Facility Based Assessment for Reproductive Health Commodities and Services
FINAL REPORT
United Nations Population Fund (UNFPA) Shanta Bhawan Road, Jhamsikhel Lalitpur, Nepal
Submitted By Nepal Development Research Institute Shree Durbar Tole, Pulchowk, Lalitpur, Nepal
Submission date: 16th March 2015
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This report is a product of research on "Facility Based Assessment for Reproductive Health Commodities and Services “carried out by Nepal Development Research Institute with the
financial support of United Nations Population Fund (UNFPA) from October 2014 to January 2015
Study Team
• Dr. Basu Dev Pandey, Team Leader
• Prof. Naveen Shrestha, Senior Consultant Expert
• Dr. Jaya Kumar Gurung, Project Coordinator
• Dr. Rabita Mulmi, Field Survey Coordinator • Ms. Saruna Ghimire, Consultant Expert • Ms. Sona Shakya , Senior Research Associate
Report By:
Nepal Development Research Institute Shree Durbar Tole, Pulchowk, Lalitpur
www.ndri.org.np
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Acknowledgement
It is a great pleasure for Nepal Development Research Institute (NDRI) to accomplish this research in collaboration with concern departments of Government of Nepal and UNFPA/Nepal. We thank UNFPA for entrusting NDRI and making congenial environment for this research work.
It's immense pleasure to acknowledge the representatives of Nepal Government's agencies particularly Dr. Senendra Raj Upreti, Director General , Department of Health services, Dr. Bhim Singh Tinkari, Director of Logistic Management Division (LMD), Dr. Pushpa Chaudhari, Director, Family Health Division (FHD), Bhogendra Raj Dotel, Senior Public Health Administrator, Mr. Gyan Bahadur BC, Planning Officer (LMD), Krishna Ghimire, Joint Secretary (LMD), Upendra Dhungana (LMD) for their invaluable cooperation into various ways; valuable inputs in the inception phase of project, important contribution in training to field researchers, arranging the district and regional level health facilities for their cooperation, and providing suggestions in the draft report.
NDRI highly appreciate UNFPA team particularly, Ms. Guilia Vallese, Country representative of UNFPA; Ms. Latika Maskey Pradhan, Assistant Representative; Dr. Shilu Adhilari, Reproductive Health specialist; Bobby Rawal Basnet, M&E Officer and Chandra Mani Dhungana, RHCS Programme Analyst for their kind cooperation in desigining research tools, their valuable inputs in data analysis, draft report and finally in shaping this report.
We also acknowledge the kind cooperation of Mr. Pradeep Paudel, M&E Advisor and Dr. Suresh Mehata, Research Advisor Health Specialists, NHSSP for their valuable inputs in finalizing survey tools and providing important suggestions in the draft report.
NDRI offers gratitude to the entire research team: Dr. Basu Dev Pandey, Team Leader; Mr. Naveen Shrestha, Senior Consultant Expert; Ms Saruna Ghimire, Consultant Expert; Ms Sona Shakya, Senior Research Associate and Dr. Rabita Mulmi, GESI Expert for their hard work from the inception period to project accomplishment. With great appreciation, I would particularly like to acknowledge the contribution of all our field supervisors and enumerators; without their contribution this study would not have been accomplished. Active contribution of Ms Roopa Bhandari for entire administrative and financial management incurred to this project is acknowledged as well.
We would also like to extent our sincere thanks to all DHO/DPHO in relevant districts for their valuable co- operations. Last but not the least, we would also like to thank all the respondent service recipients for providing the information regarding the service qualities during the exit interview, the in-charge and staffs of relevant health facilities; health posts, sub-health posts, district hospitals, regional and tertiary hospitals, private hospitals, FPAN, Marie stopes, Sangini, SEWA, PSSN, Polyclinics; for providing information and their cooperation during questionnaire survey.
Dr. Jaya Kumar Gurung Executive Director Nepal Development Research Institute (NDRI)
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Acronyms
AHW Auxiliary health workers
ANC Antenatal Care
ASL Authorized Stock Level
CEONC Comprehensive Emergency Obstetric and Neonatal Care
CPR Contraceptive Prevalence Rate
DRC Development Resource Centre
D(P)HOs District Public Health Offices
DoHS Department of Health Services
DRC Development Resource Centre
EC Emergency Contraception
EDPs External Development Partners
EHCS Essential Health Care Services
EOP Emergency Order Point
FHCP Free Health Care Policy
FHD Family Health Division
FP Family Planning
FPAN Family Planning Association of Nepal
GPRHCS Global Programme to enhance RHCS
HDC Hospital Development Committee
HFOMC Health Facility Operation and Management Committee
HP Health Post
ICT Information and Communication Technology
IUCD Intrauterine contraceptive device
ICPD International Conference on Population and Development
LMD Logistics Management Division
LMIS Logistics Management Information Systems
MDG Millennium Development Goal
MoHP Ministry of Health and Population
NHSP Nepal Health Sector eProgramme
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NFHP Nepal Family Health Program
NHRC Nepal Health Research Council
NHTC National Health Training Centre
OP Output
PHCCs Primary Health Care Centers
PNC Post Natal Care
PSSN Pariwar Swastha Sewa Network
PPA Public Procurement Act
RHDs Regional Health Directorates
RH Reproductive Health
RHCS Reproductive Health Commodity Security
RMS Regional Medical Stores
SDPs Service Delivery Points
SHP Sub Health Post
SPSS Statistical Package for Social Scientists
STI Sexually Transmitted Infections
STS Service Tracking Survey
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Table of Contents Acknowledgement ...... i Acronyms ...... ii List of Tables vii List of Figures ...... ix List of Annex ...... ix Executive summary ...... i Background ...... i Methods ...... i Key Findings ...... i Findings for exit interview...... iii Conclusion: ...... iii Recommendations...... iv PART 1: INTRODUCTION ...... 1 1.1. Background ...... 1 1.2. Rationale and Objective of the Study...... 1 1.3. Survey Organization and Management ...... 2 1.4. Methodology and Limitations ...... 2 1.4.1. Survey Design and Sampling of Facilities ...... 2 1.4.2. Data Collection ...... 12 Recruit and train field staff enumerators and supervisors and data entry staff ...... 12 Adapt and Pre-test Survey Questionnaires ...... 12 Finalize the Survey Questionnaires ...... 13 Mobilization of the Field Staffs ...... 13 1.4.3. Data Analysis and Presentation ...... 13 1.4.4. Limitation of the Survey ...... 14 PART 2: NATIONAL GUIDELINES, PROTOCOLS AND LAWS ...... 16 PART 3: SURVEY FINDINGS FOR AVAILABILITY OF COMMODITIES AND SERVICES...... 20 3.1. General Information about the Facilities ...... 20 3.1.1. Geographic Distribution of Facilities ...... 20 3.1.2. Management of Facilities ...... 21 3.1.3. Distance of SDPs from Source of Supplies ...... 21 3.2. Modern Contraceptives Offered by Facilities ...... 22 3.2.1. Contraceptives Offered by Types of Facilities ...... 22 3.2.2. Primary Facilities offering at least Three Types of Contraceptives ...... 23 3.2.3. Secondary and Tertiary Facilities offering at least Five Types of Contraceptives ...... 25
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3.2.4. Reasons for Not Offering Certain Contraceptives ...... 27 3.3. Availability of Maternal and RH Medicines ...... 28 3.3.1. Maternal and RH Medicines Available by Types of facilities ...... 29 3.3.2. Availability of Seven Essential Life-Saving Maternal and RH Medicines ...... 30 3.3.3. Reasons for Not Offering Certain Life Saving Maternal and RH Medicines ...... 33 3.4. Incidence of ‘No Stock Out’ of Modern Contraceptives ...... 35 3.4.1. ‘No Stock Out’ at the Time of Survey ...... 35 3.4.2. ‘No Stock Out’ In the Last Six Months ...... 37 3.4.3. Reasons for ‘Stock Out’ ...... 40 3.5. Supply Chain, Including Cold Chain ...... 41 3.5.1. Resupply of Medical Supplies ...... 41 3.5.2. Main Source, Frequency and Transportation of Supplies for SDPs ...... 44 3.5.3. Availability of Fridge for Storing Essential Drugs at SDPs and Source of Power ...... 47 3.6. Staff Training and Supervision...... 49 3.6.1. Availability of Staff Trained to Provide FP Services Including for Implants and IUCDs ...... 50 3.6.2. Frequency of Staff Supervision ...... 51 3.6.3. Issues included in Supervisory visits ...... 52 3.7. Availability of Guidelines, Check-lists and Job aids ...... 53 3.7.1. Family Planning Guidelines ...... 54 3.7.2. Antenatal/Postnatal Job Aids ...... 54 3.7.3. Waste Disposal Guidelines ...... 54 3.8. Use of Information Communication Technology (ICT) and Waste Disposal ...... 55 3.8.1. ICTs Available and How Acquired ...... 55 3.8.2. Uses of ICTs by SDPs ...... 57 3.8.3. Methods of Waste Disposal ...... 58 3.9. Charges for User Fees ...... 59 3.9.1. Charges and Exemptions for User Fees...... 59 PART 4: SURVEY FINDINGS FOR EXIT INTERVIEW ...... 62 4.1 Background Characteristics of Clients ...... 62 3.9.2. Sex and Age distribution ...... 62 3.9.3. Marital Status ...... 64 3.9.4. Education ...... 65 3.9.5. Frequency of visit to SDP for family planning services ...... 65 4.2 Clients’ Perception of Family Planning Service Provision ...... 66 3.10.1. Provider Adherence to Technical Aspects ...... 67 3.10.2. Organization Aspect ...... 68 3.10.3. Inter-Personal Aspect ...... 69
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3.10.4. Outcome Aspect ...... 69 4.3 Clients’ Appraisal of Cost of Family Planning Services ...... 70 3.11.1. Payment for Family Planning Service ...... 70 3.11.2. Mode of Transportation, Distance Travelled and Cost of Transportation ...... 71 3.11.3. Time Spent ...... 74 3.11.4. Source of Funds for Family Planning ...... 76 PART 5: Survey findings for indicators from NHSP II logical framework ...... 78 Major findings: ...... 78 3.11.5. OC 2.6 Percentage of clients satisfied with their health care providers at public facilities ...... 78 3.11.6. OP 1.3 Percentage of HFOMCs /HDC with at least 3 female members and at least 2 members from Dalit or Janajati ...... 78 3.11.7. OP 3.1 Percentage of sanctioned posts that are filled by Doctors at PHCCs; Doctors at District Hospitals; Nurses at PHCCs; Nurses at District Hospitals ...... 80 3.11.8. OP 3.2 Percentage of hospitals that have at least 1 obstetrician-gynaecologist or MDGP, 5 SBA trained nurses and 1 anaesthetist or anaesthetist assistant ...... 80 3.11.9. OP 4.5 Percentage of districts that have at least one facility providing all CEONC signal functions 24/7 81 3.11.10. OP 4.6 Percentage of PHCCs that provide all BEONC signal functions ...... 81 3.11.11. OP 4.7 Percentage of health posts that are birthing centres providing deliveries 24/7 ...... 81 3.11.12. OP 4.8 Percentage of safe abortion sites with long acting family planning services ...... 81 3.11.13. OP 4.9 Percentage of HPs with at least five FP methods ...... 81 3.11.14. OP 8.1 Percentage of health facilities that have undertaken social audits as per MoHP guideline in the last fiscal year ...... 81 PART 6: CONCLUSION & RECOMMENDATIONS ...... 83 5.1 Summary of Findings ...... 83 5.2 Recommendations ...... 88 BIBLIOGRAPHY ...... 92 ANNEX 93
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List of Tables
Table 1-1: Categorization of Primary, Secondary and Tertiary level care SDPs/Facilities ...... 2 Table 1-2: Country Sub-division According to Development Region and Eco-Region ...... 3 Table 1-3: Steps for district selection ...... 3 Table 1-4: Distribution of public sector SDPs as per developmental region and eco belt (sampling frame) ...... 6 Table 1-5: Relative Proportion for Tertiary Level Public SDPs ...... 7 Table 1-6: Minimal sample size all level Public SDPs (95% confidence interval and 5% confidence limit) ...... 7 Table 1-7: Corrected minimal sample size all level Public SDPs (95% confidence interval and 5% confidence limit) .... 7 Table 1-8: Distribution of Sample Sizes for public facilities (proportions) ...... 7 Table 1-9: Distribution of Sample Sizes for public facilities ...... 8 Table 1-10: Distribution of Sample Sizes for public facilities considering the Design effect (1.2) ...... 9 Table 1-11: Sample size for Exit Interview for public facilities ...... 10 Table 1-12: Distribution of private sector SDPs (Primary, Secondary and Tertiary level) for each district ...... 11 Table 1-13: Distribution of NGO sector SDPs for each district ...... 12 Table 3-1: Types of facility surveyed ...... 20 Table 3-2: Distribution of the SDP according to development regions ...... 21 Table 3-3: Distribution of the SDP according to area ...... 21 Table 3-4: Distribution of the SDP according to management ...... 21 Table 3-5: Distribution of the SDP according to distance from nearest warehouse/source of supplies ...... 22 Table 3-6: Modern Contraceptive Method offered by Type of Facility ...... 23 Table 3-7: Primary Facilities offering at least Three Types of Contraceptives ...... 24 Table 3-8: Primary Facilities offering at least Three Types of Contraceptives by development region ...... 24 Table 3-9: Primary Facilities offering at least Three Types of Contraceptives by residence ...... 24 Table 3-10: Primary Facilities offering at least Three Types of Contraceptives by management ...... 24 Table 3-11: Primary Facilities offering at least Three Types of Contraceptives by distance ...... 25 Table 3-12: Secondary and Tertiary Facilities offering at least Five types of Contraceptives ...... 26 Table 3-13: Secondary and Tertiary Facilities offering at least Five types of Contraceptives by region ...... 26 Table 3-14: Secondary and Tertiary Facilities offering at least Five types of Contraceptives by residence ...... 26 Table 3-15: Secondary and Tertiary Facilities offering at least Five types of Contraceptives by management...... 26 Table 3-16: Secondary and Tertiary Facilities offering at least Five types of Contraceptives by distance ...... 26 Table 3-17: Reasons for not offering certain contraceptives ...... 27 Table 3-18: Percentage distribution of service delivery points with any Maternal/RH Medicine available ...... 29 Table 3-19: Percentage distribution of SDPs with seven (including 2 essential)life-saving maternal/reproductive health medicines available by type of facility ...... 31 Table 3-20: Percentage distribution of SDPs with seven (including 2 essential) life-saving maternal/reproductive health medicines available by Type of government facilities ...... 31 Table 3-21: Percentage distribution of SDPs with seven (including 2 essential) life-saving maternal/reproductive health medicines available by development region ...... 32 Table 3-22: Percentage distribution of SDPs with seven (including 2 essential) life-saving maternal/reproductive health medicines available by residence ...... 32 Table 3-23: Percentage distribution of SDPs with seven (including 2 essential) life-saving maternal/reproductive health medicines available by residence ...... 32 Table 3-24: Percentage distribution of SDPs with seven (including 2 essential)life-saving maternal/reproductive health medicines available by distance ...... 32 Table 3-25: Reasons for not offering certain life saving maternal and RH medicines ...... 34
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Table 3-26: No stock out at the time of survey by the type of facility...... 35 Table 3-27: No stock out at the time of survey by the type of government facility ...... 36 Table 3-28: No stock out at the time of survey for each modern contraceptive by type of facility ...... 36 Table 3-29: No stock out at the time of survey by region, residence, distance and management of facility ...... 37 Table 3-30: No stock out during six months by the type of facility ...... 38 Table 3-31: No stock out during six months by the type of government facility...... 38 Table 3-32: No stock out during six months for each modern contraceptive by type of facility ...... 39 Table 3-33: No stock out during six months by region, residence, distance and management of facility ...... 39 Table 3-34: Reasons for No Stock out by type of modern contraceptives ...... 40 Table 3-35: Person responsible for ordering medical supplies ...... 41 Table 3-36: Person responsible for ordering medical supplies ...... 42 Table 3-37: Quantification of resupply by type of facilities ...... 43 Table 3-38: Quantification of resupply by type of government facilities ...... 44 Table 3-39: Main source of supplies by type of facilities ...... 45 Table 3-40: Main source of supplies by type of government facilities ...... 45 Table 3-41: Frequency of supplies by type of facility ...... 46 Table 3-42: Frequency of supplies by type of government facility ...... 46 Table 3-43: Responsibility for transportation of supplies by type of facility ...... 47 Table 3-44: Responsibility for transportation of supplies by type of government facility ...... 47 Table 3-45: Availability of fridge for storing essential drugs by type of facility ...... 48 Table 3-46: Availability of fridge for storing essential drugs by type of government facility ...... 48 Table 3-47: Source of power for Fridges by type of SDPs ...... 49 Table 3-48: Source of power for Fridges by type of government SDPs ...... 49 Table 3-49:Staffs trained to provide family planning services by type of SDPs ...... 50 Table 3-50: Staffs trained to provide family planning services by type of government SDPs ...... 50 Table 3-51: Staffs trained for the insertion and removal of Implants and IUCD by type of SDPs ...... 51 Table 3-52: Staffs trained for the insertion and removal of Implants and IUCD by type of government SDPs ...... 51 Table 3-53: Frequency of supervisory visits by type of SDPs ...... 52 Table 3-54: Frequency of supervisory visits by type of government SDPs ...... 52 Table 3-55: Issues included in supervisory visits by type of SDPs ...... 53 Table 3-56: Issues included in supervisory visits by type of government SDPs ...... 53 Table 3-57: Availability of family planning guidelines, ANC/PNC job aids and Waste disposal guidelines by type of SDPs ...... 55 Table 3-58: ICTs available in SDPs by type of SDPs ...... 56 Table 3-59: How ICT was acquired by type of SDPs ...... 57 Table 3-60: Main use of ICT by type of SDPs ...... 58 Table 3-61: Methods of waste disposal by type of SDPs ...... 59 Table 3-62: Issues for which user fee charged and exemptions for user fees – services provided by type of facility 60 Table 3-63: Issues for which user fee is charged and exemptions for user fees for services provided by a qualified health care provider by type of facility ...... 61 Table 4-1: Sex distribution of clients according to type of facility, region, residence and management of the SDP ... 62 Table 4-2: Age distribution of clients according to type of facility, region, residence and management of the SDP ... 63 Table 4-3: Marital status of clients according to type of facility, region, residence and management of the SDP ...... 64 Table 4-4: Education level of clients according to type of facility, region, residence and management of the SDP .... 65 Table 4-5: Frequency of visits to SDPs by clients according to type of facility, region, residence and management of the SDP ...... 66
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Table 4-6: Clients perspective of FP service provider’s adherence to technical aspects by clients ...... 67 Table 4-7: Clients perspective of FP service provider’s adherence to technical issues...... 68 Table 4-8: Clients perspective of FP service provider’s adherence to organizational aspects ...... 68 Table 4-9: Clients perspective of FP service provider’s adherence to inter-personal aspects ...... 69 Table 4-10: Clients perspective of FP service provider’s adherence to outcome aspects ...... 70 Table 4-11: Clients reporting paying for FP service and average amount paid ...... 71 Table 4-12: Clients by mode of transportation, distance travelled and cost of transportation ...... 73 Table 4-13: Average time spent by client for family planning services ...... 74 Table 4-14: Clients by activities they would have engaged in during the time spent receiving FP services ...... 75 Table 4-15: Clients by persons indicated to have performed activities on their behalf ...... 76 Table 4-16: Average amount paid to persons on behalf of clients by activities performed while client was away receiving FP services ...... 76 Table 4-17: Clients by source of funds used to pay for FP services ...... 77 Table 4-18: Average amount paid from each source by background characteristics of clients ...... 77
List of Figures
Figure 1: Selected districts according to development region and eco-region for survey ...... 4 Figure 2: Sample size distribution for public sector SDPs according to administrative unit and type of facilities ...... 5 Figure 3: Health facilities Pre-tested in Kavre district ...... 13
List of Annex
Annex 1: WHO list for life saving medicines for maternal/RH medicines Facilities ...... 93 Annex 2: Core team for the project...... 94 Annex 3: Selection of districts using systematic random sampling ...... 94 Annex 4: Distribution of number of SDPs for selected districts per developmental region and ecological belt ...... 96 Annex 5: Detailed field plan and facility allocation to each field researchers ...... 97 Annex 6: Training Schedule: (Two Days Training Schedule-14th and 15th November) ...... 119 Annex 7: Final questionnaire for the survey ...... 120 Annex 8: Persons responsible for ordering medical supplies by region, residence and management ...... 135 Annex 9: Quantification of resupply by Development region, residence and management ...... 135 Annex 10: Main source of supplies by development region, residence and management ...... 136 Annex 11: Frequency of supplies by development region, residence and management ...... 136 Annex 12: Responsibility for transportation of supplies by development region, residence and management ...... 137 Annex 13: Availability of fridges by Administrative Unit region, residence and management ...... 137 Annex 14: Source of power for Fridges used for cold chain by administrative unit region, residence and management ...... 138 Annex 15: Staffs trained for the insertion and removal of Implants and IUCD by type of government SDPs region, residence and management ...... 138 Annex 16: Frequency of supervisory visits by region, residence and management ...... 139 Annex 17: Percentage of SDPs with issues included in supervisory visits by Administrative Unit region, residence and management ...... 139
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Annex 18: Availability of family planning guidelines, ANC/PNC job aids and Waste disposal guidelines by type regions, residence and management ...... 140 Annex 19: Percentage of SDPs with types of Information Communication Technology available in region, residence and management ...... 140 Annex 20: Percentage of SDPs by How ICT was acquired by region, residence and management ...... 141 Annex 21: Main Purpose for which ICTs is used by region, residence and management ...... 142 Annex 22: Methods of waste disposal by region, residence and management...... 143 Annex 23: Issues for which user fee charged and Exemptions for user fees – services provided by region, residence and management ...... 143 Annex 24: Issues for which user fee is charged for services provided by a qualified health care provider by region, residence & management ...... 144 Annex 25: Clients perspective of FP service provider’s adherence to technical aspects by clients according to region, residence & management ...... 144 Annex 26: Clients perspective of FP service provider’s adherence to technical aspects by clients according to region, residence & management ...... 145 Annex 27: Perspective of FP service provider’s adherence to organizational aspects according to region, residence and management ...... 145 Annex 28: Clients perspective of FP service provider’s adherence to inter-personal aspects according to region, residence and management ...... 146 Annex 29: Clients perspective of FP service provider’s adherence to outcome aspects according to region, residence and management ...... 146
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Executive summary Background Along with 45 other countries across the world, Nepal is one of the recipients of fund through a Global Programme to enhance Reproductive Health Commodity Security (GPRHCS) which aims to strengthen the availability of reproductive health (RH) commodities and provision of quality Family Planning (FP) services by fulfilling gaps in areas such as supply chain management; staff training and supervision; availability of national guidelines and protocols and Information Communication Technology. Under GPRHCS programme, a baseline was conducted in 2013/2014 and for subsequent monitoring of progress; Facility Based Assessment for Reproductive Health Commodities and Services was conducted in 2014/2015. The objective of this survey was to assess the service availability, distribution and stock-out of essential lifesaving RH commodities, including contraceptives, and other key issues related to family planning service delivery at public, private and NGO sectors health facilities across the country. The survey also collected necessary data to monitor progress on selected health system related indicators from NHSP II logical framework.
