GESI

There are many organizations working on GESI in Surkhet district. Visiting all of them were possible in the limited time period therefore, the major organizations were identified and the major ones were visited. Here are name of some of the organization working on GESI: o NHSSP (Nepal Health Sector Support Program) o SAC (Social Awareness Center) o Feminist Dalit Organization (FEDO) o Women group of Marginalized people (WAM) o AAWAJ o Women and Children Development Forum

10.4.1 Social Awareness Center (SAC)

As mentioned earlier in the chapter on adolescents health, SAC carries out outreach activities on adolescents and youth friendly services and also focus on women groups, especially in the hard to reach areas. GESI is integrated from institutional level. They have formed 70 women groups and they formed VDC level micro finance groups of 25 women in each groups, they merged it in micro finance group- Mahila Shanti samuha as a legal identity in VDC and municipality. The groups conducted social awareness campaigns and 16 days VAW activities on the occasion of 16 days companion. These women groups are quite active in the VDCs. They are coordinating with VDCs to release budget which local development office has allocated for women empowerment activities. With this budget they organized skill enhancement trainings for other women from M/DAG groups. They have developed mechanism to ensure meaningful participation of M/DAG in the program. Some of the major activities of SAC are as following:  Formation of 355 child network in VDCs and Municipality, and 70 women groups  Formation of youth groups (Yuwa Sasaktikaran Manch, Naulo Bihani)  Formation of Community support center, Nagarik sachetana kendra  In the process of announcing Child marriage free areas in the district.  Provided materials to support health post.  Formed Social Inclusion group and organized awareness and literacy programs for school drops out youth and income generation activities.  Address seasonal migration problem.  Provide family planning services in 3 clusters  Formation of District AIDS Group committee

32 10.4.2 Feminist Dalit Organization (FEDO)

The FEDO is formed by Dalit community to serve socially excluded people. Currently, they are working on increasing equal access of Dalit women to health services funded by The European Union. They have been working to promote Dalit rights and eliminate caste and gender discrimination and improving the access to health services in Surkhet district. They have been working in nine VDCs and municipality of Surkhet district. They do have a partnership with CTEVT for providing ANM training to Dalit women/girls. The condition is that after receiving AMN training, the Dalit women/girl is bound to serve in Dalit community as community health volunteer for some years. As a volunteer she is not entitled for getting any salary but will receive some facilities and opportunities from HFs (eg. training and other supports).

Following are the major activities supported by FEDO: o ANM Training for Dalit women o Training of community medical Assistant o Safe motherhood and child health care training o Sanitation awareness training o Primary health care and adolescents training o Family planning training

10.4.3 Women and Children Development office

Gender equality and equity is major problem in Surkhet district. Women and children development forum is supporting to enhance capacity of rural women but still there is need to follow up after providing training and other skills. Basically Gender-based violence is major problem where women are facing even though they are skillful and trained. The district women and children development committee is working on some of the key areas where H4L's interest can be met. RA team visited Section chief of WDO. WDO have Adolescents Girls Group (Kishori Shamuha) in 10 VDCs. WDO adopted life skills base training to the groups and through this training they empower girls and enhance their capacity on decision making skills for delay marriage, family planning and economic empowerment and counseling services. To make more inclusive there are cooperative/micro credit groups in VDC Cooperative groups identify the area and then choose the adolescents girls and recommended for the training.

Most of the girls are from M/DAG community, school dropout students, and illiterate girls. Some of the key works of the organization are as follows:

 Girl adolescents group in 10 VDC.  15 VDC addressing Gender-Based Violence (GBV) program.  Micro credit group has established and they been taking responsibility to work closely with Adolescents girls/group.  H4L can play the role of bridging the gap between DDC, LDO and DHO

10.5 KEY ISSUES AND CHALLENGES

 GESI focal person is identified and updated about GESI but needs to have better understanding to translate strategy into action.

33  GESI committee is formed but not briefly oriented about the importance of GESI on health system and services. As RA team reviewed meeting minutes of committee they just sit for the meeting and no action have been taken till the dates.  No coordination with DHO and other staffs regarding GESI related services and actions.  Need to think about sensitizing on GESI issues and practices from district to health facilities.  Idea about how to integrating GESI in health is still unclear among DHO staffs and GESI focal person.  GESI should be more focused on social inclusion part as this district has various group and communities that are deprived eg. Badi, Janajati and Dalit.  Coordination with local NGOs/CBOs is strongly recommended as many organizations are focusing on health especially for marginalized community.  There are many youth and women network actively involved in Surkhet district on community awareness programs.

34 Annex 1 Table: Contact information of D/PHO Staff, Surkhet

SN Designation Name Mobile no 1 District Health Officer 2 Public Health Nurse 3 Statistics Assistant/Officer 4 FP focal Person 5 Malaria focal Person 6 Health education Tech/officer 7 DTLA/Officer 8 EPI Supervisor/Officer 9 Cold chain Assistant/ officer 10 Computer operator/ Officer 11 Store Keeper 12 Child Health focal person 13 FCHV focal person

Annex 2 List of RHCC members Chairman:- DPHA Members:- Representative of 1. District Development Committee 2. District Education Office 3. Women and Child Office 4. BNMT 5. NRS 6. Nutrition rehabilitation center 7. INF 8. WHO/IPD 9. GIZ 10. CAED 11. Deuti nursing home 12. SAC 13. DDC 14. AWAJ 15. MERISTOP 16. FEDO 17. Nawajoti Digo Samaj 18. DACC 19. ZONAL AYURBED 20. RPO 21. DADO 22. FPAN 23. WARM 24. Birendra municipality 25. PSI 26. Nepal Red Cross Society (NRCS) 27. Mery Stopes International (MSI) 28. Private Hospitals 29. Member Secretary:- RH focal person of DPHO

35 Annex 3

List of Organizations and Individuals visited/contacted during RA SN Organization Designation Name Mobile no 1 DHO District health Officer 2 Public Health Nurse 3 Statistics Assistant/Officer 4 FP focal Person 5 Malaria focal Person 6 Health education Tech/officer 7 DTLA/Officer 8 EPI Supervisor/Officer 9 Cold chain Assistant/ officer 10 Computer operator/ Officer 11 Store Keeper 12 Child Health focal person 13 FCHV focal person 14 DDC A.LDO A. NGO B. INGO

36