Methods The survey was conducted in 15 districts and covered representative sample of all types of SDPs in government (SHPs, HPs, PHCCs and Hospitals), private (Sangini/SEWA/PSSN outlets, private hospitals/nursing homes) and NGO sector (Outlets of FPAN and Marie stoppe and Hospitals run by Missions and NGOs), located in all the five development regions, all three ecological belt and in urban and rural setting. A total of 763 facilities were surveyed including 394 sub health posts, 238 health post, 36 primary health care centers, 15 district hospitals, 3 zonal hospitals, 39 sangini outlets, 8 private hospitals/ Pariwar Swastha Sewa Network (PSSN), 19 medical centers/polyclinics, 9 Family Planning Association of Nepal (FPAN)/Marie stopes and NGO hospitals and 2 facility run by projects/ community based hospital.
Key Findings The proportion of facilities in Eastern Development Region, Central Development Region, Western Development Region, Mid-Western Development Region and Far-Western Development Region were 26%, 26%, 18%, 14% and 16% respectively. 84% of the facilities were located in rural areas and only 16% of the facilities were in the urban area. 90% of the facilities were managed by Government, 9% were owned by private sector and 1% was NGO managed. Short term hormonal (such as oral contraceptive pills, and injectables) and non-hormonal family planning services (such as male condoms) were provided by most of the SDPs. Emergency Contraceptives were provided by 24% of the total facilities surveyed, the proportion being comparatively higher in private and NGO sector. Long acting methods of contraception i.e. IUCD and implants were although provided by all types of SDPs surveyed, their proportion was higher in Primary Health Care Centre, Private/ public hospitals, and NGO run SDPs. Permanent methods of contraception i.e. vasectomy and minilap was limited to public and private hospitals and few NGO sector SDPs. Female condoms were provided only by FPAN/Marie stopes/NGO hospital. Almost all (99%) the primary level care SDPs i.e. SHP, HP and PHCC; 95% sangini outlets and all the FPAN/Marie stopes offered at least three modern contraceptives. All the tertiary level care government hospitals and majority of secondary level care government hospitals (86.7%) offered at least five modern contraceptives. 20.60% of HPs provided at least five family planning methods. Almost all (94.7%) of the medical centres/polyclinics, half of the private hospitals and one third of NGO hospitals offered at least five contraceptives. The main reason for not providing IUDs, Implants and other permanent contraception methods was predominately (more than 85%) due to lack of trained staffs in those SDPs to provide the services. The availability of seven essential life saving maternal and RH medicines (including two essential drugs) was found in only about 41% of the facilities. Also, majority of private hospitals, half of medical centers/polyclinics, about 44% of the sangini outlets and merely 20% of the NGOs facilities made available seven essential drugs. Comparing to the baseline data of 2013/14, the availability of misoprostol in all levels of government facilities have increased. In
i overall compared to 18% of the government facilities providing misoprostol in 2013/14, the figure has increased to about 22% in 2014/15 survey. The main reasons for SDPs not being able to provide certain life-saving maternal and reproductive health medicines were delays on the part of the district store /warehouse to re-supply the medicine. In overall, the SDPs having stock out of any of the modern contraceptives during the time of survey is low (i.e. nearly 87% of the SDPs were in no stock out condition). The most suffered from stock out at the time of survey were the PHCCs and zonal hospitals where about 25% and 33% of the SDPs respectively experienced stock out of any of the six contraception methods. In terms of private sector facilities, most stocks outs were observed for private hospitals i.e. about 33% of the private hospitals suffered stock outs of any of the seven contraceptives at the time of the survey. For NGO sector SDPs nearly 25% had stock outs at the time of the survey. The no stock out situation in past six months was observed in overall 83% of the SDPs. PHCCs suffered the most stock out of modern contraceptives in last six months. The stock outs in last six months was mostly experienced by emergency contraceptives in health posts (25%) and sub health posts (20%) while the implants were observed to be mostly out of stocks in PHCCs (31%). Similarly no major difference in stock outs in urban and rural settings or with respect to distance was observed. In overall, in nearly 80% of the government SDPs health facility in charges was the person responsible for ordering the medical supplies. Majority of SDPs had pull system for quantification of re-supply where in nearly 60% of the facilities, the staff member of the facility made request based on calculation of quantity needed. Major source of medical supplies (90%) at all SDPs at government sector were regional/district warehouse. For private sources, most of the purchases were made from private sources and some from the local medical stores. The NGO sector had various major sources of supplies such as central medical stores, NGOs, few from local medical stores as well as private sources. The frequency of resupply of medical supplies was done once in every three months in most of the SDPs. The responsibility for transportation of supplies at all government SDPs was mainly done by district warehouse except in hospitals where the central/regional warehouse was equally responsible for transportation of supplies. However in case of NGO, facility itself or the medical suppliers were responsible for transporting the supplies. Among the government facilities, majority of hospitals (94%) and PHCC (86%) had electric fridge available in their SDPs to store the cold chain medicines/ supplies, however very few of the health posts (30%) and sub health posts (12%) had electric fridge. Only 50% of sangini outlets, about 64% of FPAN/Marie stopes/NGO hospitals, majority (74%) of medical centers/polyclinics and all of the private hospitals/PSSN made electric fridge available to store the cold chain medicines. Most of the SDPs in the urban area had the availability of fridge to store the essential drugs (nearly 55%) compared to only 23% in rural SDPs. Most of the facilities (90%) rely on the electricity from national grid for the power supply. Majority of government hospitals (88%) and primary health care centers (71%) had trained staffs in both implants and IUCD compared to sub health posts (40%) and health posts (54%). In many of SDPs (38%), the supervisory visits were undertaken once in a three months period, however, in some of the SHPs and HPs the supervisions were also done annually. The survey showed that the issues mostly included in the supervisory visits were to check the data completeness, quality, and timely reporting and also drug stock out and expiry except for the government hospitals where supervisory visits mainly looked into other aspects such as supervision of vaccine services, OPD register, ANC/PNC services besides checking of data completeness, quality, and timely reporting and drug stock out and expiry. The availability of the family planning guidelines were verified in 41.9% of the sub-health post, 56.3% of Health Post, 75.0% of PHCCs, 77.8% of Government Hospitals. However only few percentages of sangini outlets (23.1%) and Medical centres/polyclinic (15.8%) and more than half of the private hospitals/PSSN (50%) and FPAN/Marie stopes/NGO (54.5%) verified the availability of such guidelines. The ante natal care job aids were verified by only about two fifth of Sub-health post (35.8%), Private Hospitals/PSSN (37.5%) and FPAN/Marie stopes (36.4%). Nevertheless, more of the Government Hospitals (66.7%), about 61.1% of PHCCs and more than half of the Health Post (53.6%) verified the availability. In sangini outlets, the availability verification was null. The availability of waste disposal guidelines was verified in very few SHPs (6.3%) and Sangini Outlet (5.1%), health posts (19.3%), Private Hospitals/PSSN (12.5%) and Medical Centers/Polyclinic (21.1%). Similarly, 50% of the government hospitals and 30% PHCCS verified the availability of such guidelines. In majority of SDPs, mobile phones were used as a primary means for communication and most of the ICT used were staff members’ personal item. Comparing the rural and urban scenario, most of the SDPs in the urban settings used computer (43%) and internet facilities (28%) compared to only 10% and 5% of rural SDPs using computer and internet facilities respectively. The private and NGO sector
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were way ahead in terms of using computer and internet facilities compared to the government facilities where merely 12% used computer and 6% used internet facilities. Routine communication was the main purpose for which the ICT was used in majority of SDPs (more than 85% of the government SDPs). More than half of SDPs (65%) managed their waste products by burning; nearly 23% SDPs managed by buried the waste in special dump pits, few SDPs (9%) used incinerators.
Findings for exit interview Of 3823 clients , of which, 95% were female, about half of the clients were between the age group 25 to 34 years, about 59% of the clients had never attended school, 99% were married or in union and resided in rural areas. The population of literate clients was more confined in private sector SDPs. More of the clients interviewed in the urban area visited the health facilities once a month compared to the clients in the rural areas. Similarly nearly 1/4th of the clients in private and NGO sector visited the SDP once a month, which was relatively higher than the clients in government SDPs. About 99% of the clients, on an average (with a lowest of 95% for Primary Health Care Center), who were offered the family planning services, stated that they were provided with the method of their choice. A similar percentage (98.9%) agreed that client’s preference and wishes were taken into consideration and approx. about 96% of them reported that the date of return to SDP for checkups or additional supplies was explained to them. However, comparatively, quite a low percentage of respondents (74.3%) reported that they were taught how to use the method. Majority of clients (89.4%) overall, reported having received information for occurrences of any serious complication on using family planning services. Almost all the clients, as many as 99% also stated that they made their own decision to use FP service. Nevertheless, very small number of clients, merely 5% stated that they had to return from the SDP due to the lack of FP services or due to lack of maternal/RH medicines when needed, which was stated slightly more in government SDPs. Majority of clients, as many as 90% in average showed their satisfaction over the cleanliness of the health facility, privacy at the exam room as well as time allocated to their case. Almost all of the clients (98%) stated that they were treated with courtesy and respect by the staff as well as nearly every client indicated that they were satisfied with the attitude of the health provider towards them. When asked about the satisfaction over the services they received nearly all (99%) of the clients showed their satisfaction and 96% of the clients stated that they will continue visiting the SDP in the future. 94.2% of the clients of the private facilities were found to be paying for the services as opposed to a mere 2.9% in the government facilities. Major chunk of the payment made in the government driven facilities was made under registration i.e. for card payment. In case of NGOs, 35% of the clients paid for the services. A majority of the interviewed clients (92.4%) walk to the SDPs and rest (merely 8%) used any kind of vehicle to travel to the SDP preferably bicycles (4.5%). In average, a total of approximately 50 minutes were spent by the clients for travelling to and from the place of residence to the SDP and approximately nine minutes to get service from the SDPs. This somewhat indicated that the clients did not have to dedicate much time for receiving the services from the SDP. In case of male clients, nearly all of them (about 94%) paid for the services themselves, however in case of female clients though large number of them (67%) paid themselves still significant amount i.e. 32% made their spouses pay for the services they received.
Conclusion: Family planning services was provided by all types of SDPs surveyed. Contraception methods such as male condoms, oral contraceptive pills and injectables were made available in regular basis in all the facilities in the government, private and NGO sector. However, methods such as IUCDs and Implants were typically provided by government hospitals, PHCCs, Private hospitals and NGO sector facilities. Sterilization services such as Minilap and Vasectomy were limited to some of the government hospitals, private hospitals and NGO sector facilities. Almost all (98.8 %) of the primary level care SDPs (i.e. SHP, HP and PHCC) offered at least three modern contraceptives. All the FPAN/Marie stopes surveyed and majority of sangini outlets i.e. 95% offered at least three contraceptives. All the tertiary level care government hospitals and majority of secondary level care government hospitals (86.7%) offer at least five modern contraceptives. 20.60% of HPs provided at least five family planning methods. Further, almost all (94.7%) of the medical centres/polyclinics, half of the private hospitals and one third of NGO hospitals offered at least five contraceptives. Overall about 41% of the SDPs were found to have the seven (including 2 essential) life- saving maternal or reproductive health medicines. Comparing to the baseline data of 2013/14, the availability of
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misoprostol in all levels of government facilities have increased. In overall compared to 18% of the government facilities providing misoprostol in 2013/14, the figure has increased to about 22% in 2014/15 survey. The SDPs having stock out of any of the modern contraceptives during the time of survey is low. PHCCs suffered the most stock out of modern contraceptives in last six months. In overall, high positive responses from the clients were observed regarding the family planning services they received in the SDPs. It was particularly encouraging to see that the clients made their own decision to use FP services and that they did not have to return from the SDP due to the lack of FP services or any RH medicines when needed. More of the clients from government facilities had positive responses towards the facilities’ efficacy towards the technical aspect; this might be due to the high expectations of more literate clients in private facilities than the illiterate population in government facilities.
Recommendations Additional studies must be conducted to assess the feasibility and acceptability of EC and female condom among general population to inform possibilities of provision of these methods through the national FP program. The provision of long acting and permanent methods of contraception at all levels should be increased. Mandatory training with periodic refreshers training for long acting contraceptive methods for service providers is recommended. The survey showed that the main reasons for non availability of the essential drugs were delays on the part of the district store /warehouse to re-supply, thus, a close co-ordination and communication between Logistic Management Division the warehouses and the service delivery points is recommended for maintenance of adequate stock of essential life saving RH commodities. The availability of cold chain equipment not limiting to refrigerators should be made universally available in all health facilities. Due to the problem of high interrupted power supply in Nepal and high dependence on the national grid for the power supply, in most of the SDPs, backup power supply such as generators or solar powered should be highly encouraged for providing uninterrupted supply to the fridges storing essential medicines. The use of ICT should not only be limited to personal communication but its use should be expanded to greater horizon for patient registration, clinical consultation and health worker training and report writing.
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PART 1: INTRODUCTION
1.1. Background UNFPA Nepal Country Office, in its 7th programme cycle (2013-2017), is working with the Ministry of Health and Population (MoHP) to support the strengthening of the national family planning program, both at national and at below-national levels, for increasing demand as well as utilization of family planning services. Nepal is also receiving funding and technical support through a Global Programme to enhance Reproductive Health Commodity Security (GPRHCS) along with other 45 countries across the world. This UNFPA-managed thematic fund aims to strengthen the availability of reproductive health (RH) commodities and provision of quality Family Planning (FP) services by fulfilling gaps in areas such as supply chain management; staff training and supervision; availability of national guidelines and protocols and Information Communication Technology. UNFPA has to conduct the facility based assessment for reproductive health commodities and services on an annual basis. For this, a baseline in 2013/2014 was conducted for subsequent monitoring of progress. Similar studies will be conducted by UNFPA on a regular basis, most likely annually from 2014 to 2017. For this, Nepal Development Research Institute (NDRI) supported UNFPA for conducting a survey in 2014 for subsequent monitoring of progress of the program in Nepal.
1.2. Rationale and Objective of the Study The survey methodology is adapted to national context, i.e. the sample districts will be identified to ensure that they are representative of the whole country. The total number of facilities to be surveyed will be carried out at different public, private and NGO sectors. This survey was conducted in 15 districts ensuring national representation (all developmental region and eco-region). The objective of this survey is to assess the service availability, distribution and stock-out of essential lifesaving RH commodities, including contraceptives, and other key issues related to family planning service delivery at public, private and NGO sectors health facilities across the country. The survey will also collect necessary data to monitor progress on selected health system related indicators from NHSP II logical framework. The specific objectives are: 1. To assess the number of Service Delivery Points (SDPs) offering at least three modern methods of contraceptives 2. To assess the availability and stock out of seven life-saving maternal/RH medicines – which must include Magnesium Sulphate and Oxytocin plus any other five drugs from the WHO list (Error! Reference source not found.) including contraceptives 3. To assess the issues around supply chain management (including cold chain). 4. To identify gaps in staff training and supervision for provision of quality RH services. 5. To assess the availability of national guidelines, protocols, standards and job-aids on provision of quality RH services in the health facilities. 6. To assess the issues around availability and use of Information Communication Technology. 7. To assess the issues around method of waste disposal. 8. To appraise and assess clients’ perception about the cost for family planning services.
To monitor the progress on selected health system related indicators in the NHSP-2 Logical Framework (only at the public sector health facilities).
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1.3. Survey Organization and Management
A survey executive committee was formed to accomplish the project consisting of the following members. The details of the core team are provided in Error! Reference source not found..
Undertaking consultations with relevant stakeholders at the national level
One day stakeholder meeting was organized on 10th November, 2014 with participants from Logistic Management Division (LMD), Family Health Division Offices (FHD), UNFPA and NDRI. The objective of this consultation meeting was to discuss on objectives, sampling modality, and the questionnaires to be asked for the survey. In LMD, the meeting was conducted with Dr.B.S Tinkari, Director of LMD, Mr. Krishna Prasad Gautam, Undersecretary LMD, and Mr. BR Dotel, Sr.DHA, FHD. Dr. Jaya Kumar Gurung, Executive Director of NDRI gave an overall recap of baseline survey conducted in 2013 and he highlighted the objectives of monitoring survey to be conducted in 2014. Regarding the 2014 survey, Mr. Chandramani Dhungana from UNFPA elaborated the necessity of conducting the monitoring survey in 2014 and further emphasized its objectives indicating that there has been slight change in the scope of the work compared to 2013 as few indicators of Nepal Health Sector Support Progamme (NHSSP) was also added in 2014 survey. Dr. Gurung further stated that the tools for the survey have already been drafted so for the finalization of tools he requested LMD and FHD for their critical comments and suggestions. In this, Dr. Tinkari appreciated the project and committed for the necessary cooperation and suggested NDRI to make an official request to issue a letter from LMD to all district offices for necessary cooperation. Dr. Basu Dev Pandey, Team leader for the project, NDRI debriefed about the overall methodology of the project and how 15 districts were selected. Mr. Dotel suggested that certain essential drugs such as misoprostol, magnesium sulphate and oxytocin should be analyzed most critically and he also committed to provide all the necessary comments to the finalize the tools. He suggested consulting district health offices to identify the government including the entire private and NGO facilities to be surveyed as the list of facilities such as sangini outlets, Marie stopes, etc was not readily obtainable.
1.4. Methodology and Limitations
1.4.1. Survey Design and Sampling of Facilities
This survey will consider the following broad categories of Service Delivery Points (SDPs) in public, private and NGOs sectors that provide modern methods of contraceptives and maternal/RH services as stratums: Table 1-1: Categorization of Primary, Secondary and Tertiary level care SDPs/Facilities
a) Primary Level Care b) Secondary level care SDPs/hospitals c) Tertiary level care SDPs/facilities SDPs/hospitals i. Public sector-Zonal, Sub i. Public sector –PHCC, HP, i. Public sector – District Hospitals regional, Regional, Central SHP and District Clinics Hospitals ii. Private sector – private ii. Private sector – ii. Private sector - private hospitals/clinics with Sangini/SEWA outlets and hospitals/nursing homes with the specialist services and other outlets service of a medical doctor Pariwar Swastha Sewa Network (PSSN) outlets iii. NGO sector- Central level iii. NGO sector iii. NGO sector - – District level outlets FPAN clinics, Marie stoppe Peripheral Outlets of FPAN of FPAN and Marie stoppe, clinics, Other NGOs and Marie stoppe Hospitals run by Missions and Hospitals with specialist NGOs services
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Selection of Districts The key objective that guided the selection of districts was “random selection of districts resulting in nationally representative sample, covering all ecological belts and development regions.” Nepal is divided into three ecological belts (mountain, hill and tarai) and five development regions. Subsequently, the country can be divided into 15 sub-regions i.e. mountain, hill and tarai region in each of the five development regions. The table below illustrates the 15 sub-division that will be followed in this survey: Table 1-2: Country Sub-division According to Development Region and Eco-Region SN Development Region Eco-region SN Development Region Eco-region 1. Mountain 10. Mountain 2. Far-Western Hills 11. Central Hills 3. Terai 12. Terai 4. Mountain 13. Mountain 5. Mid-Western Hills 14. Eastern Hills 6. Terai 15. Terai 7. Mountain
8. Western Hills
9. Terai
In first step, systematic random sampling is done to select the districts within each eco-region for each developmental region. We understand that study need to be representative of collect the data from the sampled districts, representing three ecological zones from five development regions. Thus, 15 districts will be selected from three ecological regions of five development region by using systematic random sampling. The sampling design for selecting the representative districts involved the following stages:
Table 1-3: Steps for district selection Steps Description 1 Listing out all the districts in eco-region under each development region Calculating the sample interval using the formulae as below: Sample interval (i)= 2 Total no. of districts of each ecological zone under each development region (N) Required sample size from respective region (n)
Finally random number was generated using the calculated sample interval (i) and corresponding district was selected. Random number is generated using the formula: (Rand()*(b-a)+a &F9 (to provide constant random number) 3
The detailed process of district selection is provided as Annex 3 follows:
Districts selections for the survey are shown in Figure 1.
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Figure 1: Selected districts according to development region and eco-region for survey
Public Sector Sampling The sampling distribution for public sector SDPs according to administrative unit and type of facility is shown in Figure 2 below:
Sampling Frame For public sector health facilities the database from the previous year and now has changed. Most of the primary health facilities have been upgraded. Thus, the updated sampling frame (in accordance to the data in Annual report provided by Department of Health Services under the Ministry of Health and Population for the year 2012/13) is used for this methodology. The updated list of the health facilities for selected districts is used to produce the end result table which contains the name of districts to be surveyed and the total number of health facilities to be surveyed under each category of SDPs.
Sampling Formula to obtain Sample Size Taking the types of the SDPs in public sector (primary, secondary and tertiary) as the main attributes, therefore the total sample should contain a minimal number of each type of facility to support good estimation of the parameters of the population. It is in this respect, from each of the 15 randomly selected districts, the SDPS in the respective district will be calculated by using the following formula (as demanded in the RFP): ( ) = (Equation 1) 2 푍 푝 푝−1 2 푛 푑 Page | 4
Public Sector SDPs
Eastern Development Central Development Western Development Mid-Western Far-Western Region Region Region Development Region Development Region
Mou Hill Terai Mou Hill Terai Mou Hill Terai Mou Hill Terai Mou Hill Terai ntain ntai ntain ntain ntain
District Randomization
PL SL TL PL PL SL TL SL TL PL SL TL PL SL TL
Figure 2: Sample size distribution for public sector SDPs according to administrative unit and type of facilities
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Where, n = Minimal sample size for each domain Z = Z score that corresponds to a confidence interval p = the proportion of the attribute (type of SDP) expressed in decimal d = per cent confidence level in decimal The formula is used to obtain the minimal sample size for the proportions of each category of SDPs under the assumptions of normal distribution and hence lends the data to comparison between populations. The formula adopts an approach that gives large (tertiary and secondary facilities) a higher probability of inclusion in the survey because of their small number and provides a guide for choosing a sample of the primary facilities. The following step by step guide given by UNFPA has been followed for using the formula to derive sample sizes. Step One Designing of Sample Frame Distribution of public sector SDPs as per developmental region and ecological belt are shown in Table 1-4 below: The list of all SDPs from selected district in each stratum of five developmental regions and three ecological divisions is given below in Table 1-4. This list will serve as a frame for the selection of samples. Table 1-4: Distribution of public sector SDPs as per developmental region and eco belt (sampling frame) Primary Level Eco-Region Districts Secondary Level Tertiary Level Total SHP HP PHCC Mountain Darchula 26 14 1 2 0 43 Eco belt Hill Baitadi 50 15 2 1 0 68 Far-West Terai Kanchanpur 7 15 3 1 1 27 Total 83 44 6 4 1 138
Mountain Kalikot 15 13 1 1 0 30 Eco belt Hill Jajarkot 21 11 2 2 0 36 Mid-West Terai Banke 31 13 3 1 1 49 Total 67 37 6 4 1 115
Mountain Manang 3 10 0 1 0 14 Eco belt Hill Parbat 33 19 2 1 0 55 Western Terai Kapilbastu 57 16 2 3 0 78 Total 93 45 4 5 0 147
Mountain Sindhupalchowk 56 19 3 1 0 79 Eco belt Hill Dhading 24 25 2 2 0 53 Central Terai Rautahat 80 12 4 2 0 98 Total 160 56 9 5 0 230 Mountain Taplejung 42 8 2 2 0 54 Eco belt Hill Bhojpur 39 21 3 1 0 64 Eastern Terai Saptari 95 18 4 0 1 118 Total 176 47 9 3 1 236 Mountain 142 64 7 7 0 220 Eco belt Hill 167 91 11 7 0 276 Total Terai 270 74 16 7 3 370 Total 579 229 34 21 3 866 Step Two Calculation of relative proportion for the types of SDPs The relative proportion for Tertiary level SDPs is calculated as follows: [Total number of tertiary SPDs]÷ [Total number of SDPs on the sample frame].The procedure is repeated for secondary and primary facilities and the results are presented in Table1-5 below.
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Table 1-5: Relative Proportion for Tertiary Level Public SDPs Primary Level Secondary Tertiary Total SHP HP PHCC Level Level Number of SDPs 579 229 34 21 3 866 Relative Proportion 0.668591 0.264434 0.03926097 0.024249 0.003464 1
Step Three Applying the formula above (equation 1) to obtain the minimal sample size for each Type of SDP By the use of a confidence interval as proposed, the formula provides a range of values where a given true population parameter is likely to be. The range of value is also determined by the confidence limit or the precision of the estimated value. The confidence interval is set at Z-score = 95 per cent and 5 per cent confidence limit. Table 1-6: Minimal sample size all level Public SDPs (95% confidence interval and 5% confidence limit) Primary Level Secondary Tertiary Total SHP HP PHCC Level Level Number of SDPs 579 229 34 21 3 866 Relative Proportion 0.668591 0.264434 0.03926097 0.024249 0.003464 1 1-p 0.331409 0.735566 0.96073903 0.975751 0.996536 0 p(1-p) 0.221577 0.194509 0.037719546 0.023661 0.003452 0 D2 0.0025 0.0025 0.0025 0.0025 0.0025 Z2 (Z score at 95%) 3.8416 3.8416 3.8416 3.8416 3.8416 N 340 299 58 36 5 739
Correction for abnormal oversize samples: In this case, the minimal sample size is greater than the population size as shown in Table1-7; the whole population of the category under consideration will be included in the sample.
Table 1-7: Corrected minimal sample size all level Public SDPs (95% confidence interval and 5% confidence limit) Corrected minimal sample size of Service Delivery Point Confidence Interval and Primary Level Secondary Tertiary Confidence Limit Total SHP HP PHCC Level Level 95% confidence interval (z=1.96) and 5% 340 229 34 21 3 627 confidence limit (D=0.05) Step Four Distribution of Sample Sizes for Administrative Units The total sample size for each category of SDPs has to be distributed among the Development Regions and Ecological Belt units according to the Development Regions and Ecological Belt’s share of a particular category of SDP. This requires the calculation of the relative proportions for each domain. For example the Proportion of Tertiary Level hospitals in Eastern Developmental Region Mountain Belt= Number of Tertiary level care SDPs/hospitals in Eastern Developmental Region Mountain Belt ÷ Total of Tertiary level care SDPs/hospitals. The results are presented in Table 1-8 below: Table 1-8: Distribution of Sample Sizes for public facilities (proportions) Primary Level Secondary Tertiary Eco-Region Districts Total SHP HP PHCC Level Level Mountain Darchula 0.044905 0.061135 0.029412 0.095238 0 0.049654 Eco Far- Hill Baitadi 0.086356 0.065502 0.058824 0.047619 0 0.078522 belt West Terai Kanchanpur 0.01209 0.065502 0.088235 0.047619 0.333333 0.031178 Total 0.143351 0.19214 0.176471 0.190476 0.333333 1.03577
Mid- Eco Mountain Kalikot 0.025907 0.056769 0.029412 0.047619 0 0.034642
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West belt Hill Jajarkot 0.036269 0.048035 0.058824 0.095238 0 0.04157 Terai Banke 0.053541 0.056769 0.088235 0.047619 0.333333 0.056582 Total 0.115717 0.161572 0.176471 0.190476 0.333333 0.977569
Mountain Manang 0.005181 0.043668 0 0.047619 0 0.016166 Eco Hill Parbat 0.056995 0.082969 0.058824 0.047619 0 0.06351 Western belt Terai Kapilbastu 0.098446 0.069869 0.058824 0.142857 0 0.090069 Total 0.160622 0.196507 0.117647 0.238095 0 0.712871
Mountain Sindhupalchowk 0.096718 0.082969 0.088235 0.047619 0 0.091224 Eco Hill Dhading 0.041451 0.10917 0.058824 0.095238 0 0.061201 Central belt Terai Rautahat 0.138169 0.052402 0.117647 0.095238 0 0.113164 Total 0.276339 0.244541 0.264706 0.238095 0 1.023681 Mountain Taplejung 0.072539 0.034934 0.058824 0.095238 0 0.062356 Eco Hill Bhojpur 0.067358 0.091703 0.088235 0.047619 0 0.073903 Eastern belt Terai Saptari 0.164076 0.078603 0.117647 0 0.333333 0.136259 Total 0.303972 0.20524 0.264706 0.142857 0.333333 1.250109 Mountain 0.24525 0.279476 0.205882 0.333333 0 0.254042 Eco Hill 0.288428 0.39738 0.323529 0.333333 0 0.318707 Total belt Terai 0.466321 0.323144 0.470588 0.333333 1 0.427252 Total 1 1 1 1 1 1
Step Five
Distribution of Sample Sizes for Administrative Units The samples for each category of SDP are distributed among the various Development Regions and Ecological Belt by applying the proportions in above Table1-8 to the minimal sample sizes for each type of SDP indicated in sample size. The results are presented in Table 1-9 below: Table 1-9: Distribution of Sample Sizes for public facilities Primary Level Secondary Tertiary Eco-region Districts Total SHP HP PHCC Level Level Mountain Darchula 15 14 1 2 0 31 Eco Hill Baitadi 29 15 2 1 0 49 Far-West belt Terai Kanchanpur 4 15 3 1 1 20 Total 49 44 6 4 1 104
Mountain Kalikot 9 13 1 1 0 22 Eco Hill Jajarkot 12 11 2 2 0 26 Mid-West belt Terai Banke 18 13 3 1 1 36 Total 39 37 6 4 1 87
Mountain Manang 2 10 0 1 0 10 Eco Hill Parbat 19 19 2 1 0 40 Western belt Terai Kapilbastu 34 16 2 3 0 57 Total 55 45 4 5 0 109
Mountain Sindhupalchowk 33 19 3 1 0 57 Eco Hill Dhading 14 25 2 2 0 38 Central belt Terai Rautahat 47 12 4 2 0 71 Total 94 56 9 5 0 164 Mountain Taplejung 25 8 2 2 0 39 Eco Hill Bhojpur 23 21 3 1 0 46 Eastern belt Terai Saptari 56 18 4 0 1 86 Total 103 47 9 3 1 163 Mountain 84 64 7 7 0 159 Eco Hill 98 91 11 7 0 200 Total belt Terai 159 74 16 7 3 268 Total 340 229 34 21 3 627
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Step Six
Applying Design Effect to Estimated Sample Size Though design effect increases the number of facilities in calculation, all the increased facilities cannot be sampled as it exceeds the total number of facilities within that district. Thus only the districts where the increased sample size is not greater than the actual facility in each district, the design effect is considered. This is also applicable to private health facilities. Table 1-10: Distribution of Sample Sizes for public facilities considering the Design effect (1.2) Primary Level Secondary Tertiary Eco-Region Districts Total SHP* HP PHCC Level Level Mountain Darchula 18 14 1 2 0 35 Eco Hill Baitadi 35 15 2 1 0 53 Far-West belt Terai Kanchanpur 5 15 3 1 1 25 Total 59 44 6 4 1 114
Mountain Kalikot 11 13 1 1 0 26 Eco Hill Jajarkot 15 11 2 2 0 30 Mid-West belt Terai Banke 22 13 3 1 1 40 Total 47 37 6 4 1 95
Mountain Manang 2 10 0 1 0 13 Eco Hill Parbat 23 19 2 1 0 45 Western belt Terai Kapilbastu 40 16 2 3 0 61 Total 66 45 4 5 0 120
Mountain Sindhupalchowk 40 19 3 1 0 63 Eco Hill Dhading 17 25 2 2 0 46 Central belt Terai Rautahat 56 12 4 2 0 74 Total 113 56 9 5 0 183 Mountain Taplejung 30 8 2 2 0 42 Eco Hill Bhojpur 28 21 3 1 0 53 Eastern belt Terai Saptari 67 18 4 0 1 90 Total 124 47 9 3 1 184 Mountain 100 64 7 7 0 178 Eco Hill 118 91 11 7 0 227 Total belt Terai 191 74 16 7 3 291 Total with design effect 409 229 34 21 3 696 * With application of design effect of 1.2
Last Step Seven The last step is to choose the specific SDPs to be included in the study. For this, systematic random sampling of types of SDPs for each Developmental region and ecological belt was done. The following steps were followed: 1. For each domain the facilities were listed without any order or regard to any characteristics (listing of all facilities within each selected district in each developmental region was done). A Sampling Interval (i) was determined for each domain. This was done by dividing the total number of facilities in the domain by the sample size for that domain:
N i = n Where: I=sampling interval for the domain N = number of SDPs in the domain n = sample size for that domain
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2. Starting point K was selected by randomly selecting a number between 1 and i (the sample interval). Here, K becomes the first SPD in the domain to be chosen. 3. Then select successive SDPs for inclusion in the sample by moving at the interval K+i; K+2i; K+3i; K+4i; K+5i; etc until you have chosen the required sample size from the domain. 4. Steps 1 to 4 will be repeated for each domain in the population. The overall selected SDPs for each district in each eco-region in each development region is provided in Annex 4. Guidelines used for Client Interview The clients of SDPs will be interviewed as they leave the health facility to learn about their opinion and satisfaction with the service received, and their appraisal of various cost elements related to accessing FP services. The information will assist in / some aspects of the quality of care and cost for FP services from the client’s perspective’. The authorities of the SDPs must be informed and their permission obtained before the client interview section can be completed for a particular SDP. Most importantly the consent of the individual clients must be obtained. The interviewer must inform the client about the purpose of the client interview. The interview must be conducted in private. Steps should be taken to ensure that no other person is present for the interview. Confidentiality must be ensured; so the interviewers should not discuss the respondents’ answers with anyone, except their survey supervisors. Also, no particulars of the clients should be recorded. Although client exit interviews are not expected to be based on representative samples of the population, however, efforts must be made to ensure that they are representative of those who visit the facility on that day. In this respect the interviewer should ensure that those interviewed are systematically selected. Therefore; A: In primary SDPs, the interviewer should talk to all the clients visiting the facility on the day the client interview is conducted. B: For secondary and tertiary SDPs, with high attendance, the interviewer can talk to a sample of clients. The sample should be chosen systematically. Where possible it is necessary to interview at least 5 attendees per primary SDPs (more attendees will be interviewed depending on their availability during the survey period) and 20 per secondary or tertiary SDPs. It should be recognized that these limits depend on the number who attend SDP at the time of the survey. It is therefore left to the survey team to device strategies for collecting information from as many persons as possible. Depending on the country and region, specific times of the day (e.g., morning hours); specific days (market days for some rural communities); or designated clinic days etc., can be explored to reach as many attendees as possible. Table 1-11: Sample size for Exit Interview for public facilities Public Development Region Districts Primary Level Secondary Tertiary Total SHP HP PHCC Level Level Mountain Darchula 92 70 5 40 0 207 Eco Hill Baitadi 176 75 10 20 0 281 Far- belt West Terai Kanchanpur 25 75 15 20 20 155 Total 293 220 30 80 20 643
Mountain Kalikot 53 65 5 20 0 143 Eco Hill Jajarkot 74 55 10 40 0 179 Mid- belt West Terai Banke 109 65 15 20 20 229 Total 236 185 30 80 20 551
Mountain Manang 11 50 0 20 0 81 Eco Hill Parbat 116 95 10 20 0 241 Western belt Terai Kapilbastu 201 80 10 60 0 351 Total 328 225 20 100 0 673
Mountain Sindhupalchowk 198 95 15 20 0 328 Eco Hill Dhading 85 125 10 40 0 260 Central belt Terai Rautahat 282 60 20 40 0 402 Total 565 280 45 100 0 990
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Mountain Taplejung 148 40 10 40 0 238 Eco Hill Bhojpur 138 105 15 20 0 278 Eastern belt Terai Saptari 335 90 20 0 20 465 Total 621 235 45 60 20 981
Mountain 501 320 35 140 0 996 Eco Hill 589 455 55 140 0 1239 Total belt Terai 953 370 80 140 60 1603 Total 2043 1145 170 420 60 3838
Private Sector Sampling Sample selection The selection of districts within each eco-region for each development region for private sector sampling of health facilities is based on the systematic random sampling process carried out for public sector i.e. the same districts are considered for the sampling of private sector facilities. Since the complete list of all the private and NGO facilities could not be obtained, the sampling process used to select public facilities could not be applicable in the case of private and NGO facilities selection. However, attempt was made to sample using existing list of the private sector facilities, which resulted in unequal distribution of the sample in each district i.e. most of the samples were collected to certain districts only. Thus to avoid such biasness in data collection, the sample selection for private facilities was done on the basis that from primary level i.e. sangini outlets at least 3 sample facilities, from secondary and tertiary level i.e. medical centers/polyclinics and hospitals/PSSN at least one facilities each should be visited during the survey (Refer Table1-12). In case of exit interview from each private SDP at least five clients were to be interviewed. Table 1-12: Distribution of private sector SDPs (Primary, Secondary and Tertiary level) for each district Private
Development Eco- District Primary Level Secondary Level Tertiary Level Region region Sangini/ SEWA Medical Centers/ Hospitals/ Total Outlets Polyclinic PSSN Darchula Mountain 3 1 1 5 Far-Western Baitadi Hills 3 1 1 5 Kanchanpur Terai 3 1 1 5 Kalikot Mountain 3 1 1 5 Mid-Western Jajarkot Hills 3 1 1 5 Banke Terai 3 1 1 5 Manang Mountain 3 1 1 5 Western Parbat Hills 3 1 1 5 Kapilvastu Terai 3 1 1 5 Sindhupalchowk Mountain 3 1 1 5 Central Dhading Hills 3 1 1 5 Rautahat Terai 3 1 1 5 Tapleljung Mountain 3 1 1 5 Eastern Bhojpur Hills 3 1 1 5 Saptari Terai 3 1 1 5 Grand Total 45 15 15 75
NGO Sector Sample selection For the NGOs sector sampling, all the FPAN outlets, Marie stoppe clinics and hospitals run by Missions and NGOs in the selected district were considered. For each district, data from at least two FPAN or Marie stoppe outlets or NGO
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hospitals were to be collected. In case of exit interview from each NGO facilities, at least five clients were to be interviewed (Refer Table 1-13). Table 1-13: Distribution of NGO sector SDPs for each district NGO Development Region Eco-region District Outlets of FPAN and Marie stoppe and NGO Hospitals Mountain Darchula 2 Far-Western Hills Baitadi 2 Terai Kanchanpur 2 Mountain Kalikot 2 Mid-Western Hills Jajarkot 2 Terai Banke 2 Mountain Manang 2 Western Hills Parbat 2 Terai Kapilvastu 2 Mountain Sindhupalchowk 2 Central Hills Dhading 2 Terai Rautahat 2 Mountain Tapleljung 2 Eastern Hills Bhojpur 2 Terai Saptari 2 Grand Total 30
1.4.2. Data Collection
Recruit and train field staff enumerators and supervisors and data entry staff
All the selected field staffs i.e. 5 field supervisors, 85 field enumerators were trained before commencing data collection. Two days training November 2014 was conducted on 14th and 15th November, 2014. The training focused on familiarizing the field staffs on brief description of project, research methodology and sample size calculation and distribution and on the research ethics to be strictly followed by the field staffs; as well as training the field staffs on the questionnaire and data collection technique. In addition to the classroom training, field practice and mock interviews were conducted to allow them to gain familiarity with the questionnaires and experience in interviewing. Supervisors were further trained on supervising field work, editing questionnaires in the field and managing logistics. Along with training on the questionnaires, the field staffs were also made familiar about their survey districts and respective health facilities. The resource people involved in the training and the detailed schedule of the training session is provided in the Error! Reference source not found. below.
Adapt and Pre-test Survey Questionnaires
The pre-test of the survey questionnaires was conducted on 17th November, 2014. In this pre-testing session all the trained supervisors and group leaders appointed for each district participated. A total of 20 selected field researchers were divided in five groups and pre-testing was conducted in five different health facilities namely Dhulikhel Hospital, Dhulikhel PHC, Ugratara janagal HP, Scheer Memorial Hospital and sangini outlet in Kavre district (Banepa and Dhulikhel municipality).
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Figure 3: Health facilities Pre-tested in Kavre district
The purpose of the pre-testing was to check the clarity and relevance of the tools, ease or reluctance of the respondents in answering questions and time taken to complete the questionnaire. After the pre-testing all the field staffs were brought together and confusions and problems encountered in the field were thoroughly discussed and addressed by technical experts. The results of the pilot survey were used to further refine the questionnaire and pre- empt pitfalls during the survey process.
Finalize the Survey Questionnaires The draft questionnaire prepared by UNFPA and NDRI was further refined by incorporating all problems and feedbacks from the training session and also from findings during pretesting. The final version of the survey questionnaire was translated in Nepali language and is provided in Error! Reference source not found..
Mobilization of the Field Staffs A total of 85 field enumerators and 5 field supervisors were mobilized to the field. The number of field enumerators to be allocated for each district is based on total number of health facilities to be surveyed in each district. Two working days were allocated for one facility (including exit interview) for the field enumerators. One field supervisor was allocated for each development region. Similarly, the number of health facilities to be surveyed by each enumerator and districts allocated to them (detailed field plan) were designed and provided to each of them before deploying them to the field (Refer Error! Reference source not found.). Further, the field staffs were provided letter from Department of Health Services, MOHP to facilitate data collection from the health facilities.
1.4.3. Data Analysis and Presentation Data processing was done in three phases namely data entry program development, data entry and data cleaning. The following process was carried out for overall data management:
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• Development of coding system: A scientific coding system was developed using alphabets and numbers denoting questionnaire IDs, development regions, eco-regions, districts, VDCs, wards and type of facilities of survey. • Selection of software, data masking and data entry: MS-Excel was used for the data entry purpose. The data validation feature in excel was used as per the need/requirement of the data. In case of data masking, all the variables used in the questionnaire was properly labeled along with the corresponding value codes in English and entered in the Excel database. During the data entry process, strict data quality control procedures, codes and checks were undertaken. For example, a feature in data validation called data entry to a whole number within limits was used to define restrictions on what data can or should be entered in a cell. This prevented the users from entering invalid data. The data validation also allowed input messages to define what input we expect for the cell, and instructions to help data entry operators correct any errors. Also, random re-checking of data entered with the field data was carried out. • Data cleaning and reporting: In the final step, data entered in excel was converted to SPSS format and was checked for all the inconsistencies. Data cleaning was approached much like a logic problem. Two sources of detectable errors i.e. data entry errors (such as mistyping responses, entering data out of range or leaving an answer blank when a valid response was included) and enumerator errors (such as failing to accurately follow a skip pattern, writing a response that is difficult to interpret or providing false answers) were both considered while cleaning the data. The SPSS Descriptive was used to run an initial check on the data to show the minimum and maximum values for each variable in the file such that data entered out of range could be easily seen. For checking the data errors in skip patterns, a few SPSS syntax was written. For this a new variable was created and a logical statement was provided to identify cases violating the skip patterns. From here we were able to identify the case ID of each violating case and go back to the questionnaire and fix the problem. • Data analysis: As per requirements, some intervening variables were developed for cross-tabulations. The cross- tabulations were done to examine the relationship between two variables. While doing cross tabulations independent and dependent variables was identified and percentage values and observed values (frequency) was calculated for each category of the independent variable. The cross tabulations was particularly done in relationship with type of facility, development region, distance, area, where applicable. Multiple response data where the respondents can choose or provide more than one response, for such multiple response analysis was done. The multiple responses was organized in multiple dichotomy (i.e. 1=yes and 2= no). The multiple responses were defined for all questions where multiple responses were expected. Then the crosstab option was used to obtain frequencies or percentages according to number of respondents/responses. (The syntax used is: Analyze - multiple response - define variable sets. Create the sets. Then going back to the command: Analyze -multiple response - frequencies or crosstabs). The analyzed data was presented into tabular and graphical forms while drafting the report.
1.4.4. Limitation of the Survey
The research tool along with the sample designing for this survey has been revised several times such that the output/findings from the survey could be nationally representative. However, the research contains some limitations which were out of our control.
The total SDPs to be surveyed were distributed among the various and total sample size was calculated. While doing the systematic random sampling to distribute the selected facilities for each development region and ecological belt, the sample seemed to be scattered in all 75 districts of the country. Since the survey could not be conducted in all districts, due to budgetary constraints, the survey was limited to 15 districts only. Fifteen districts were selected from three ecological regions of five development region by using systematic random sampling such that they are representative of each ecological region.
All the public, private and NGO sector SDPs were then randomly selected from these 15 districts which somewhat limited the number of NGOs to be surveyed, though attempt were made to survey all the NGOs in these 15 districts.
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A total of 696 public facilities were to be distributed among 15 districts only, which resulted in collecting almost all the SDPs from various districts, due to which some of the inaccessible (not reachable within the limited time frame) SDPs were to be replaced (where possible) or excluded from the survey particularly in Manang district.
Only descriptive analysis reported at the national and sub national level is provided with no districts specific estimates are given in this report.
The client exit interviews were conducted as a regular process of program monitoring, the information from such interview are quite subjective in nature, which may not necessarily represent perception of all the clients visiting the facility as well as not reflect the actual situation of the SDP.
In most of the private and NGO sector SDPs, particularly in Marie stopes and sangini outlets lack of client exit interview were faced by field researchers. However, a total of nearly 380 clients were interviewed from about 77 private/NGO sector facilities which were considered to be rather satisfactory.
1.4.5. Outline of Report
Before venturing into the data analysis, data updating and validating was done. As per requirements, some intervening variables were developed for cross-tabulations. The preliminary findings were presented by populating the dummy tables. The quantitative techniques of data analysis were employed. The overall analysis part incorporates the following topics:
I. Availability of commodities and services • Modern contraceptives offered by facilities • Availability of Maternal and RH medicines • Incidence of ‘No Stock Out’ of modern contraceptives in the last six months • Incidence of ‘No Stock Out’ of modern contraceptives on the day of the survey • Supply chain, including cold chain • Staff training and supervision • Availability of guidelines, checklists and job aids • Use of ICT • Waste disposal • Chargers for user fees
II. Clients exit interview • Background characteristics of clients • Clients’ perception of family planning service provision • Clients’ appraisal of cost of family planning services
The reporting of the activities is done following the format and guidelines provided by UNFPA. NDRI will also support UNFPA to disseminate survey findings widely and also to promote its utilization for planning and programming by all the relevant partners.
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PART 2: NATIONAL GUIDELINES, PROTOCOLS AND LAWS
Reproductive health is a crucial part of general health and a central feature of human development. Reproductive health may not necessarily be limited to a set of illness but must be understood in the context of physical and psychosocial comfort and closeness in relationships: fulfillment and risk; desired family size and birth spacing, to avoid unwanted or unsafe pregnancy.
The government of Nepal has committed to improve the reproductive health status throughout the nation after having the signatory of International Conference on Population and Development (ICPD) 1994 and millennium development goals by 2015. All aspects of Reproductive health services i.e. promotive, preventive and curative health services are provided throughout the country under the directives of Department of Health Service (DoHS). The sub health post (SHP) is the first contact point for the basic health care and referral services. The level above SHP includes HP, PHCC, secondary and tertiary level hospitals in ascending order. Each level above SHPs is a referral point in hierarchical networks.
In Nepal, there is no specific strategy, or protocols for Provision of Modern Contraceptives and Maternal/RH Medicines. Different strategy or protocols related to reproductive health outlines the provision and dissemination of these commodities in Nepal.
There are many policies, documents, and service delivery guidelines in Nepal that are explicitly or implicitly related to reproductive health. Some of these include: • National Health Policy (1991) • National Population Policy (1991) • Second Long Term Health Plan (1997 – 2017) • Poverty Reduction Strategy Paper (PRSP: 2002-2007) • National Safe Motherhood Plan (2002 - 2017) • National Reproductive Health Strategy (2004) • Health Sector Strategy: An Agenda for Reform (2004) • Nepal Health Sector Program – Implementation Plan (2004-09) • Vulnerable Community Development Plan for Nepal Health Sector Program Implementation Plan (2004/5 – 2008/9)
National Reproductive Health Strategy National Reproductive Health Strategy is the key strategy that governs the effective and efficient provision of quality Reproductive Health services in Nepal. It provides overall policy framework for National Reproductive Health Programme in Nepal. The National RH strategy fits within the context of the 1991 health policy as well as the 1997 Second Long Term Health plan. The existing policy and plan support the national objectives of reducing infant, child and maternal morbidity and mortality. As well as contributing to a reduction in total fertility. The new Health Policy and Second Long Term Health Plan place emphasis on community involvement, increasing access through outreach, sub health posts, health post and primary health care centers, establishing functional referral mechanisms between all levels. Furthermore, due emphasis is placed on strengthening management capacity including planning, monitoring/supervision and performance review/evaluation. This strategy also provides guidelines for INGO, NGO and private sectors to develop and implement their activities. Nepal's National Reproductive Health Strategy embraces following key strategies:
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• Implement the 'Integrated Reproductive Health Package' at all level of health institutions as well at the community level based on standardized and clinical protocols and operational guidelines. • Enhance integration of Reproductive Health activities carried out by different divisions of Ministry of Health and Population and Population. • Advocacy of the concept of Reproductive Health including environment of collaboration of all sectors • Review and develop IEC materials to support all level of interventions • Review and update the existing training curricula of various health workers • Ensure effective management systems by strengthening and revitalizing existing committees at all levels • Construct/upgrade appropriate service delivery and training facilities at all levels • Institutional strengthening through structured planning, monitoring/supervision and performance review • Develop an appropriate RH program for adolescents • Support for national experts/consultants • Promote inter-sectoral and multi-sectoral coordination
RH Guideline and Protocols For effective implementation of the national Reproductive Health Strategy, Government of Nepal/ Ministry of Health and Population/ Family Health Division has developed comprehensive and integrated nationwide Reproductive Health guidelines (operational/management) and protocols (clinical/service delivery). The purpose of these guidelines and protocols are: • Strengthen and decentralize managerial capacity to implement and efficient and effective RH program at all levels. • Clearly define a standard quality of routine RH service, IEC, counseling and referral to be provided at all levels. • Guide service providers in a minimum selection of life-saving skills which will lead to a reduction in maternal and prenatal mortality.
RH operational/management guidelines provides the basis for nationwide orientation and training of all Sub-health post, health post, PHC centre, district hospitals and district health office in-charge. Accordingly, three types of RH operational/management guidelines are available in Nepali Language for three institutional levels: SHP-HP level, PHC level and District level. Before using these guidelines, thorough orientation and training is provided to all RH service providers and manager at different levels. The key issues focused by each of the RH operational/management guidelines include: reproductive health in context to Nepal, 8 RH components and their goals/ objectives, the type of reproductive health services provided at various level of health care, role/responsibility of HP/SHP level RH programme manager and co-ordination with RH related local GO/NGO/INGO. The guideline provides the provision of dissemination of short term hormonal (such as oral contraceptive pills, and injectables) and non-hormonal family planning services (such as condoms) at all levels of health facility. Norplant and IUCD are provided through District level and above health facilities. Depending upon the availability of a trained provider and commodities, PHCCs and health posts can also provide IUCD and implant services. In addition, PHCC and hospitals are also authorized to provide long acting contraceptives methods i.e minilap and vasectomy, depending upon the availability of a trained provider.
The RH clinical protocols are available in both Nepali and English languages and for various levels of health service provider/health workers such as Village Health Worker (VHW), Maternal Child Health Worker (MCHW), Auxiliary Health Worker (AHW), Auxiliary Nurse Midwife (ANM), Health Assistant (HA), Staff Nurse (SN) and Medical Officer (MO). The respective clinical protocols outlines exactly what is expected from the concerned health workers of governmental and non-governmental organizations at every level of national health care system. Protocols guided the service provider effectively and systematically on client’s assessment, treatment and referral, counseling and information giving process. The clinical protocols for MO, SN, HA, AHW and ANM cover all 8 RH components; family planning, safe motherhood, Neonatal health, STD/AIDS, adolescent reproductive health, prevention and Management of Sub-fertility, Prevention and Management of Complication of Abortion, life cycle RH issues. Whereas, the protocols for MCHW cover 5 MCHW: family planning, safe motherhood, Neonatal health, Prevention and
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Management of Complication of Abortion, life cycle RH issues. Only 4 of the eight RH components viz. family planning, Neonatal health, Prevention and Management of Complication of Abortion and life cycle RH issues are included in the clinical protocol for VHW. The clinical protocols are introduced to all service providers through nationwide orientation and training. Health workers as per their job aid should implement the protocols during the treatment process.
Reproductive Health Commodity Security (RHCS) Strategy (2007 – 2011) Reproductive Health Commodity Security (RHCS) is defined as ensuring a secure supply and choice of quality contraceptives and other RH commodities to meet every person’s needs at the right time and in the right place. As the ultimate aim or goal of RHCS is focused on meeting the clients’ needs, reproductive Health Commodity Security is believed to be achieved when people are able to reliably choose, obtain, and use the contraceptives, condoms, and other essential reproductive health supplies they want. RH Commodity Security (RHCS) is essential to meeting the target of universal access to reproductive health by 2015, as called for by the International Conference on Population and Development and the Millennium Development Goals. Thus to ensure a regular supply and choice of quality contraceptives and other RH commodities to meet every person’s needs at right time and in the right place, Reproductive Health Commodities Security (RHCS) strategy was developed. Regular supply of reproductive health commodities is crucial in order to achieve the quality services at all levels.
Objectives of National RHCS Strategy The objective of the National RHCS Strategy is to address all elements of RHCS in a holistic manner and streamlined activities to meet ICPD’s goal of universal access to reproductive health. The National RHCS Strategy has the following specific objectives relating to each element: I. Context: Promote/create favorable policy environment by cataloguing present policies and suggesting new ones II. Client Utilization and Demand: Address the unmet need of RH services and commodities and increase accessibility III. Commodities: Identify/finalize RH commodities, diversify portfolio of donors and increase GON’s commitment IV. Commitment: Improve and formalize collaborative commitments on RHCS from within public, donors and private sector V. Capital: Consolidate 5 years running budgetary requirement for RH commodities/program and ensure funding commitments from public, donors, and private sector VI. Capacity: Build capacity of stakeholders including district level for RHCS management towards achieving 6 “Rights” of logistics management VII. Coordination: Strengthen/establish formal functional coordination groups with defined roles and responsibilities
Family Health Division of DoHS is responsible for implementing RH strategies and Logistics Management Division (LMD) of DoHS is responsible for procurement, warehousing, and distribution of reproductive health commodities including supplies and equipment. Major contributing factors to quality health care delivery include supply of various commodities (medicines, instruments, equipment, furniture, and other supplies), physical infrastructure (peripheral facilities, hospitals, laboratories, etc.), and consulting services as part of capacity research and enhancement programme. In order to correct procurement related anomalies that have existed for decades in the country and delayed the development process, the Government enacted a Public Procurement Act (PPA) in 2007 that addresses procurement of commodities, works and services. Under the Ministry, commodities are procured from the LMD/DoHS, Regional Health Directorates (RHDs) and District (Public) Health Offices. Health commodities are distributed from the central store (and regional directorates) to the regional medical stores and then to the district stores which dispatch them to the service delivery points. Delays, standard/quality, capacity, transparency, pilferage, price control/economy of scale, management efficiency, interference, procurement as a specialty, preparatory work, procurement plan concurrently with budget estimation,
Page | 18 transparent practices, quality assurance, multi-year procurement, capacity development, state – non state mix are some of the major issues to address on procurement and distribution.
The Global Programme to Enhance Reproductive Health Commodity Security (GPRHCS)
The Global Programme to Enhance Reproductive Health Commodity Security (GPRHCS) is a unique and effective mechanism to deliver results in key priority countries. This UNFPA programme operates as a thematic pooled fund with a focused mission to ensure a secure, steady and reliable supply of quality reproductive health commodities and improve access and use by strengthening national health systems and services. GPRHCS supports national action to reach poor and marginalized women and girls in countries with high unmet need for family planning and high rates of maternal death. GPRHCS is the only United Nations programme that specifically addresses reproductive health commodity security (RHCS). GPRHCS procures contraceptives, medicine and equipment for family planning, HIV/STI prevention and maternal health services. Nepal is one of the 46 priority countries that are being supported by the second phase of the GPRHCS programme (2013-2020). The programme uses an enhanced Programme Monitoring Framework that tracks nearly 100 indicators to measure country progress towards RHCS. Data for measuring progress towards goals, outputs and outcomes are collected through annual country surveys of service delivery points (SDP).
Summary of Guidelines, Protocols and Laws for Provision of Maternal/RH Medicines
There is no specific strategy or protocols for provision of maternal/RH medicines in Nepal. However, the RH clinical protocols for different health workers include the instructions on maternal/RH medicines to be used for various maternal health issues. Ministry of Health and Population (MoHP) has the provision to distribute 70 types of medicines under the essential drug list to patients free of cost. Of these 70 drugs, 6 of the drugs (Amoxycilin/ Ampicillin, Azithromycin, Gentamycin, Metronidazole, Amlodipine/ Nifedipin, Compound solution of Sodium lactate and Sodium chloride) are also the life saving medicines for maternal/RH medicines Facilities listed by WHO.
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PART 3: SURVEY FINDINGS FOR AVAILABILITY OF COMMODITIES AND SERVICES
3.1. General Information about the Facilities
This chapter presents the general information of the facilities surveyed such as geographic location, management of the facility and distance of SDPs from source of supplies. A total of 763 facilities were surveyed including 394 sub health posts (majority), 238 health post, 36 primary health care centers, 15 district hospitals, 3 zonal hospitals, 39 sangini outlets, 8 private hospitals/ Pariwar Swastha Sewa Network (PSSN), 19 medical centers/polyclinics, 9 Family Planning Association of Nepal (FPAN)/Marie stopes and NGO hospitals and 2 facility run by projects/ community based hospital. In contrast, the baseline survey included only public health facilities, whereby a total of 189 facilities were surveyed including 62 sub health posts, 68 health posts, 20 primary health care centers and 39 hospitals. (Refer Table 3-1)
Table 3-1: Types of facility surveyed Types of facility Frequency Percent Sub Health Post 394 51.6 Health Post 238 31.2 Primary Health Care Centre 36 4.7 District Hospital 15 2.0 Zonal Hospital 3 0.4 Sangini outlets 39 5.1 Medical centers 13 1.7 Poly clinic 6 0.8 Private hospitals/ PSSN 8 1.0 FPAN/Marie stopes/NGO hospitals 11 1.5 Total 763 100.0
3.1.1. Geographic Distribution of Facilities
This survey covered the facilities from all the development regions as well as all the eco-regions, thus trying to create a nationally representative sample. In terms of percentage distribution, more of the sample is collected from Eastern and Central development regions and fewer from Far-west and Mid-west regions. Due to Nepal’s mountainous terrain, some areas of the country mostly Mid-Western and Far-Western regions are very remote. Thus, such remote areas tend to have fewer or inadequate reproductive health care facilities with fewer supplies.
This survey covered the facility of all the development regions. In terms of percentage distribution, nearly equal proportion of the sample facility was taken from Eastern, Central and Western development regions and fewer sample facilities were taken from Mid-Western and Far-Western region. (Refer Table 3-2)
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Table 3-2: Distribution of the SDP according to development regions Development region Frequency Percent Eastern Development Region 196 25.7 Central Development Region 197 25.8 Western Development Region 135 17.7 Mid-Western Development Region 110 14.4 Far-Western Development Region 125 16.4 Total 763 100.0
The facilities within each district were selected from both the urban and rural regions. The urban rural categorisation was done as per classification of the country where all the municipalities are considered as urban and village development committees (VDC) fall under rural category. Since more than 80% of the population in Nepal resides in rural areas of Nepal the sampling was also designed to represent majority of facilities in the rural areas. Therefore, this survey covers 84% of the facility in the rural areas and only 16% of the facility in the urban area. A comparative trend was also followed in baseline where 78% of the facilities were in the rural areas and only 21.2 % of the facilities were in the urban area. (Refer Table 3-3)
Table 3-3: Distribution of the SDP according to area Area of Service Delivery Point (As per classified by Nepal) Frequency Percent Urban 119 15.6 Rural 644 84.4 Total 763 100.0
3.1.2. Management of Facilities
Majority of the facilities surveyed under this study are government managed facility. However some of the private managed facilities providing reproductive health facilities such as sangini outlets, private hospitals/Pariwar Swastha Sewa Network (PSSN), and medical centers/polyclinics are also included in the study. Besides few NGOs such as FPAN, Marie stopes and NGO hospitals are also included. In contrast, all the facilities surveyed in baseline were managed by government and private/NGOs health facility providing reproductive health facilities were excluded. (Refer Table 3-4) Table 3-4: Distribution of the SDP according to management Management of the facilities Frequency Percent Government 686 89.9 Private 66 8.7 NGO 11 1.4 Total 763 100.0
3.1.3. Distance of SDPs from Source of Supplies
This study also explores the distance between the location of the health facility and the nearest warehouse where healthcare supplies are stored and from which the SDP receives its regular supplies. The distance of SDPs from the nearest warehouse/ source of supplies was classified into six major categories as shown in Table 3-5. More of the SDPs (65%) were found to be within a distance of 20 kilometres from their source of supplies, which was similar to baseline survey. The distance of SDPs was further classified according to eco-region i.e. Mountain, Hill and Terai.
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More of the facilities in the Terai (70%) were found in the distance of less than 20 kms compared to the Hills (56%) and Mountains (49.5%). This in a way interprets that most of the facilities in Terai are accessible than other eco- regions, because in Terai regions comparatively less difficult geographic condition makes these areas more accessible. Although the baseline reveals a slight contrary result, where more of the facilities in the hills (69%) and mountains (63%) are found in the distance of less than 20 kms compared to the Terai (57%). Nevertheless, this does not interpret that most of the facilities in the hills and mountains are accessible than in Terai, because in hills and mountains mostly due to the difficult geographic condition, makes these areas highly inaccessible. The contradiction of the result is justified by the fact that the health facilities selected in both the survey are different and thus have different location. (Refer Table 3-5)
Table 3-5: Distribution of the SDP according to distance from nearest warehouse/source of supplies Distance from nearest warehouse/source of supplies (in Km) Eco-region Total <10 10-20 21-30 31- 40 41-50 >51 N 41 56 33 5 8 53 196 Mountain % 20.9% 28.6% 16.8% 2.6% 4.1% 27.0% 100.0% N 66 77 46 24 9 31 253 Hills % 26.1% 30.4% 18.2% 9.5% 3.6% 12.3% 100.0% N 131 90 41 20 14 18 314 Terai % 41.7% 28.7% 13.1% 6.4% 4.5% 5.7% 100.0% N 238 223 120 49 31 102 763 Total % 31.2% 29.2% 15.7% 6.4% 4.1% 13.4% 100.0%
3.2. Modern Contraceptives Offered by Facilities
In Nepal, FP services are available through government, social marketing, private health facilities, non-govermental organisations and are available free of cost in public health facilities. The survey results showed that almost all the facilities surveyed provided the family planning services. In this section the situation of modern contraceptives i.e. male condoms, female condoms, oral contraceptive pills, injectables, intrauterine contraceptive devices (IUCD), implants, minilap, vasectomy and emergency contraceptives services offered by the facilities is illustrated in detail.
3.2.1. Contraceptives Offered by Types of Facilities
In Nepal, the temporary FP methods such as (male condoms, pills, and injectables) are made available by almost all the public managed facilities. The government guidelines suggest that at least three temporary contraception methods, are supposed to be available at all types of health facilities.
Our result showed that mostly all the facilities in the government, private and NGO sector provided male condoms, oral pills and injectables. However, methods such as IUCDs and Implants were typically provided by government hospitals, PHCCs, Private hospitals and NGO sector facilities. Sterilization services such as Minilap and Vasectomy were limited to some of the government hospitals, private hospitals and NGO sector facilities. In few PHCCs and health posts the sterilization services were provided but through scheduled seasonal or mobile outreach services.
The use of Emergency Contraception (EC) has been rapidly increasing in Nepal (Shrestha et al., 2010), however there is no system in place within the government's health information system to collect data about the use of EC. Similarly, the use of female condoms (FC) has not been so prevalent in Nepal. FC experience in Nepal is limited to small pilot research/acceptability studies with specific population groups through NGOs and others (Usmani, 2002). Additionally, the national RH strategy and guideline has no provision of Emergency Contraception (EC) and female condom for public health facilities. However, both EC and female condom has also been included as part of the modern contraceptive method in this survey in order to collect data from private/NGO managed health facilities. Our survey result showed that majority of the private and NGO sector facilities provided EC service in a very regular basis compared to the government facilities where the availability were mostly limited to hospitals only. Similarly, the
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survey result showed that only few FPAN/Marie stopes were able to provide the female condoms in a regular basis, however no government facilities made available such services.
From the results , we can to some extent assume that the most offered contraception methods by any SDP or the most popular contraception methods were short term hormonal (such as oral contraceptive pills, and injectables) and non- hormonal family planning services (such as male condoms). However, the least popular ones were the permanent method (minilap and vasectomy) and female condoms. Also the high availability of EC in all kinds of government private and NGO hospitals showed a possibility that individuals may opt to use EC to prevent pregnancies rather than using other certain contraception methods.
Table 3-6: Modern Contraceptive Method offered by Type of Facility Modern contraceptive method offered at the regular basis(percentage) Total
SDPs providing
Type of Facility
Family
Planning Services Male Condoms Female Condoms Oral Pills Injectables (Depo) IUDs/Copper T Implants (Zdal) Sterilization for Females (Minilap) Sterilization for Males (Vasectomy) Emergency Contraceptives Sub Health Post 99.2 0.0 99.7 99.5 3.8 4.6 0.0 0.0 11.7 394 Health Post 99.2 0.0 99.2 99.2 24.4 25.2 0.0 0.0 23.5 238 Primary Health 97.2 0.0 97.2 100.0 80.6 69.4 0.0 0.0 38.9 36 Care Centre Government 100.0 0.0 100.0 100.0 94.4 88.9 38.9 66.7 72.2 18 Hospital Sangini outlet 100.0 0.0 95.00 97.4 7.7 2.6 0.0 0.0 69.2 39 Medical center/ 100.0 0.0 89.5 73.7 10.5 0.0 0.0 0.0 68.4 19 Poly clinic Private hospital 100.0 0.0 100.0 100.0 50.0 50.0 16.7 33.3 100.0 6 FPAN/Marie stopes/NGO 100.0 27.3 100.0 90.9 72.7 81.8 9.1 9.1 81.8 11 hospital Total 99.2 0.5 98.9 98.6 17.7 17.3 1.2 2.0 24. 2 761
3.2.2. Primary Facilities offering at least Three Types of Contraceptives
The primary SDPs providing at least three types of contraceptives and secondary and tertiary SDPs providing at least five modern contraceptives in a particular geographic area is one of the crucial indicators for GPRHCS study. The proper demarcation of primary, secondary and tertiary SDPs seemed feasible for only government managed facility in Nepal hence for this indicator only government managed facilities are taken into consideration, however findings for other facilities are placed separately as shown in Table 3-7 below.
The government guidelines indicate that short term hormonal (such as oral contraceptive pills, and injectables) and non-hormonal family planning services (such as condoms) should be available at all levels of health facility. The result showed that almost all the primary level care SDPs i.e. SHP, HP and PHCC offered at least three modern contraceptives; however the baseline data of 2013/14 showed 100% availability of at least three modern contraceptive methods at the primary level SDPs.
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Table 3-7: Primary Facilities offering at least Three Types of Contraceptives Percentage Type of Facility Offering at least three modern contraceptive Total methods Primary Level Care SDPs (SHP, HP and PHCC- Public facilities) 98.8 668 Sangini outlets 95.0 39 FPAN/Marie stopes 100.0 8
Further, sangini outlets and FPAN/Marie stopes are also considered under the primary level care category. The availability of at least three types of contraceptives was also analyzed for sangini outlets and FPAN/Marie stopes. The data showed that all the FPAN/Marie stopes surveyed and majority of sangini outlets i.e. 95% offered at least three contraceptives.
The SDPs offering at least three contraception methods were further analyzed in terms of development region, residence, management and distance from nearest warehouse/source of supplies. The results showed that SDPs offering at least three modern contraceptives were almost equally distributed in all regions as well as in urban and rural setting. Also, no significant percentage difference was observed in government, private and NGO sector as well as in SDPs categorized according to distance from nearest warehouse/source of supplies. This can be interpreted as region, residence, management and distance did not make any difference at least three contraceptive methods being offered by the SDPs. (Refer Table 3-8 to Table 3-11) Table 3-8: Primary Facilities offering at least Three Types of Contraceptives by development region Percentage of Primary SDP Total facility
Administrative Unit (Region) Offering at least three modern contraceptive providing FP services methods (N) Eastern Development Region 97.8% 185 Central Development Region 99.5% 186 Western Development Region 98.4% 125 Mid-Western Development Region 97.0% 101 Far-Western Development Region 99.2% 118 Total 98.5% 715
Table 3-9: Primary Facilities offering at least Three Types of Contraceptives by residence Percentage of Primary SDP Total facility Residence Offering at least three modern contraceptive methods providing FP services (N) Urban 98.9% 88 Rural 98.4% 627 Total 98.5% 715
Table 3-10: Primary Facilities offering at least Three Types of Contraceptives by management Percentage of Primary SDP Total facility Management Offering at least three modern contraceptive methods providing FP services (N) Government 98.8% 668 Private 95.5% 39 NGO 100.0% 8 Total 98.5% 715
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Table 3-11: Primary Facilities offering at least Three Types of Contraceptives by distance Distance from nearest Percentage of primary SDP Total facility warehouse/source of Offering at least three modern contraceptive providing FP supplies (in Km) methods services (N) <10 99.5% 218 10-20 98.2% 221 21-30 98.3% 120 31-40 95.8% 48 41-50 100.0% 30 >50 97.4% 78 Total 98.5% 715
3.2.3. Secondary and Tertiary Facilities offering at least Five Types of Contraceptives
In this study, the availability of at least five types of contraceptives at district hospitals and zonal hospitals along with medical centres/ polyclinics facilities, private and NGO hospitals was also analyzed. The revised logical framework indicator for family planning in NHSP IP II reflects that the five forms of modern contraception i.e. condoms, oral contraceptive pills, injectables, intrauterine contraceptive devices (IUCD) and implants should be available at least at health posts level (FHD, 2007).
The result showed that all the tertiary level care government hospitals and majority of secondary level care government hospitals (86.7%) offer at least five modern contraceptives. The baseline data for 2013 showed that 100% of secondary and tertiary level government hospitals offered the five modern contraceptives. Further, almost all (94.7%) of the medical centres/polyclinics, half of the private hospitals and one third of NGO hospitals offered at least five contraceptives.
Only, 35 % of primary SDPs offered atleast five modern contraceptive methods which were almost equally distributed in all development regions and most of them were from urban areas. Also, if we compare the findings of this study with STS data (2012) on the percentage of health posts that provide all five methods of FP we can find improvement in this; an increase from 8% (reported in STS 2012) to 20% (reported in this survey). Similarly, the percentage of HPs with at least five FP methods is an important indicator in M&E Framework of NHSP II (Output (OP) 4.9). In accordance to this framework the target for 2013 is 35% and 2015 is 60%. Although the target for 2013 i.e. 35% of the HP should be providing at least five modern contraception method has not been met but nevertheless the progress can be considered satisfactory.
In addition, in terms of development regions, SDPs offering at least five modern contraceptives were almost equally distributed among central, western and mid-western regions with highest percentage of SDPs being in the central and western region and lowest in eastern and far western region (Table 3-13). Baseline 2013/14 reported that SDPs offering at least five modern contraceptives were almost equally distributed in all regions with highest percentage of SDPs being in the Far western region and lowest in mid western region. Compared to only 35% in rural areas, 52% of SDPs in urban areas offer five methods of modern contraception. Baseline 2013/14 report shows that 23% of SDPs in rural areas and 83% of SDPs in urban areas offer five methods of modern contraception. Also, the result showed that government facility seemed to better (89%) equipped to provide at least five contraception methods compared to NGOs and private sector facilities. Majority of the secondary and tertiary SDPs were confined either within the distance of less than10 kms or more than 50 kms from their source of supply. Table 3-16 below shows that more of the SDPs within 10 kms provided at least five contraceptives compared to more than 50 kms away.
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Table 3-12: Secondary and Tertiary Facilities offering at least Five types of Contraceptives Percentage of secondary and tertiary SDP Total facility Type of Facility Percentage of secondary and tertiary SDP Offering at providing FP
least five modern contraceptive methods services (N) Secondary Level Care SDPs (District Hospitals ) 86.7% 15 Tertiary Level Care SDPs (Zonal Hospitals ) 100.0% 3 Medical centers/ Polyclinics 94.7% 19 Private hospitals 50.0% 6 NGO hospitals 33.3% 3
Table 3-13: Secondary and Tertiary Facilities offering at least Five types of Contraceptives by region Percentage of secondary and tertiary SDP Total facility Administrative Unit (Region) Offering at least five modern contraceptive providing FP services methods (N) Eastern Development Region 27.3% 11 Central Development Region 60.0% 10 Western Development Region 60.0% 10 Mid-Western Development Region 50.0% 8 Far-Western Development Region 28.6% 7 Total 45.7% 46
Table 3-14: Secondary and Tertiary Facilities offering at least Five types of Contraceptives by residence Percentage of secondary and tertiary SDP Total facility
Offering at least five providing FP Residence modern contraceptive methods services (N) Urban 51.7% 29 Rural 35.3% 17 Total 45.7% 46
Table 3-15: Secondary and Tertiary Facilities offering at least Five types of Contraceptives by management Percentage of secondary and tertiary SDP Management of facility Offering at least five modern Total contraceptive methods Government 88.9% 18 Private 19.2% 26 NGO 33.3% 3 Total 45.7% 46
Table 3-16: Secondary and Tertiary Facilities offering at least Five types of Contraceptives by distance Percentage of secondary and tertiary Distance from nearest SDP Total facility warehouse/source of Offering at least five providing FP services (N) supplies (in Km) modern contraceptive methods <10 57.9% 19 10-20 0.0% 2 31-40 100.0% 1 41-50 0.0% 1 >50 39.1% 23 Total 45.7% 46
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3.2.4. Reasons for Not Offering Certain Contraceptives
As mentioned in Table 3-6, all the contraception methods are not made available to the clients in the regular basis. The analysis showed that three (oral pills, male condoms and injectables )out of the nine modern contraceptives were being offered to clients at almost all of the SDPs but the percentage proportion for the rest of the contraceptive methods was generally less than 25 percent.
The reasons for not offering the contraception methods was only recorded for those SDPs which are supposed or expected to offer certain contraception in line with the current national protocols, guidelines or laws and are not able to offer those contraception methods in a regular basis. The reasons based on the verbal response as reported by the respondents (Auxiliary health workers (AHW), Medical officer/superintendent, health facility in charge) are provided in the Table 3-17.
The main reason for not providing IUDs, Implants and other permanent contraception methods was predominately (more than 85%) due to lack of trained staffs in those SDPs to provide the services. Some of the respondents also stated that though SDPs had their staffs trained; they were not capable enough (experienced) to provide the services (particularly in case of IUCD). Further, in few of SDPs lack of equipments was also recorded to be the reason for not providing the permanent contraception methods. The baseline survey in 2013 also reported the lack of trained staffs as the chief reason for non-service, yet reasons such as low client demand and lack of equipments were also noteworthy particularly in case of IUCDs and permanent methods.
Emergency contraception is emerging as the most potential method to avoid unintended pregnancies, still only some of the SDPs offer such services. The major reasons for not offering such services as reported by the respondents were low demand at the SDP, delays or no supply by the main source to resupply and lack of trained staff to provide such services. Table 3-17: Reasons for not offering certain contraceptives Reasons for not offering certain contraceptives Delays on Delays Contraceptives No the part of by this is not train Modern main source Low or no Any SDP to available in staff to No Contraceptives institution/ demand/need other Total request the market for provide supply ware house at this SDP Reason* for the SDP to this at to re-supply supply procure the SDP this SDP Male condoms 16.7 66.7 0.0 0.0 0.0 0.0 16.7 6 Oral contraception 0.0 0.0 0.0 100.0 0.0 0.0 0.0 2 (Pills) Injectables (Depo) 50.0 0.0 0.0 25.0 25.0 0.0 0.0 4 IUCDs/Copper T 4.5 0.0 0.0 2.2 85.5 3.0 3.7 134 Implants (Zdal) 4.5 0.0 0.0 2.3 85.8 3.0 4.5 133 Sterilization for 0.0 0.0 0.0 0.0 85.0 2.5 12.5 40 female (Minilap) Sterilization for 0.0 0.0 0.0 2.9 82.9 2.9 11.4 35 male (Vasectomy) Emergency 28.2 4.2 2.8 29.6 15.5 15.5 4.2 71 Contraceptives Total 8.2 1.6 0.5 7.3 71.5 3.1 7.8 425 Note: Since there are less than 1% of the facilities providing female condoms restricted to only FPAN/ Maries stopes, reasons for not providing the service has been not shown in the table, though most prevalent reasons stated by those not providing were due to no supply/lack of supply. *Others include: Staff trained but not experienced enough to provide the service (IUCD) , minilap and vasectomy services provided only during camps, lack of equipments, etc
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3.3. Availability of Maternal and RH Medicines
The availability of Maternal and RH medicines are ensured throughout the country under the directives of DoHS, which has the responsibility of delivering preventive and curative health services including promotional activities. Maternal and RH medicines including the essential medicines ensure healthy pregnancy and delivery outcomes, as well as prevention and treatment of STIs and HIV/ AIDS. Though a visible decline of maternal mortality over the last three decades have been observed in Nepal still the number remains to be high largely due to lack of availability of certain medicines such as oxytocin (Poudyal, et al., 2014). Also, since the poor maternal and reproductive health constitutes a considerable proportion of the disease burden in developing country such as Nepal, essential medicines for maternal and RH are not available to the majority of the population (Logez, et.al, 2013). Thus, it is essential to analyze the availability of maternal and RH medicines in all level SDPs in Nepal.
According to Free Health Care Policy (FHCP), Ministry of Health and Population (MOHP) provides 25 essential drugs from SHPs, 35 essential drugs from HPs and PHCCs, and 40 essential drugs from up to 25 bedded hospitals to clients, free of cost. This chapter explores the availability of seventeen priority life-saving maternal and RH medicines (from the WHO list) excluding hydrazine in all levels of health facility which provide maternal health services including delivery services (e.g. with a maternity unit or section for delivery) in the country and also discuses on the reasons as why the certain essential medicines are offered by the facilities.
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3.3.1. Maternal and RH Medicines Available by Types of facilities
In this survey, the availability of seventeen maternal and RH medicines life saving drugs excluding hydrazine was assessed by type of facility. Among seven essential drugs five drugs (Ampicillin, Gentamycin, Metronidazole, Magnesium sulphate and Oxytocin) are supposed to be available in all level of government health facilities according to the Free Health Care Policy (FHCP). This survey showed that almost all the drugs mentioned were available in almost all level of facilities expect for Ampicillin. Ampicillin was available at only 25% of the overall surveyed facilities. This percentage has slightly increased from baseline 2013 where Ampicillin was available at only 23% of the overall surveyed facilities. Drugs such as Azithromycin, Cefixime, Methyldopa, and Benzathine benzyl penicillin were scarcely available compared to the other drugs and their availability was mostly limited to hospitals in case of public facilities. The result is similar to baseline survey 2013/14.
Table 3-18: Percentage distribution of service delivery points with any Maternal/RH Medicine available Maternal/RH Medicines (currently available) (%)
Total
SDPs
providing
Maternal (1) (2) (3) (4) (5) (6) (7) (9) Or Or
Characteristics (10) (11) (12) (13) (14) (15) (16) (17) Either Either health Cefixime Oxytocin Ampicillin* Nifedipine Benzathine Benzathine Gentamicin Methyldopa Mifepristone Azithromycin services Misoprostol** Tetanus toxoid Tetanus Metronidazole Sodium lactate Betamethasone Betamethasone benzylpenicillin Sodium chloride Dexamethasone Calcium gluconate Calcium solution compound Magnesium sulfate Magnesium Type of Facility Sub Health Post 17.3 4.5 2.7 18.5 5.8 2.1 80.3 58.5 1.2 98.8 3.9 14.8 2.4 74.8 81.2 50.6 330 Health Post 19.9 9.5 3.6 42.5 15.8 3.6 89.1 77.4 5.9 97.7 19.9 24.4 11.8 87.8 87.8 71.0 221 Primary Health 42.9 14.3 0.0 62.9 42.9 22.9 94.3 94.3 8.6 97.1 40.0 42.9 31.4 97.1 85.7 88.6 35 Care Center Government 88.9 61.1 55.6 88.9 72.2 72.2 94.4 83.3 50.0 94.4 61.1 50.0 66.7 94.4 94.4 100.0 18 Hospital Sangini outlet 68.8 87.5 18.8 87.5 62.5 81.3 87.5 56.3 43.8 100.0 25.0 25.0 18.8 37.5 75.0 75.0 16 Medical centers/ 72.7 90.9 27.3 81.8 45.5 90.9 81.8 45.5 27.3 100.0 27.3 9.1 45.5 36.4 81.8 72.7 11 Polycinics Private Hospitals/ 100. 100. 85.7 100.0 57.1 100.0 85.7 85.7 71.4 100.0 57.1 57.1 42.9 100.0 100.0 100.0 7 PSSN 0 0 FPAN/ Marie Stopes/ 60.0 60.0 20.0 60.0 80.0 80.0 60.0 20.0 0.0 80.0 80.0 40.0 40.0 80.0 60.0 100.0 5 NGO hospitals Total 24.9 13.4 5.9 35.1 16.6 10.9 85.2 67.7 6.8 98.1 15.1 21.5 10.9 79.9 84.0 63.0 643 Note: *For Kapilvastu district stock of Amoxycillin was observed in place of Ampicillin ** Out of total 15 surveyed districts, Misoprostol is implemented in only 9districts according to the data provided by FHD. Thus, the estimation of availability of Misoprostol is done for only these 9 districts.
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The drugs such as Magnesium sulphate and Oxytocin are considered as mandatory drugs in maternal/RH medicines. Post partum haemorrhage is the leading cause of maternal deaths in Nepal (Poudyal, et al., 2014). Oxytocin is one of the emergency drugs, which prevents and manages post partum haemeorrhage, listed in essential drug list, and supplied to hospitals and Primary Health Care centers in Nepal. The survey result showed that in almost all the government hospitals, PHCCs, HPs and majority of SHPs Oxytocin was made available. Similar findings were reported by baseline survey 2013. Apart from government sector, the availability of Oxytocin was most prevalent in private hospitals and in almost all NGO sector facilities.
Similarly, timely referral and optimal management of cases of eclampsia with magnesium sulphate in hospitals are key issues to prevent mortality/ morbidity associated with it (Thapa and Jha, 2008). The findings showed that the availability of Magnesium Sulphate is prevalent in almost all of HPs, PHCCs, government hospitals and majority of SHPs. Compared to baseline 2013, the availability of Magnesium sulphate has decreased in PHCC (100% in 2013 to 94.3% in 2014) and government Hospitals (100% in 2013 to 83.3% in 2014) and increased in SHP (42.9% in 2013 to 58.5% in 2014), HP (70.2% in 2013 to 77.4% in 2014). Also, the prevalence of MgSO4 drugs was observed higher in private hospitals.
Nepal first piloted distribution of misoprostol tablets in Banke district under the leadership of Family Health Division (FHD) and District Public Health Office (DPHO) Banke, for increasing uterotonic coverage after birth, for deliveries that take place at home without skilled birth attendants and where injectable oxytocin is not available (NFHP II, 2010). Currently, Misoprostol programme has already been implemented in 41 districts of Nepal as reported by Family health division (FHD) (list of districts was provided by FHD). For the estimation of availability of Misoprostol in this study, the districts where the programs are implemented are only considered. Out of total 15 surveyed districts, the program was implemented in almost nine surveyed districts. In case of government facilities, misoprostol was available mostly in hospitals (almost half of the hospitals) and PHCCs (43%). Comparing to the baseline data of 2013/14, the availability of misoprostol in all levels of government facilities have increased. In overall compared to 18% of the government facilities providing misoprostol in 2013/14, the figure has increased to about 22% in 2014/15 survey.
Also, Tetanus toxiod, which is used as the prevention against most common lethal causes for newborn mortality, was observed to be available at almost all the government hospitals and PHCCs, more than 65% of HPs and nearly half of the SHPs. This figure has not remarkably changed for any of the government facilities compared to the baseline 2013/14 survey.
3.3.2. Availability of Seven Essential Life-Saving Maternal and RH Medicines
The availability of seven essential life saving maternal and RH medicines was an important element of this study. The availability of these seven life saving drugs with two essential drugs were assessed through stock verification of all seventeen drugs during the field survey. The list of seven life saving drugs included two mandatory medicines (Magnesium sulphate and Oxytocin) and any other five of the remaining medicines among the seventeen drugs available in each SDP surveyed, however, the drugs such as sodium chloride and sodium lactate compound solution was considered alternative and Dexamethasone was considered alternate to Betamethasone.
The availability of seven essential life saving maternal and RH medicines (including two essential drugs) was analysed in all levels of health facilities. The results showed that in overall government facilities only about 41% of the SDPs met the criteria (Table 3-20) which is comparatively lower than the figure calculated in 2013/14 survey (i.e. 60%). The figures have relatively dropped for all the government facilities except for SHPs where the SDPs having seven essential drugs increased from 14.3% in 2013/14 to 24.5% in 2014/15 survey. Also, majority of private hospitals, half of medical centers/polyclinics, about 44% of the sangini outlets and merely 20% of the NGOs facilities made available seven essential drugs.
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The availability of seven life-saving maternal or reproductive health medicines was also analyzed by development region, rural and urban area and management of the facility and distance from the nearest warehouse. In terms of development region, the SDPs meeting the criteria of having seven life saving drugs were mostly concentrated in Mid- Western (72%) and Far-Western Regions (55%). The difference in availability is quite low in SDPs residing in urban and rural settings as almost half of the SDPs in the urban areas and 40% of the SDPs in rural areas had seven life saving drugs made available. This might be due to unavailability of drugs in NGO and private sector SDPs where most of the SDPs (nearly 60%) are resided in urban settings compared to only 10% of government facilities in urban areas. The result is much lower compared to baseline survey 2013, where 91.4% of the SDPs in the urban areas and 51.3 % of the SDPs in rural area had seven life saving drugs. More of the SDPs in private sectors made available seven essential drugs compared to government and NGO sector facilities.
In terms of distance from nearest source of supplies, the SDPs having the life saving drugs are almost evenly distributed with the least percentage of SDPs within 10 kms and majority SDPs concentrated within 31-40 kms made available the seven essential drugs (Table 3-24). This data showed that the distance of the SDPs from their source of supplies had no relevance or influence in SDPs offering the life saving maternal/reproductive health medicines.
Table 3-19: Percentage distribution of SDPs with seven (including 2 essential)life-saving maternal/reproductive health medicines available by type of facility Percentage Total facility
Seven (including 2 essential) life- providing maternal health Type of Facility saving maternal/reproductive health medicines available services (N) Sub Health Post 24.5% 330 Health Post 53.8% 221 Primary Health Care Center 85.7% 35 Government Hospital 94.4% 18 Sangini outlet 43.8% 16 Medical centers/ Polycinics 54.5% 11 Private Hospitals/ PSSN 85.7% 7 FPAN/Marie Stopes/ 20.0% 5 NGO hospitals Total 41.5% 643
Table 3-20: Percentage distribution of SDPs with seven (including 2 essential) life-saving maternal/reproductive health medicines available by Type of government facilities Percentage Total facility Seven (including 2 essential) life- providing maternal Type of Facility saving maternal/reproductive health health services (N) medicines available Primary (SHP, HP and PHCC) 39.2% 586 Secondary (District Hospital) 93.3% 15 Tertiary (Zonal Hospital) 100.0% 3 Total 40.9% 604
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Table 3-21: Percentage distribution of SDPs with seven (including 2 essential) life-saving maternal/reproductive health medicines available by development region Percentage Total facility
Seven (including 2 essential) life- providing maternal Administrative Unit (Region) saving maternal/reproductive health services (N) health medicines available Eastern Development Region 38.5% 161 Central Development Region 35.4% 178 Western Development Region 25.8% 132 Mid-Western Development 72.2% 79 Region Far-Western Development 54.8% 93 Region Total 41.5% 643
Table 3-22: Percentage distribution of SDPs with seven (including 2 essential) life-saving maternal/reproductive health medicines available by residence Percentage Total facility Seven (including 2 essential) life- Residence providing maternal saving maternal/reproductive health health services (N) medicines available Urban 51.1% 88 Rural 40.0% 555 Total 41.5% 643
Table 3-23: Percentage distribution of SDPs with seven (including 2 essential) life-saving maternal/reproductive health medicines available by residence Percentage
Management of facility Seven (including 2 essential) life-saving Total maternal/reproductive health medicines available Government 40.9% 604 Private 55.9% 34 NGO 20.0% 5 Total 41.5% 643
Table 3-24: Percentage distribution of SDPs with seven (including 2 essential)life-saving maternal/reproductive health medicines available by distance Percentage Distance from nearest Seven (including 2 essential) Total facility warehouse/source of life-saving Providing maternal supplies (in Km) maternal/reproductive health health services (N) medicines available <10 31.2% 202 10-20 40.4% 198 21-30 47.6% 105 31-40 60.0% 45 41-50 50.0% 28 >50 50.8% 65 Total 41.5% 643
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3.3.3. Reasons for Not Offering Certain Life Saving Maternal and RH Medicines
As shown in Table 3-18 and Table 3-19, not all the facilities have made available all the life saving maternal and RH medicines, there are various reasons stated (as shown in Table 3-25). The reasons for not offering life saving medicines are only recorded for those SDPs which are supposed or expected to offer certain medicines in line with the current national protocols, guidelines or laws but are not able to offer those contraception methods in a regular basis.
The two main reasons, as reported by the respondents (Auxiliary health workers (AHW), Medical officer/superintendent, health facility in charge) for SDPs not being able to provide certain life-saving maternal and reproductive health medicines were (a) Delays on the part of the district store /warehouse to re-supply this SDP and (b) No supply from the government. In addition to delays on the part of the district store /warehouse to re-supply, the baseline report 2013/14 also identified lack of commodity from district store and low or no demand for the medicine at the SDP as the reasons for not being able to provide certain life-saving maternal and reproductive health medicines.
In case of misoprostol along with above mentioned reasons, poor quality issues were also reported due to which the medicine was returned. Further, in case of tetanus toxoid most prominent reason for the unavailability as reported was that it was only provided by the SDPs during immunization/ vaccination camps and few SDPs could not make the drug available due to the lack of cold chain.
For medicines such as magnesium sulphate, oxytocin and gentamicin along with delays in the main source, low or no demand/need for the medicine at the SDP was also noted as the main reason for unavailability of the drugs. The disposal of drugs due to date expiry issues was also reported particularly for magnesium sulphate. For Nifedipine drug, the delays by the SDP itself to request for supply of the medicine was also considered as one of the important reasons for the unavailability of drug.
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Table 3-25: Reasons for not offering certain life saving maternal and RH medicines
Reasons for not offering certain life saving maternal and RH medicines Medicine is No train Delays by Low or no SDP does Delays on the part of not staff to this SDP to demand/ not have main source available provide No supply Maternal and RH Medicines request need for a cold Any other institution/warehouse to in the this (from Total for supply the chain to Reason** re-supply this SDP with market for medicine government)* of the medicine store the this medicine the SDP to at the medicine at this SDP medicine procure SDP Ampicillin 44.4 18.5 2.5 2.5 3.7 0.0 28.4 0.0 81 Azithromycin 59.3 8.6 2.5 2.5 1.2 0.0 24.7 1.2 81 Benzathine benzyl penicillin 32.1 28.2 3.8 6.4 3.8 0.0 24.4 1.3 78 Betamethasone or 60.5 4.7 2.3 2.3 3.5 0.0 25.6 1.2 86 Dexamethasone or both Calcium gluconate 50.6 5.1 3.8 8.9 7.6 0.0 21.5 2.5 79 Cefixime 50.7 4.3 10.1 5.8 0.0 0.0 26.1 2.9 69 Gentamicin 54.1 8.2 0.0 18.0 0.0 0.0 19.7 0.0 61 Magnesium sulfate 50.0 7.1 0.0 31.3 2.7 0.0 6.3 2.7 112 Methyldopa 55.8 5.8 5.8 11.5 0.0 0.0 21.2 0.0 52 Metronidazole 100.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 3 Mifepristone 41.1 2.7 13.7 0.0 11.0 0.0 23.3 8.2 73 Misoprostol 39.5 2.6 0.0 1.3 6.6 0.0 35.5 14.5 76 Nifedipine 40.0 21.7 0.0 13.3 3.3 0.0 20.0 1.7 60 Oxytocin 51.9 3.7 0.0 27.8 5.6 0.0 7.4 3.7 54 Sodium lactate compound solution or Sodium chloride or 50.0 7.4 3.7 11.1 9.3 0.0 18.5 0.0 54 both Tetanus toxoid 10.4 0.0 0.0 0.0 0.0 16.2 1.4 72.1 222 Total 41.8 7.6 2.7 8.4 3.4 2.9 17.9 15.3 1241 * Others include: provided only during immunization/ vaccination camps (for tetanus toxoid); due to some quality issues medicine was returned (misoprostol and mifepristone), disposed due to date expiry issues (mgso4)
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3.4. Incidence of ‘No Stock Out’ of Modern Contraceptives
This chapter provides the information on the incidence of ‘no stock out’ of modern contraceptives in each type of facility. In this survey ‘no stock out’ indicates a situation in which a SDP providing family planning services does not run out of supplies of any one or more of the modern methods of contraceptives at any point in time over the last 6 months preceding the survey and hence was available to clients at all times (UNFPA, 2011). The incidence of ‘no stock out’ during six months of the survey as well as at the time of the survey was observed in this survey which is an important index of determining Reproductive Health Commodity Security in any country.
The stock out situation is assured if any SDP have stock out of one of the six ( male condoms, oral contraception, Injectables, IUCDs, implants and emergency contraceptives) ; the SDP is considered as stock out. The stock out situation of female condoms is neglected from the study as very few, less than one percent of the facilities were able to provide the contraceptive in a very regular basis only limited to FPAN/ Maries stopes. This is because the national protocols, guidelines or laws have no provision for female condoms in government SDPs. Further, the stock out situation of each contraceptive method (as listed above) is provided. Consequently, the reasons why the stock outs occurred for certain contraceptives are also provided.
3.4.1. ‘No Stock Out’ at the Time of Survey
The Table 3-26 below shows that in overall, the SDPs having stock out of any of the modern contraceptives during the time of survey is low (i.e. nearly 87% of the SDPs were in no stock out condition). The percentage of no stock out has slightly increased compared to baseline survey 2013 which reported more than 85% of the SDPs to be in no stock out condition The most suffered from stock out at the time of survey were the PHCCs and zonal hospitals where about 25% and 33% of the SDPs respectively experienced stock out of any of the six contraception methods. (Refer Table 3-26 and 3-27). The baseline survey carried out in 2013/14, the stock out was estimated for only five modern contraceptives i.e. (male condoms, oral contraception, Injectables, IUCDs, and implants). In the baseline survey, the most stock outs at the time of survey were observed for health posts (22%).
In terms of private sector facilities, most stocks outs were observed for private hospitals i.e. about 33% of the private hospitals suffered stock outs of any of the seven contraceptives at the time of the survey. For NGO sector SDPs nearly 25% had stock outs at the time of the survey.
Table 3-26: No stock out at the time of survey by the type of facility Modern contraceptive method Total SDPs providing Family Type of Facility in stock at the time of the Planning Services (N) survey[‘no stock out’] Sub Health Post 92.1% 394 Health Post 84.9% 238 Primary Health Care Center 75.0% 36 Government Hospital 83.3% 18 Private Hospitals/PSSN 66.7% 6 Sangini outlet 75.0% 39 Medical Centers/ Poly clinics 73.7% 19 FPAN/Marie Stopes/NGO 72.7% 11 hospitals Total 87.0% 761 Note: Stock out situation: One or more of the contraceptive methods offered by this SDP has been out-of- stock on a given day in the last six months preceding the survey. No stock out situation: All contraceptive method offered by this SDP has been available/ in-stock on all days in the last six months preceding the survey.
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Table 3-27: No stock out at the time of survey by the type of government facility Modern contraceptive Total SDPs providing Type of Facility method in stock at the time Family Planning of the survey[‘no stock out’] Services (N) Primary (SHP, HP and PHCC) 88.6% 668 Secondary (District Hospital) 86.7% 15 Tertiary (Zonal Hospital) 66.7% 3 Total 88.5% 686 Note: Stock out situation: One or more of the contraceptive methods offered by this SDP has been out- of- stock on a given day in the last six months preceding the survey. No stock out situation: All contraceptive method offered by this SDP has been available/ in- stock on all days in the last six months preceding the survey.
The ‘no stock out’ situation of six different modern contraceptives was also analyzed by types of facilities. The data in Table 3-28 shows that the main contraceptive items in stock at the time of the survey. All the contraceptive methods expect implants were completely in stock at the government hospitals. The findings are comparatively better than baseline report, where the government hospitals reported 97.4 % (male condoms), 97.4% (oral pills), 94.9% (injectables), 97.4% (IUDs) and 89.5% (Implants) no stock outs. The contraceptive least in stock in PHCCs, SHPs and HPs was emergency contraceptives as well as IUCDs in SHPs. The stock out of IUCDs can be mostly related to the unavailability or insufficiency skilled staffs in such SDPs. Male condoms, oral pills and injectables were in stock in nearly all of the SDPs and the findings were similar to baseline 2013. For the private hospitals IUCDs and implants suffered most of the stock outs at the time of the survey and rest five of the contraceptives were in stock in majority of the private and NGO sector SDPs. Overall, the no stock out at the time of survey for male condom, pills, Injectables, IUCDs and Implant were 99.6 %, 99.6%, 100%, 95.1% and 97.1% respectively in STS 2013, which is comparative to findings of this study.
Table 3-28: No stock out at the time of survey for each modern contraceptive by type of facility No stock out of Modern contraceptive method at the time of the survey
- Total SDPs providing Type of Facility Family Planning
Services
Emergency Contracepti ves Male Condoms Oral Pills Injectables (Depo) IUDs/Copper T Implants (Zdal) Sub Health Post 98.0% 99.2% 99.2% 70.6% 92.6% 77.8% 394 Health Post 99.2% 99.6% 97.9% 86.2% 93.3% 74.4% 238 Primary Health 97.2% 100.0% 100.0% 90.3% 84.8% 80.0% 36 Care Center Government 100.0% 100.0% 100.0% 100.0% 88.9% 100.0% 18 Hospital Sangini outlet 100.0% 100.0% 100.0% 60.0% 70.0% 100.0% 39 Medical Centers/ 100.0% 100.0% 100.0% 100.0% 87.5% 92.9% 19 Poly clinics Private Hospitals 100.0% 100.0% 83.3% 66.7% 75.0% 100.0% 6 FPAN/Marie Stopes/NGO 90.9% 90.9% 100.0% 100.0% 100.0% 88.9% 11 hospitals Total 98.4% 99.3% 98.8% 86.7% 90.7% 82.1% 761
Stock out situation at the time of survey was also analyzed by regions, residence distance and management of the facility. In terms of distance, the SDPs in far western region experienced the most stock outs at the time of survey.
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Similarly no major difference in stock out in SDPs of urban/rural settings was observed. Also, the SDPs at the distance of about 31-40kms experienced the most stock outs. Compared to majority of (88%) the government facility with no stocks situation about 73% of the no stock out situation was observed in NGO and private sector facilities. (Refer Table 3-29 below).
Table 3-29: No stock out at the time of survey by region, residence, distance and management of facility Modern contraceptive Total SDPs providing method in stock at the Characteristics Family Planning Services time of the survey[‘no (N) stock out’] Region Eastern Development Region 93.4% 196 Central Development Region 93.4% 196 Western Development Region 81.5% 135 Mid-Western Development Region 91.7% 109 Far-Western Development Region 68.8% 125 Residence Urban 85.5% 117 Rural 87.3% 644 Distance from nearest warehouse/source of supplies (in
Km) <10 88.6% 237 10-20 88.8% 223 21-30 85.0% 120 31-40 79.6% 49 41-50 93.5% 31 >50 83.2% 101 Management of facility Government 88.5% 686 Private 73.4% 64 NGO 72.7% 11
Total 87.0% 761
3.4.2. ‘No Stock Out’ In the Last Six Months
The incidence of no stock outs of modern contraceptives in last six months was also explored in this study. This was considered as an important index of availability and a proxy indicator of access to contraceptive commodities in the country.
Table 3-30 below shows that in general, the incidence of stock outs affected a small portion of SDPs that offer family planning services mostly the health posts. The no stock out situation in past six months was observed in overall 83% of the SDPs. In terms of government facilities, the PHCCs experienced the most stock outs i.e. in nearly 31% of PHCCs. Comparing to 2013/14 survey, most stock outs were faced by health posts and PHCCs were the one of the most reliable contraceptive service delivery institutions however in this survey, stock outs has been experienced more by PHCCs. All of the private hospitals and NGO facilities did not experience any stock out in last six months. (Refer Table 3-30 and 3-31).
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Table 3-30: No stock out during six months by the type of facility Modern contraceptive method in Total SDPs providing Type of Facility stock [‘no stock out’] in the last six Family Planning months Services (N) Sub Health Post 85.5% 394 Health Post 79.8% 238 Primary Health Care Center 69.4% 36 Government Hospital 83.3% 18 Sangini outlet 87.2% 39 Medical Centers/Polycinics 89.5% 19 Private Hospitals 100.0% 6 FPAN/Marie Stopes/NGO 100.0% 11 hospitals Total 83.4% 761 Note: Stock out situation: One or more of the contraceptive methods offered by this SDP has been out- of- stock on a given day in the last six months preceding the survey. No stock out situation: All contraceptive method offered by this SDP has been available/ in-stock on all days in the last six months preceding the survey.
Table 3-31: No stock out during six months by the type of government facility Modern contraceptive method in Total SDPs providing Type of Facility stock [‘no stock out’] in the last six Family Planning months Services (N) Primary (SHP, HP and PHCC) 82.6% 668 Secondary (District Hospital) 86.7% 15 Tertiary (Zonal Hospital) 66.7% 3 Total 82.7% 686 Note: Stock out situation: One or more of the contraceptive methods offered by this SDP has been out- of- stock on a given day in the last six months preceding the survey. No stock out situation: All contraceptive method offered by this SDP has been available/ in-stock on all days in the last six months preceding the survey.
The data in Table 3-32 shows that the main contraceptive items in stock during the six months prior the survey.The stock outs in last six months was mostly experienced by emergency contraceptives in health posts (25%) and sub health posts (20%) while the implants were observed to be mostly out of stocks in PHCCs (31%) higher than the health post and sub health posts. Expect for implants all the contraception was in stock for government hospitals. In overall scenario, the most stock outs were found for contraceptives such as emergency contraception and implants. This can be compared to result of 2013/14 survey where the most affected contraceptives by stock outs were Implants and IUCDs. All of the six contraceptives were observed to be in stock in private hospitals and NGO facilities.
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Table 3-32: No stock out during six months for each modern contraceptive by type of facility No stock out of Modern contraceptive method during six months
Total SDPs providing Type of Facility Family Planning Services (Depo) Oral Pills Injectables
Emergency I IUDs/CopperT Implants (Zdal) Contraceptives Male Condoms Male Sub Health Post 97.2% 97.2% 95.1% 85.5% 81.1% 75.3% 394 Health Post 95.4% 97.5% 95.7% 90.8% 93.2% 80.2% 238 Primary Health 100.0% 97.1% 100.0% 88.2% 69.7% 90.0% 36 Care Center Government 100.0% 100.0% 100.0% 100.0% 83.3% 100.0% 18 Hospital Sangini outlet 97.4% 100.0% 97.4% 81.8% 87.5% 96.3% 39 Medical Centers/ 94.7% 94.4% 93.3% 100.0% 87.5% 84.6% 19 Poly clinics Private Hospitals 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 6 FPAN/Marie Stopes/NGO 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 11 hospitals Total 96.8% 97.5% 95.9% 90.4% 87.1% 83.5% 761
Also in terms of development region the SDPs in Far western region have experienced more of the stock outs, nearly 35% of the facilities had experienced stock outs in past 6 months. Similarly no major difference in stock outs in urban and rural settings was observed. The SDPs at the distance of 31-40kms experienced more of the stock outs compared to the SDPs which are more than 50 kms away. All of the SDPs in NGO sector did not experience any stock out compared to government and private sector facilities. The no stock out situation in last six months was observed to be better in private and NGO sector than the government sector (Refer Table 3-33).
Table 3-33: No stock out during six months by region, residence, distance and management of facility Modern contraceptive Total SDPs providing method in stock [‘no Family Planning Services stock out’] in the last six (N) Characteristics months Region Eastern Development Region 91.3% 196 Central Development Region 86.7% 196 Western Development Region 78.5% 135 Mid-Western Development Region 87.2% 109 Far-Western Development Region 68.4% 125 Residence Urban 88.0% 117 Rural 82.6% 644 Distance from nearest warehouse/source of supplies (in
Km) <10 89.5% 237 10-20 79.8% 223 21-30 81.7% 120 31-40 75.5% 49
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Modern contraceptive Total SDPs providing method in stock [‘no Family Planning Services stock out’] in the last six (N) Characteristics months 41-50 77.4% 31 >50 85.1% 101 Management of facility Government 82.7% 686 Private 89.1% 64 NGO 100.0% 11 Total 83.4% 761
3.4.3. Reasons for ‘Stock Out’
As discussed above the stock out situation of the overall six modern contraceptives both during the survey and six months prior the survey was not high in most of the SDPs. Though the stock out situation seems to be rare in majority of SDPs, various reasons as reported by the respondents are listed down in the Table 3-34 and discussed below.
The most prominent reason for stock out of male condoms, oral contraception and injectables was due to the delay on the part of the main source/warehouse to resupply the SDP with the contraceptives. Also few of the SDPs faced the stock out of injectables, male condoms and pills due to the lack of supply as there was a high demand for such contraceptives and also due to lack of proper storage.
The stock outs of IUCDs and implants were more related to the lack of services due to unavailability of experienced/ trained staffs to provide such contraceptives in the SDP than the delays in supplies from the source. Similar finding was observed for IUCDs and implants in 2013/14 survey where almost 50% and 80% SDPs respectively faced the stock outs due to the lack of trained staffs. Thus, this shows that the lack of trained staffs to provide IUCDs and implants have been a persistent cause of the stock out of such contraceptives. For emergency contraceptives, the issue of expiration date was reported as one of the major reasons for stock out besides the low or no demand of such contraceptive at the SDP and delays in supply from the main source. |
Table 3-34: Reasons for No Stock out by type of modern contraceptives Reasons of stock out of any modern contraceptive method Delays on the Lack of Delays by No train part of main equipment Modern this SDP to Low or no staff to Any source for the Total Contraceptives request for demand/need provide other institution/wareh provision of supply of at this SDP this at Reason* ouse to re-supply this the medicine the SDP this SDP contraceptive Male condoms 87.5 0.0 0.0 0.0 0.0 12.5 24 Oral contraception 78.9 5.3 5.3 0.0 0.0 10.5 19 (Pills) Injectables (Depo) 83.9 0.0 3.2 0.0 0.0 12.9 31 IUCDs/Copper T 15.4 7.7 0.0 69.2 7.7 0.0 26 Implants (Zdal) 23.5 0.0 2.9 61.8 2.9 8.8 34 Emergency 31.0 0.0 38.1 0.0 0.0 31.0 42 Contraceptives Total 49.7 2.0 11.2 20.3 1.5 15.2 197 *Others include: emergency contraceptives was date expired, No supply/lack of supply of implants and pills, destroyed by rats due to improper storage (pills/condoms), lack of supply due to high demand (injectables/condoms)
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3.5. Supply Chain, Including Cold Chain
Nepal’s supply system is improving in a greater pace. As reported by USAID in 2014, Nepal seemed to have moved from ad hoc-managed (i.e. Low performance-frequent stock outs and high inefficiencies) to an integrated system i.e. high level performance with low stock outs and optimized network, on the path of supply chain evolution. The supply chain carries approximately 200 products from 9 health programs to 4,000 facilities in Nepal (ibid).
This chapter presents the supply chain of the medical supplies, use of logistic forms, frequency and transportation of supplies for SDPs, storage of supplies that are supposed to be in cold chain and the type of cold chain available at SDPs and its source of power.
3.5.1. Resupply of Medical Supplies
Person Responsible for Ordering Medical Supplies
This survey reported that in most SDPs particularly sub health posts, health posts and, primary health care centers, health facility in-charge were mainly responsible for ordering medical supplies. In overall, in nearly 80% of the government SDPs health facility in charges was the person responsible for ordering the medical supplies (Table 3- 35). However, in some government hospitals and PHCCs nurse, storekeepers and other personnel (medical doctors in government hospitals) were also responsible for ordering medical supplies. Similar findings were depicted by baseline survey 2013.
In private sector facilities, along with health facility in charge, pharmacists were also responsible for ordering the medical supplies. In FPAN/marie stopes/NGO hospital, proprietors of the SDPs were also main person responsible for ordering the medical supplies. (Refer Table 3-35).
In terms of development region, in overall more than 85% of the SDPs, health facility in charge were responsible for ordering the supplies. In few of the SDPs in Mid-Western region, even nurses/AHW/ ANM ordered the supplies. Unlike almost all the SDPs in rural settings, in urban SDP along with health facility in charge even pharmacist and storekeepers ordered the medical supplies. Also, compared to private and NGO sector facilities almost all of the facilities managed by the government supplies were ordered by health facility in charge whereas in private and NGO facilities even proprietor of the facility, health assistant and public health inspector ordered the resupplies. (Annex 8) Table 3-35: Person responsible for ordering medical supplies Percentage Total Health Storekee number Type of Facility Pharma Nurse/ Others Facility In Medical Doctor per of SDPs cist AHW/ ANM * Charge (N) Sub Health Post 93.9% 0.0% 2.3% 2.8% 0.0% 1.0% 394 Health Post 92.4% 0.0% 1.3% 3.8% 1.7% .8% 238 Primary Health Care 63.9% 8.3% 0.0% 8.3% 16.7% 2.8% 36 Center Government Hospital 38.9% 11.1% 11.1% 16.7% 22.2% 0.0% 18 Sangini outlet 35.9% 0.0% 33.3% 5.1% 0.0% 25.6% 39 Medical centers/ Poly 52.6% 0.0% 36.8% 0.0% 0.0% 10.5% 19 clinic Private hospitals /PSSN 62.5% 12.5% 25.0% 0.0% 0.0% 0.0% 8 FPAN/Marie 54.5% 0.0% 18.2% 0.0% 0.0% 27.3% 11 stopes/NGO Hospital Total 85.8% .8% 5.0% 3.7% 1.8% 2.9% 763 *Others include: Proprietor, Health assistant, public health inspector, CMA, etc
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Table 3-36: Person responsible for ordering medical supplies Percentage Nurse/ Health Total number Type of Facility Medical AHW/ Storekeeper Facility In Pharmacist Others* of SDPs (N) Doctor ANM Charge
Primary (SHP, HP and 91.8% 0.4% 1.8% 3.4% 1.5% 1.0% 668 PHCC) Secondary (District 33.3% 13.3% 6.7% 20.0% 26.7% 0.0% 15 Hospital) Tertiary (Zonal 66.7% 0.0% 33.3% 0.0% 0.0% 0.0% 3 Hospital) Total 90.4% 0.7% 2.0% 3.8% 2.0% 1.0% 686 *Others include: Proprietor, Health assistant, public health inspector, CMA, etc
Quantification of Re-supply
Appropriate quantification of the commodities incorporating forecasting and supply planning is a process to ensure adequate amounts of the required products in the supply chain system. The appropriate quantification of commodities is highly dependent on good data access, knowledgeable personnel, and the coordination of key stakeholders including MOHP officials, program staff, supply chain personnel, and service delivery staff, without which stocks hardly meet demands, and results in either under stocking or overstocking.
After quantification, procurement of the medical supplies is done. During procurement the goods are either supplied in a pull system or in push system. As per the existent situation of Nepal, both Push (central to regional medical store) and Pull (district to regional medical store) of drug supply is in place. Regional Medical Stores (RMS) sends all the free drugs by push system to respective districts and all the D(P)HOs distribute drugs to the health facilities particularly through pull system (based on demand) (DRC, 2012), however for certain RH commodities push system is also functional. The pull system is proving to be more worth for Nepal due to the flexibility to adjust the flow of supplies as the annual estimated consumption of a health facility is held at the district store for demand-based quarterly resupply.
Also under the pull system, the health facilities calculates the required quantities of resupply for coming quarter (three months period) based on the standard system of Logistics Management Information Systems (LMIS) report. Here Authorized stock level (ASL) refers to the quantity stocked for the maximum duration such as for PHC, HP and SHP, the quantity of any medicine should be stocked for maximum of 5 months duration. It is calculated by multiplying the average consumption of the medicine per month with the ASL. Emergency order point (EOP) refers to the quantity stocked for the minimum duration such as for PHCC, HP and SHP, the quantity of any medicine should be stocked for minimum of 1 month. It is the quantity required for one month. The stock of any medicine should not be below than the EOP. The formula for quantification is based on the following calculations:
Name of Unit Remaining Received Total Damaged Remaining Authorized Emergency Required medicines balance in this withdrawn or balance stock level order quantities of last quarter from store expired at the end (ASL) point quarter of (EOP) quarter 1 2 3 4 5 6 7 8 9 10 7=3+4- 10=8-7 5-6 Note: the numbers 1,2……..10 denote the number of columns and columns 7 and 10 show the process of calculation
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ASL and EOP for District, PHCC, HP and SHP Levels ASL EOP District 10 months 3 months PHCC, HP and SHP 5 months 1 month
This survey showed that majority of SDPs had pull system where in nearly 60% of the facilities, the staff member of the facility made request based on calculation of quantity needed using the above mentioned formula, about 21% of the facilities made request by filling the demand form as per need or as per the stock and rest of the SDPs made adhoc demand. Nearly 60% of government facilities practiced pull system which enabled their staff at the lower levels to order the supplies they needed, using calculations that were based on LMIS data (Table 3-37).
Few of the private sector SDPs also followed the CRS distribution system. The push system was followed by nearly17% of the SDPs where the quantity was determined by the institution/warehouse responsible for supplying the SDPs. Compared to only 11% of the government facilities in 2013/14 survey; slight increase i.e. 19% of the government facilities in 2014/15 survey followed the push system for the quantification of resupply.
Likewise in terms of development regions, most of the SDPs in far western region (70%) followed the pull system where resupply were quantified as per the requests made by staff members based on calculation of quantity needed using formula and relatively more of the SDPs (32%) in eastern western followed by the push system where resupply were determined by the institution/warehouse responsible for supplying the SDPs. In most of the SDPs of rural as well as urban area, resupply of medical supplies were quantified as per the request made by the staff member based on calculation of quantity needed using formula. In terms of management, in more than 60% of the SDPs in the government sector, the resupply were quantified based on the calculation based on the formula where this method was followed least by private sector facilities where nearly 50% of the facilities made demand as per their stock. (Refer Annex 9).
Table 3-37: Quantification of resupply by type of facilities Percentage Pull System Push system Staff member(s) Type of health of this facility Demand Quantity is Total facilities makes request form As per stock Any other determined by the based on filled as demand is method institution/warehouse calculation of per made used* responsible for quantity needed need supplying this SDP using a formula Sub Health Post 59.6% 14.5% 4.6% 1.0% 20.4% 394 Health Post 64.7% 11.3% 4.6% 2.1% 17.2% 238 Primary Health Care 66.7% 11.1% 5.6% 11.1% 13.9% 36 Center Government Hospital 55.6% 27.8% 5.6% 5.6% 5.6% 18 Sangini outlet 47.5% 2.5% 40.0% 10.0% 0.0% 39 Medical centre/ 26.3% 5.3% 63.2% 5.3% 0.0% 19 Poly clinic Private 37.5% 0.0% 62.5% 0.0% 0.0% 8 hospitals/PSSN FPAN/Marie 54.5% 0.0% 27.3% 0.0% 18.2% 11 stopes/NGO hospital Total 59.3% 12.5% 8.9% 2.5% 16.9% 763 *Others include: CRS distributor, Adhoc demand by the facility
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Table 3-38: Quantification of resupply by type of government facilities Percentage Pull System Push System Staff member(s) of Type of health this facility Quantity is Total facilities makes request Demand form As per stock determined by the Any other method based on filled as per demand is institution/warehouse used* calculation of need made responsible for quantity supplying this SDP needed using a formula Primary (SHP, HP 61.4% 13.2% 4.6% 1.9% 18.9% 668 and PHCC) Secondary (District 53.3% 33.3% 6.7% 0.0% 6.7% 15 Hospital) Tertiary (Zonal 66.7% 0.0% 0.0% 33.3% 0.0% 3 Hospital) Total 58.6% 13.6% 4.7% 1.9% 18.6% 686 *Others include: CRS distributor, Adhoc demand by the facility
3.5.2. Main Source, Frequency and Transportation of Supplies for SDPs
Main Source of Supplies
In Nepal Logistics Management Division (LMD) under the Ministry of Health and Population is responsible for all the supply of equipment, essential drugs, contraceptive and vaccines to the government facilities as well as health units all over the country. Centrally they are procured through the LMD and then distributed to district (public) health offices (D/PHOs) through regional warehouses.
In this survey, it was found that major source of medical supplies (90%) at all SDPs at government sector were regional/district warehouse with few of the SDPs also being supplied from other local sources such as from illaka (mainly during vaccine route and mostly for sub health posts), local medical stores as well as nearby health facilities. The findings were similar to baseline 2013 report where 89.4 % of all SDPs at government sector were supplied by regional/district warehouse. In some hospitals (nearly 27%) central medical stores was the main source of supplies. Central medical stores were the main source of supplies for 23.1 % of government hospitals in baseline 2013. For private sources, most of the purchases were made from private sources and some from the local medical stores. The NGO sector had various major sources of supplies such as central medical stores, NGOs, few from local medical stores as well as private sources. (Refer Table 3-39 and Table 3-40)
Accordingly, in terms of development regions, regional/district warehouse was found to be the main source of supplies in all regions with the highest percentage of SDPs from Far western development region and the lowest from Eastern developing region. In most of rural SDPs (86%) compared to the urban ones (55%) the main source of medical supplies was regional/district warehouse. For urban facilities other sources of supplies mostly the private source and the local medical stores were also taken as main source for the supplies (Refer Annex 10). About 94.6% of rural SDPs and 70.0 % of urban SDPs had regional/district warehouse as the main source of medical supplies in baseline survey 2013.
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Table 3-39: Main source of supplies by type of facilities Percentage Local Regional/ Type of health Central medical Other district Private Total facilities medical store on NGO local warehouse or sources stores the same sources* institution site Sub Health Post 2.8% 87.8% 2.0% 0.0% 0.0% 7.4% 394 Health Post 4.2% 95.4% 0.0% 0.0% 0.0% 0.4% 238 Primary Health Care 5.6% 91.7% 2.8% 0.0% 0.0% 0.0% 36 Center Government Hospital 26.7% 73.3% 0.0% 0.0% 0.0% 5.6% 18 Sangini outlet 2.6% 5.1% 12.8% 5.1% 74.4% 0.0% 39 Medical centre/ Poly 10.5 0.0% 5.3% 26.3% 57.9% 0.0% 19 clinic % Private hospital/PSSN 12.5% 0.0% 25.5% 0.0% 50.0% 12.5% 8 FPAN/Marie 36.4 36.4% 0.0% 18.2% 9.1% 0.0% 11 stope/NGO Hospital % Total 4.5% 81.4% 3.0% 1.0% 5.9% 4.2% 763 *Others: Supplied from illaka (mainly during vaccine route)/nearby health facilities
Table 3-40: Main source of supplies by type of government facilities Percentage Type of health Central Regional/district Local medical Total facilities medical warehouse or store on the Other local sources * stores institution same site Primary (SHP, HP and 3.4% 90.7% 1.3% 4.5% 668 PHCC) Secondary (District 26.7% 73.3% 0.0% 0.0% 15 Hospital) Tertiary (Zonal 33.3% 33.3% 0.0% 33.3% 3 Hospital) Total 4.1% 90.0% 1.3% 4.5% 686 *Others: Supplied from illaka (mainly during vaccine route)/nearby health facilities
Frequency of Supplies
In this survey, the frequency of resupply of medical supplies was done once in every three months in all level government facilities (64%) except in hospitals where the frequency of supplies was done once every month or less by all the tertiary level and about 40% by secondary level facilities. This finding was similar to the baseline 2013/14 survey. Also in most of the sangini outlets, medical centres/polyclinics, private hospitals/PSSN and FPAN/Marie stope/NGO hospitals the resupplies were mainly done once every one month or less (Refer Table 3- 41and Table 3-42).
Accordingly, in terms of development regions, the resupply was done once in every three month in majority of developing regions except in Mid-western development region where in most health facilities resupply was done once a month or less. In most of SDPs of rural area, frequency of resupply of medical supplies was found to be once in every three months whereas, in most of the SDPs of urban area the frequency of resupply was often done once a month or less period. Both these finding resembles baseline 2013 findings. Similarly compared to government facilities where about 64% of facilities made resupplies in once every three months, most of the facilities in private i.e. 91% and in NGO i.e. 73% sectors made resupply once every month or less. This implies the frequency of supplies
Page | 45 was done more often by the private and NGO sector facilities compared to the government facilities (Refer Annex 11). Table 3-41: Frequency of supplies by type of facility Percentage Type of Facility Total number Once every 1 Once every Once every six of SDPs(N) month or less three months months Sub Health Post 19.8% 70.6% 9.6% 394 Health Post 31.1% 58.4% 10.5% 238 Primary Health Care Center 38.9% 50.0% 11.1% 36 Government Hospital 50.0% 38.9% 11.1% 18 Sangini outlet 89.7% 7.7% 2.6% 39 Medical centre/ Poly clinic 94.7% 5.3% 0.0% 19 Private hospital/PSSN 87.5% 12.5% 0.0% 8 FPAN/Marie stope/NGO 72.7% 18.2% 9.1% 11 Hospital Total 31.8% 58.8% 9.3% 763
Table 3-42: Frequency of supplies by type of government facility Percentage Type of Facility Total number Once every 1 Once every Once every six of SDPs(N) month or less three months months Primary (SHP, HP and PHCC) 24.9% 65.1% 10.0% 668 Secondary (District Hospital) 40.0% 46.7% 13.3% 15 Tertiary (Zonal Hospital) 100.0% 0.0% 0.0% 3 Total 25.5% 64.4% 10.1% 683
Responsibility for Transportation of Supplies
The regional medical store is responsible for transporting medical supplies for individual health facility and its transportation to the respective district stores. The districts would then be responsible for onward distribution of commodities to the respective facilities.
In this survey, the responsibility for transportation of supplies at all government SDPs was mainly done by district warehouse except in hospitals where the central/regional warehouse was equally responsible for transportation of supplies. This finding is in line with the baseline survey 2013. In most of the private sector, the facility itself had the responsibility for the transportation of the supplies. However in case of NGO, facility itself or the medical suppliers were responsible for transporting the supplies. Compared to only 22% of the government facilities, where the responsibility of the transportation was taken by the facility themselves, majority of facilities themselves were responsible for the transportation of supplies in private (80%) and NGO (55%) (Refer Table 3-43 and Table 3-44)
Regarding the development regions, along with the district warehouses, substantial number of facilities themselves was mainly responsible for transporting the supplies in all regions. In most of SDPs of rural area, district warehouse had responsibility for transportation of supplies whereas, in urban areas along with the district warehouses, the facility themselves were responsible for transportation of supplies (Annex 12). Similar findings were reported by baseline survey 2013/14.
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Table 3-43: Responsibility for transportation of supplies by type of facility Percentage Type of health facilities Central/Regional District Facility Total Others warehouse warehouse itself Sub Health Post 14.0% 59.4% 25.6% 1.0% 394 Health Post 10.1% 71.4% 17.6% .8% 238 Primary Health Care 13.9% 72.2% 13.9% 0.0% 36 Center Government Hospital 38.9% 38.9% 16.7% 5.6% 18 Sangini outlet 5.1% 2.6% 82.1% 10.3% 39 Medical centre/ Poly 0.0% 0.0% 78.9% 21.1% 19 clinic Private hospital/PSSN 0.0% 12.5% 75.0% 12.5% 8 FPAN/Marie 9.1% 0.0% 54.5% 36.4% 11 stope/NGO Hospital Total 12.3% 57.5% 27.5% 2.6% 763 *others include: Medical supplier themselves
Table 3-44: Responsibility for transportation of supplies by type of government facility Percentage Central/ Type of health facilities District Facility Total Regional Others warehouse itself warehouse Primary (SHP, HP and PHCC) 12.6% 64.4% 22.2% .9% 668 Secondary (District Hospital) 40.2% 40.5% 20.0% 0.0% 15 Tertiary (Zonal Hospital) 33.3% 33.3% 0.0% 33.3% 3 Total 13.3% 63.5% 22.1% 1.0% 686 *others include: Medical supplier themselves
3.5.3. Availability of Fridge for Storing Essential Drugs at SDPs and Source of Power
Availability of Fridge
Maintaining the cold chain to ensure the proper storage of critical medicines, vaccines and supplies is very crucial for developing countries such as Nepal such that these critical supplies may reach those in need. A variety of different refrigeration technologies have been developed to maintain the proper temperature for cold chain drugs. Thus, the availability of any kind of refrigeration with constant supply of power is the minimum requirement of any health facilities.
This survey showed that among the government facilities, majority of hospitals (94%) and PHCC (86%) made the electric fridge available in their SDPs to store the cold chain medicines/ supplies, however very few of the health posts (30%) and sub health posts (12%) had electric fridge. Compared to baseline 2013 report, although the percentage of SDPs having refrigerator has been the same for hospitals and increased by nearly 16% for PHCCs, the number of SDPs with refrigerator have decreased tremendously for health posts and sub health posts i.e. decreased by 18% and 11% respectively. The respondents also reported that in case of unavailability of fridge or where continuous power supplies for the fridge is not possible; few of the facilities also used ice boxes with regularly replenish ice supply to maintain the correct temperature of the drugs. This figure was seen to be lower than the data reported by STS 2012 where at least 40% of SHPs had fridge.
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Likewise for only 50% of sangini outlets, about 64% of FPAN/Marie stopes/NGO hospitals, majority of 74% of medical centers/polyclinics and all of the private hospitals/PSSN made electric fridge available to store the cold chain medicines. (Refer Table 3-45 and 3-46)
Most of the SDPs in the urban area had the availability of fridge to store the essential drugs (nearly 55%) compared to only 23% in rural SDPs. The percentage has decreased compared to baseline where 88% of the SDPs in the urban area and 42 % of the SDPs in the rural area had the availability of fridge to store the essential drugs. In terms of development region, more of the facilities in Eastern and Mid-western region did not have any kind of cold chain to store the medicines. Referring to the management of the facility majority of private and NGO sector SDPs had refrigerator as compared to government facilities, where more than 70% of the facilities lacked any kind of cold chain. (See Annex 13)
Some of the drugs which were stored in the fridge were mostly found to be Tetanus and Oxytocin including some of the vaccines which is an essential drug for all levels of health facility. Almost all the facilities having fridge stored Tetanus toxoid and few stored oxytocin in their fridges. The findings are supported by baseline 2013 findings.
Table 3-45: Availability of fridge for storing essential drugs by type of facility Percentage Type of cold chain available No cold Type of Facility Ice box Total chain Electric (SDP have to regularly available Fridge replenish ice supply) Sub Health Post 83.8% 11.7% 4.6% 394 Health Post 63.0% 30.3% 6.7% 238 Primary Health Care Center 11.1% 86.1% 2.8% 36 Governmental Hospital 5.6% 94.4 0.0% 18 Sangini outlet 46.2% 51.3% 2.6% 39 Medical centres/ Poly clinic 26.3% 73.7% 0.0% 19 Private hospitals /PSSN 0.0% 100.0% 0.0% 8 FPAN/Marie stopes/NGO 27.3% 63.6% 9.1% 11 Hospitals Total 67.0% 28.2% 4.8% 763
Table 3-46: Availability of fridge for storing essential drugs by type of government facility Percentage Type of cold chain available No cold Type of Facility Ice box Total chain Electric (SDP have to regularly available Fridge replenish ice supply) Primary (SHP, HP and PHCC) 72.5% 22.3% 5.2% 668 Secondary (District Hospital) 6.7% 93.3% 0.0% 15 Tertiary (Zonal Hospital) 0.0% 100.0% 0.0% 3 Total 70.7% 24.2% 5.1% 686
Source of Power
Establishing a cold chain where there is a use of traditional electric refrigeration system becomes quite complicated mainly due to the lack of electricity and intermittent power supply. The result shows that most of the facilities (90%) rely on the electricity from national grid for the power supply. All of the tertiary hospitals had electricity from
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national grid for the power supply. The facilities with unreliable source of power also use kerosene or solar-powered refrigerators. In our survey also, some of the SDPs mostly in government facilities also seemed to rely on solar power for their supplies and also some relied on electricity from local grid. SDPs were found to be using similar source of supply in 2013/14 survey. Very negligible HPs also had kersone/paraffin as their power supply; such use was not found in any of the facilities in 2013/14 survey. (Refer Table 3-47 and 3-48)
Most of the SDPs in Mid western region though relied on electricity from national grid; they also had solar power as main source of supply in about 17% of the SDPs. Apart from using electricity from national grid as their main source of supplies in rural SDPs, few SDPs (7%) also relied on solar power supply. All of the NGO sector facilities relied on electricity from national grid for their power supply and few SDPs in government and private sector also relied on solar power and local grid. (See Annex 14)
Table 3-47: Source of power for Fridges by type of SDPs Percentage Total facility Type of Facility Electricity from national grid Solar power Others* using fridge (N) Sub Health Post 95.7% 4.3% 0.0% 46 Health Post 86.1% 6.9% 6.9% 72 Primary Health Care Center 80.6% 9.7% 9.7% 31 Government Hospital 88.2% 5.9% 5.9% 17 Sangini outlet 95.0% 0.0% 5.0% 20 Medical centres/ Poly clinic 85.7% 7.1% 7.1% 14 Private Hospital/PSSN 100.0% 0.0% 0.0% 8 FPAN/Marie stopes/NGO 100.0% 0.0% 0.0% 7 Hospital Total 89.3% 5.6% 5.1% 215 *Others :Electricity from local grid, Kerosene/Paraffin(negligible)
Table 3-48: Source of power for Fridges by type of government SDPs Percentage Type of Facility Total facility Electricity from national grid Solar power Others* using fridge (N) Primary (SHP, HP and PHCC) 87.9% 6.7% 5.4% 149 Secondary (District Hospital) 85.7% 7.1% 7.1% 14 Tertiary (Zonal Hospital) 100.0% 0.0% 0.0% 3 Total 87.9% 6.7% 5.5% 166 *Others :Electricity from local grid, Kerosene/Paraffin(negligible)
3.6. Staff Training and Supervision
The Ministry of Health and Population (MoHP)/Department of Health Services (DoHS) has developed several policies/guidelines with the emphasis on various training in health facilities, after the development of the strategy in 1997. The tenth plan, 2002-2007 has envisaged National Health Training Centre (NHTC) as responsible body for providing and overseeing in-service training for capacity building of health human resources within Nepal’s health system. It offers several trainings each year depending on training requirements identified by the different program units. Training is one of the most important function of health system that increases the efficiency and the effectiveness of staffs which results in better delivery of services.
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3.6.1. Availability of Staff Trained to Provide FP Services Including for Implants and IUCDs
The staffs trained to provide family planning services was observed to be high in all the type of health facilities. All the government hospitals had staff trained in family planning services. Even in SHP level about 73% of the SHPs had staffs trained to provide FP services. Though the majority of SDPs had staffs trained to provide family planning services, only some of government SDPs (38%) had staffs trained specifically in insertion and removal of implant and IUCD contraceptives. Only about 36% of the primary level facility had staffs trained in implants/IUCDs with least percentage of SHPs (only 20%). Thus it can be implied that staffs in most of the SDPs generally lacked the necessary knowledge and skills to provide quality services such as implants and IUCDs. (Refer Table 3-49 and Table 3-50)
Table 3-49:Staffs trained to provide family planning services by type of SDPs SDPs with staffs SDP with staff trained to provide Type of Facility Total SDPs trained in Implants family planning /IUCD services Sub Health Post 73.1% 394 19.8 Health Post 83.6% 238 51.3 Primary Health Care 94.4% 36 91.2 Center Government Hospital 100.0% 18 94.4 Sangini outlet 84.6% 39 12.1 Medical centres/Poly 84.2% 19 12.5 clinic Private hospitals /PSSN 100.0% 8 50.0 FPAN/Marie 90.9% 11 90.0 stopes/NGO Hospital Total 79.4% 763 37.3
Table 3-50: Staffs trained to provide family planning services by type of government SDPs SDPs with staffs trained to SDP with staff Total Type of Facility provide family planning trained in SDPs services Implants/IUCD Primary (SHP, HP and PHCC) 78.0% 668 36.5% Secondary (District Hospital) 100.0% 15 93.3% Tertiary (Zonal Hospital) 100.0% 3 100.0% Total 78.6% 686 38.4%
Also regarding the number of SDPs trained for the insertion and removal of Implants and IUCD, the results shows that majority of government hospitals (88%) and primary health care centers (71%) had trained staffs in both implants and IUCD compared to sub health posts (40%) and health posts (54%) (This calculation was made only among the 37% SDPs which had their staffs trained in IUCD or implants). This is relatively higher compared to baseline (2013/14) data where only 30% in SHPs and 39% in HPs had staffs trained in both IUCD and Implants. The staffs trained in implants have also tremendously increased for SHPs i.e. 40% in 2013/14 to 70% in 2014/15. Compared to all the tertiary level government SDPs and majority of secondary level facilities (86%); only about half of the primary level government SDPs had staffs trained in both the IUCD and Implant services (Refer Table 3-51 and 3- 52).
In case of geographical area, percentage of SDPs with staff trained in implants and IUCD were found to slightly higher in urban areas as compared to the rural areas. Compared to only about 56% of the SDPs with staff trained in
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IUCD and Implant both; majority of the SDPs in private (70%) and NGO (89%) sectors had staffs trained in both. (See Annex 15)
Table 3-51: Staffs trained for the insertion and removal of Implants and IUCD by type of SDPs Total SDP with Staff trained in Staff trained Staff trained staff trained in Characteristics IUCD and Implant in Implants in IUCD Implants and both IUCD Type of Facility Sub Health Post 70.2% 70.2% 40.4% 57 Health Post 79.4% 74.5% 53.9% 102 Primary Health Care Center 77.4% 93.5% 71.0% 31 Government Hospital 94.1% 94.1% 88.2% 17 Sangini outlet 75.0% 100.0% 75.0% 4 Medical centres/Poly clinic 0.0% 100.0% 0.0% 2 Private hospitals /PSSN 100.0% 100.0%% 100.0% 4 FPAN/Marie stopes/NGO 100.0% 88.9% 88.9%% 9 Hospital Total 78.3% 79.2% 57.5% 226
Table 3-52: Staffs trained for the insertion and removal of Implants and IUCD by type of government SDPs Total SDP with Staff trained in Staff trained Staff trained staff trained in Type of Facility IUCD and Implant in Implants in IUCD Implants and both IUCD Primary (SHP, HP and PHCC) 76.3% 76.3% 52.6 190 Secondary (District Hospital) 92.9% 91.7% 85.7% 14 Tertiary (Zonal Hospital) 100.0% 100.0% 100.0% 3 Total 77.8% 77.8% 55.6% 207
3.6.2. Frequency of Staff Supervision
In order to improve health worker’s performance and to achieve better service quality, systematic supervision is quite essential. Supervision is a process where higher authorities encourage personnel to optimize their performance in a supportive environment and recognize them when they attain a high level of performance. Some of the studies have shown that systematic supervision using an objective set of indicators could improve health worker performance. Effective supervisions lead to a balance between monitoring and evaluating services and providing support and encouragement to staff.
This survey showed that in majority of SDPs (38%), the supervisory visits were undertaken once in a three months period however in some of the SHPs and HPs the supervisions were also done annually. In baseline survey also, in most SDPs the supervisions were carried out in every three months. In some of the hospitals (28%) supervisions was done every six monthly. In very few of the government hospitals (9%), the supervision was not done at all, the percentage being highest for the tertiary hospitals. (Refer Table 3-53 and 3-54).
However, in case of location majority of SDPs from both urban and rural areas had supervisory visits once in three months. There was no notable difference in SDPs in urban area and rural areas in terms of supervisory visits were found nevertheless besides three monthly visits, more of the SDPs in rural settings were supervised annually. Also, in case of management, more of the private SDPs were not supervised compared to government and NGO sector facilities. (See Annex 16)
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Table 3-53: Frequency of supervisory visits by type of SDPs Frequency of supervisory visits Not Total Type of Facility Every three Every four Every six supervised Sample Annually monthly monthly monthly (%) Size (N) Sub Health Post 33.8% 7.1% 19.0% 28.2% 11.9% 394 Health Post 42.9% 10.1% 18.9% 23.9% 4.2% 238 Primary Health 52.8% 11.1% 19.4% 11.1% 5.6% 36 Care Center Government 44.4% 16.7% 27.8% 0.0% 11.1% 18 Hospital Sangini outlet 23.1% 2.6% 20.5% 20.5% 33.3% 39 Medical centres/ 50.0% 0.0% 50.0% 0.0% 0.0% 19 Poly clinic Private hospitals/ 45.5% 9.1% 27.3% 18.2% 0.0% 8 PSSN FPAN/Marie stopes/NGO 33.8% 7.1% 19.0% 28.2% 11.9% 11 Hospital Total 38.0% 8.3% 19.3% 24.2% 10.2% 763
Table 3-54: Frequency of supervisory visits by type of government SDPs Frequency of supervisory visits (%) Not Total Type of Facility Every three Every four Every six supervised Sample Annually monthly monthly monthly (%) Size (N) Primary (SHP, HP 40.0% 20.0% 33.3% 0.0% 6.7% 668 and PHCC) Secondary (District 40.0% 20.0% 33.3% 0.0% 6.7% 15 Hospital) Tertiary (Zonal 66.7% 0.0% 0.0% 0.0% 33.3% 3 Hospital) Total 38.2% 8.6% 19.2% 25.1% 8.9% 763
3.6.3. Issues included in Supervisory visits
Supervisions particularly help in strengthening relationships within the system, identifying and resolving problems, helping optimize the allocation of resources, and promoting higher standards, teamwork and better communication.
Though the supervisory visits looks into numerous aspects, the survey showed that the issues most included in the supervisory visits were to check the data completeness, quality, and timely reporting and also drug stock out and expiry except for the government hospitals where supervisory visits mainly looked into other aspects such as supervision of vaccine services, OPD register, ANC/PNC services besides checking of data completeness, quality, and timely reporting and drug stock out and expiry. (Refer Table 3-55 and 3-56)
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Table 3-55: Issues included in supervisory visits by type of SDPs Issues included in Supervisory visits (mostly) Review use of Drug Staff Data Staff specific guideline stock availability completeness, clinical or job aid for Others Total Type of Facility out and and quality, and timely practices reproductive expiry training reporting health Sub Health Post 9.2% 19.3% 8.1% 42.7% 6.1% 14.7% 347 Health Post 10.1% 22.4% 11.8% 39.5% 6.6% 9.6% 228 Primary Health Care 8.8% 8.8% 5.9% 44.1% 11.8% 20.6% 34 Center Government Hospital 12.5% 18.8% 18.8% 18.8% 6.3% 25.0% 16 Sangini outlet 3.8% 80.8% 0.0% 7.7% 7.7% 0.0% 26 Medical centers/ Poly 20.0% 53.3% 0.0% 13.3% 6.7% 6.7% 15 clinic Private hospitals/ PSSN 25.0% 37.5% 0.0% 37.5% 0.0% 0.0% 8 FPAN/Marie stopes/NGO 27.3% 9.1% 9.1% 36.4% 0.0% 18.2% 11 Hospital Total 10.1% 22.9% 8.9% 39.0% 6.4% 12.7% 685 *others include: supervision of vaccine services, OPD register, ANC/PNC services
Table 3-56: Issues included in supervisory visits by type of government SDPs Issues included in Supervisory visits (mostly) Review use of Drug Staff Data Staff specific guideline stock availability completeness, clinical or job aid for Others Total Type of Facility out and and quality, and timely practices reproductive expiry training reporting health Primary (SHP, HP and 9.5% 19.9% 9.4% 41.5% 6.6% 13.1% 609 PHCC) Secondary (District 14.3% 21.4% 21.4% 21.4% 0.0% 21.4% 14 Hospital) Tertiary (Zonal Hospital) 0.0% 0.0% 0.0% 0.0% 50.0% 50.0% 2 Total 9.6% 19.8% 9.6% 41.0% 6.6% 13.4% 625 *others include: supervision of vaccine services, OPD register, ANC/PNC services
3.7. Availability of Guidelines, Check-lists and Job aids
Nepal has several policies, documents, and service delivery guidelines related to population and reproductive health; all of which are supportive to certain elements of reproductive health commodity security. Family health protocols guideline and job aids are developed by Ministry of Health and Population (MoHP) in Nepal to strengthen service delivery and implementation of innovative approaches to enhance the quality of and increase access to FP information and services, ANC/PNC service especially by those in rural and marginalized communities at all level of service delivery point.
Different guidelines, checklists are provided as per the level of SDPs for strengthening the quality services. The status of availability for some of the family planning guidelines and waste disposal guidelines has been one of the major objectives of this research. The availability of such guidelines, job-aids or the checklists was either done through verbal response of the respondents or inventory check for verification where possible.
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3.7.1. Family Planning Guidelines
To know the availability of family planning guidelines, National Medical Standard (NMS) volume-1 was referred in this survey. This document is particularly designed to provide policymakers, district health officers, hospital directors, clinical supervisors and service providers with accessible, clinically oriented information to guide the provision of reproductive health services in Nepal.
The data showed that out of 394 sampled sub-health post, in about more than two fifth (41.9%) the availability of the family planning guidelines were verified, whereas about in one fifth (21.8%) of the sub-health post the family planning guidelines were not verified. In case of Health Post, in more than half (56.3%), the availability of the guidelines was verified, but only few (17.2%) were not verified out of 238 samples. The highest percentage of PHCCs (75.0%) and Government Hospitals (77.8%) stated the availability of family planning guidelines and was verified too. The results were similar to the baseline survey data, however with slight increase in availability of NMS guidelines in sub health posts. However only few percentages of sangini outlets (23.1%) and Medical centres/polyclinic (15.8%) and more than half of the private hospitals/PSSN (50%) and FPAN/Marie stopes/NGO (54.5%) verified the availability of such guidelines. (Refer Table 3-57)
The comparative study of the data in five development regions showed that in eastern development region the availability of family planning guidelines was reported in most of the SDPs (55% of family planning guidelines). In terms of urban and rural scenarios, the availability verification was interestingly more for rural areas. Similarly, a comparative study in terms of management governed by government, private and NGO showed that for Family planning guidelines, about half (49.6%) of government SDPs verified the availability, and more than fifty percentages (54.5%) were verified by the NGO sector SDPs. (See Annex18)
3.7.2. Antenatal/Postnatal Job Aids
The ANC/PNC job aids are prepared by NFHP-II under the Ministry of Health and Population which gives the list of minimum requirement that should be provided by any health facilities including the private clinics during both ANC and PNC period.
The ante natal care jobs were verified by only about two fifth of Sub-health post (35.8%), Private Hospitals/PSSN (37.5%) and FPAN/Marie stopes (36.4%). Nevertheless, more of the Government Hospitals (66.7%), about 61.1% of PHCCs and more than half of the Health Post (53.6%) verified the availability. In sangini outlets, the availability verification was null. Besides, slight increase in availability of ANC job aids in HPs compared to 45% in baseline survey, the overall availability and verification data was observed to be same. (Refer Table 3-57)
The comparative study of the data in five development regions showed that in eastern development region, the availability of ANC/PNC job aids was reported in more than half (53%) of the SDPs. In terms of urban and rural scenarios, the availability verification was also more for rural areas (43% in rural compared to 27% in urban). This showed that the use of ANC/PNC guidelines should be encouraged more at the urban areas. (See Annex18)
3.7.3. Waste Disposal Guidelines
Government has prepared the waste disposal guideline under the Nepal Health Research Council (NHRC, 2002) to safeguard the public health from adverse effects of improper management of health care waste. Certain norms and regulations are provided in this guideline which indicates the minimum standard for safe and efficient waste management for health care Institutions in Nepal.
Thus, the research also explored the availability of such waste guidelines. The result showed that very few SHPs (6.3%) and Sangini Outlet (5.1%) verified the availability of waste disposal guideline but in comparisons to them, slightly more of the health posts (19.3%), Private Hospitals/PSSN (12.5%) and Medical Centers/Polyclinic (21.1%)
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verified the availability of the waste disposal guidelines. Similarly, the government hospitals (50%) and PHCCS (30%) were the ones that verified the availability of such guidelines. The availability of waste disposal guidelines have decreased in SHPs, HPs and increased for PHCCs compared to the baseline data though in overall the availability seemed to be relatively decreased i.e. 27% in baseline to 14% in this survey. (Refer Table 3-57)
The comparative study of the data in five development regions showed that the availability of waste disposal guidelines was observed to be highest (20%) for mid western development region. In terms of urban and rural scenarios, unlike the above FP guidelines and antenatal job aids, the availability verification was more for urban regarding the waste disposal guidelines. The verification of the waste disposal guideline was also highest (36%) for the NGO sector SDPs. (See Annex18)
Table 3-57: Availability of family planning guidelines, ANC/PNC job aids and Waste disposal guidelines by type of SDPs Percentage Family planning guidelines Waste disposal Total ANC/ PNC job-aids (national-NMS Vol-1) guidelines Sample Type of Facility Yes, Yes, Yes, Yes, Yes, Yes, Availability Size Availability Availability not Availability Availability Availability not verified (N) verified verified verified verified not verified Sub Health Post 41.9% 21.8% 35.8% 23.1% 6.3% 8.9% 394 Health Post 56.3% 17.2% 53.6% 19.4% 19.3% 13.0% 238 Primary Health 75.0% 11.1% 61.1% 22.2% 30.6% 11.1% 36 Care Center Government 77.8% 22.2% 66.7% 16.7% 50.0% 5.6% 18 Hospital Sangini outlet 23.1% 12.8% 0.0% 5.1% 5.1% 2.6% 39 Medical centers/ 15.8% 10.5% 15.8% 0.0% 21.1% 0.0% 19 Poly clinic Private hospitals/ 50.0% 0.0% 37.5% 12.5% 12.5% 25.0% 8 PSSN FPAN/Marie stopes/NGO 54.5% 27.3% 36.4% 18.2% 36.4% 9.1% 11 Hospital Total 47.4% 19.0% 40.9% 20.1% 13.4% 9.8% 763
3.8. Use of Information Communication Technology (ICT) and Waste Disposal
The wider use of information and communication technology (ICT) in healthcare is a basic condition for the development, implementation and further generation of innovative health care technologies. It is part of healthcare structure in any organizations to support the processes and consequently to deliver better outcome to organization and particularly to the patient. Therefore social capacity, knowledge and acceptance to utilize ICT technologies among citizens and medical professionals need to be strengthened throughout the country.
This section briefs on the availability and use of the different types of ICT being used, how ICT was acquired and use of ICT in the health sector as well as method of waste disposal used by the SDPs.
3.8.1. ICTs Available and How Acquired
ICTs Available in SDPs
This survey showed that, in majority of SDPs mobile phones were used as a primary means for communication. Similarly computer, landline telephone and Internet were also used in most SDPs for communication. The use of internet facilities in case of PHCCs (46%) and government hospitals (67%) were higher compared to other
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government facilities however, the use of internet facilities in the government facilities was limited to only hospitals in baseline study (2013/14). The use of computer in the government SDPs have also increased in PHCCs and government hospitals compared to the baseline data. Also from this survey it was found that computers were highly used in private hospitals (100%) and NGO sector (90.9%). (Refer Table 3-58)
While comparing the rural and urban scenario, most of the SDPs in the urban settings used computer (43%) and internet facilities (28%) compared to only 10% and 5% of rural SDPs using computer and internet facilities respectively. The private and NGO sector were way ahead in terms of using computer and internet facilities compared to the government facilities where merely 12% used computer and 6% used internet facilities. (See Annex19) Table 3-58: ICTs available in SDPs by type of SDPs Percentage Total Sample Characteristics Mobile Landline Internet Size Computer Others* phones telephone facilities (N) Type of Facility Sub Health Post 3.8% 93.6% 3.2% .3% .6% 343 Health Post 9.4% 93.8% 10.7% 4.0% 3.6% 224 Primary Health 68.6% 91.4% 40.0% 45.7% 2.9% 35 Care Center Government 77.8% 88.9% 83.3% 66.7% 61.1% 18 Hospital Sangini outlet 23.1% 92.3% 48.7% 12.8% 12.8% 39 Medical centers/ 63.2% 94.7% 57.9% 42.1% 21.1% 19 Poly clinic Private hospitals 100.0% 87.5% 87.5% 75.0% 62.5% 8 /PSSN FPAN/Marie stopes/NGO 90.9% 72.7% 72.7% 45.5% 18.2% 11 Hospital Total 15.9% 93.0% 15.6% 8.9% 5.5% 697 * Others include: Fax, tablets, TV, FM/Radio
How ICTs was Acquired by SDPs
When asked about the how those ICT was obtained by the SDPs most of them (93%) reported that the ICT they used were staff members’ personal item. However, in most of the PHCCs (67%) and government hospitals (78%) ICT were also provided through government. The baseline data showed that though large number of SDPs had the ICT as the staff members’ personal items still about 38% of the SDPs had reported that they received the ICT from the government; this figure has decreased to 10% only in this survey. (Refer Table 3-59)
Apart from the ICTs being acquired as the staff members personal item, more of the SDPs in urban setting have received the ICT from the government as well as HDP/HFOMC/proprietor of the company compared to the rural SDPs. Few of the SDPs also have received the ICT as donation highest being for rural SDPs. More of the NGO sector facilities have received the ICT from the proprietor of the company compared to government and private facilities. (See Annex 20)
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Table 3-59: How ICT was acquired by type of SDPs Percentage Provided by Total Sample Staff Provided HDP/HFOMC/ Received as Size Characteristics members by proprietor of Donation (N) personal item government company Type of Facility Sub Health Post 96.8% 2.0% .6% .9% 343 Health Post 95.5% 8.5% 3.1% 3.1% 224 Primary Health Care 77.1% 65.7% 0.0% 2.9% 35 Center Government 77.8% 77.8% 5.6% 16.7% 18 Hospital Sangini outlet 89.7% 2.6% 10.3% 0.0% 39 Medical centers/ 94.7% 10.5% 87.5% 0.0% 19 Poly clinic Private hospitals 62.5% 0.0% 72.7% 0.0% 8 /PSSN FPAN/Marie stopes/NGO 45.5% 9.1% .6% 0.0% 11 Hospital Total 93.3% 9.6% 4.9% 2.0% 697
3.8.2. Uses of ICTs by SDPs
The use of ICT in any health facilities provides better opportunities for medical professionals and healthcare providers to obtain information, communicate with professionals, promote awareness programmes, and promote preventive programmes and so on. Its application in health includes more effective planning, decision making and monitoring and more effective resource management. ICT can play a vital role in training and updating the knowledge and practices of health professionals in health facilities in urban settings as well as in rural areas, where it is often needed the most.
As reported by the respondents, routine communication was the main purpose for which the ICT was used in majority of SDPs (more than 85% of the government SDPs). Similar result was obtained in 2013/14 survey where nearly 75% of the government SDPs used ICT for routine communication.
One of the major uses of information technologies in the medical world is the use of mobile terminals to provide healthcare from remote locations, or to provide speedy on-the-spot responses to medical emergencies, along with the increase in the use of Internet and Intranet technologies. This has also been observed in our survey as more than 38% of the SDPs had reported to use ICT for clinical consultation i.e. long distance communication with the experts. Besides, the use of ICT was also commonly observed for supply chain management and stock control (35%) and health worker training (24%). The use of ICT for patient registration though was done by few of the SDPs; this was prevalent for most of the government hospitals and private hospitals. Compared to nearly 30% of the government SDPs using ICT for facility record keeping as reported in baseline data, only 10% of them were using ICT for the similar purpose in this survey. (Refer Table 3-60)
In case of geographical area, apart from routine communication supply chain management and stock control was the main purpose for which ICT was used in both urban and rural areas. Also, most of the SDPs in the urban area (27%) also used ICT for patient registration purpose compared to the rural ones (5%). Compared to more than 80% of the facilities using ICT for routine communication only half of the NGOs used ICT for the same purpose. The use of ICT was mostly done for patient registration, clinical consultation and health worker training in NGO sector. (See Annex 21)
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Table 3-60: Main use of ICT by type of SDPs Percentage
Characteristics
ance
money cash
Total Sample size
keeping Patient registration Patient record Facility Mobile and transfers payments Routine communication Clinical consultation (long dist communication with experts) Awareness and creation demand activities Supply chain management/stock control worker Health training Others Type of Facility Sub Health Post 0.9% 2.9% .3% 89.5% 36.2% 12.2% 29.2% 21.9% 6.7% 343 Health Post 6.7% 8.0% 1.8% 85.3% 40.6% 20.5% 36.6% 28.1% 8.1% 224 Primary Health 20.0% 42.9% 5.7% 74.3% 34.3% 31.4% 45.7% 28.6% 28.6% 35 Care Center Government 50.0% 66.7% 22.2% 77.8% 44.4% 44.4% 61.1% 44.4% 33.3% 18 Hospital Sangini outlet 10.3% 23.1% 7.7% 82.1% 30.8% 17.9% 53.8% 2.6% 10.3% 39 Medical 42.1% 52.6% 10.5% 78.9% 57.9% 21.1% 52.6% 21.1% 15.8% 19 centers/Poly clinic Private hospitals 100.0% 87.5% 37.5% 75.0% 37.5% 12.5% 25.0% 12.5% 25.0% 8 /PSSN FPAN/Marie stopes/NGO 63.6% 90.9% 18.2% 54.5% 54.5% 36.4% 45.5% 54.5% 63.6% 11 hospital Total 8.8% 13.1% 3.0% 85.7% 38.3% 17.6% 35.4% 24.1% 10.5% 697 *Others include : Individual patient records/Electronic Medical Record, Health Insurance Claims and Reimbursement System, etc.
3.8.3. Methods of Waste Disposal
The increase in number of health care institutions in Nepal, have consequentially increased the amount of medical waste. The large amounts of diverse wastes, most of which are hazardous, generated by health institutions require proper collection, transportation and disposal. Studies revealed that majority of health care institutions do not practice safe waste handling, storage and disposal methods, resulting in high incidence of hospital-acquired injection. Thus, the management of health-care waste has been an integral part of the health care system.
Table 3-61 below shows the methods of waste disposal in different SDPs. This survey result showed that more than half of SDPs (65%) managed their waste products by burning; nearly 23% SDPs managed by buried the waste in special dump pits, few SDPs (9%) used incinerators whereas disposing away from the SDPs and disposed with regular garbage were practiced in a negligible proportion. In case of government facilities, use of incinerators were mostly common in hospitals compared to other public facilities, similar finding was observed in baseline survey. Also comparatively the use of incinerators has increased in all level government facilities. The practice of disposing the health facility waste with other wastes was observed to be relatively less (0.3%) compared to the baseline data (about 2%).
In case of development region, common method of waste disposal was burning in most of SDPs in all regions and the incineration was relatively more practiced in the SDPs in Mid-western and Far-western region. In case of geographical area, burning was used as the primary method of waste disposal in more of the SDPs from rural areas (69%) whereas in urban area in addition to burning practiced by 49% of SDPs, the use of incinerators and burying in special dump pits were also common. In terms of management, the use of incinerators was the primary source of waste disposal method in NGO sector facilities (73% practiced incineration in NGO sector) however burning was a common practice observed in Government as well as NGO sector facilities. (See Annex 22)
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Table 3-61: Methods of waste disposal by type of SDPs Percentage Centrally collected Disposed Total Use of Type of Facility Bury in special by specific agency with Sample Burning Incinerators size dump pits for disposal away regular from the SDP garbage Sub Health Post 69.5% 24.1% 5.6% .3% .5% 394 Health Post 68.5% 21.0% 10.1% .4% 0.0% 238 Primary Health Care 52.8% 30.6% 16.7% 0.0% 0.0% 36 Center Government Hospital 50.0% 22.2% 22.2% 5.6% 0.0% 18 Sangini outlet 56.4% 15.4% 2.6% 20.5% 5.1% 39 Medical centers/ Poly 36.8% 21.1% 5.3% 31.6% 5.3% 19 clinic Private hospitals /PSSN 37.5% 12.5% 0.0% 37.5% 12.5% 8 FPAN/Marie 18.2% 9.1% 72.7% 0.0% 0.0% 11 stopes/NGO hospital Total 65.4% 22.5% 8.7% 2.6% .8% 763
3.9. Charges for User Fees
3.9.1. Charges and Exemptions for User Fees
User fees is one of the major source of facility revenue in many low-income countries, often used for purchasing drugs and supplies and paying incentives to health workers. However, the removal or the exemption in user fee has been practiced in most of the public health facilities to reduce impoverishment, and eventually reduce maternal and neonatal mortality. In past five year, in response to difficulty in accessing the health facilities as well as rising poverty in the country, government has been trying out various approaches to remove or exempt user fees (witter, et.al, 2011). The abolition or the exemptions of fees can be focused either on level of health services or type of health facilities (public or private) or on population group depending on the country context however in any of the context studies showed an increase in the number of visits of the clients between the periods before and after fees abolition (Morestin and Valery, 2009).
This survey also looks into the issue of charges for user fees regarding the services provided by the SDP as well as for services provided by a qualified health care provider. Further, the exemption in user fees by services provided by SDP as well as services provided by a qualified health care provider is also inquired in all levels SDPs.
Facility Charging Patients and Exemptions of User Fees- Services provided by the Facility
In terms of facility charging patients, very few of SHPs and HPs i.e. about 10% reported that they charge their patients for the services provided which was observed to be higher than the baseline survey where hardly 3% of the SDPs claimed to charge for the services provided. In government hospitals about 44% reported to charge their patients for service provided which is comparatively higher than baseline survey where only 23% of the hospitals were charged their patients for the services provided by the SDP. Nevertheless, the important thing to be noted is that in government facilities, the patients are charged for registration fee only for the services they have taken in the SDP. In majority of the private (about 90%) and NGO sector facilities (72%) user fees was charged to their patients for the services provided to them.
Regarding the exemptions for the user fees for services, almost all the government facilities exempted the fees for family planning services, antenatal care services, delivery services as well as post natal care services. Very few of the public SDPs exempted for care of sick children under 5 years and HIV care (e.g. HTC and ART) services. More of
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the SHPs and PHCCs exempted for user fees for HIV care services compared to hospitals. The exemptions for user fee were limited to some of the medical centers/ Polyclinics and FPAN/maries topes and NGO hospitals particularly for family planning services. (Refer Table 3-62)
Relatively few of the SDPs in rural area paid for the charges for the services provided and in the same way most of the exemptions for the user fees were made by rural SDPs particularly for antenatal care, delivery and family planning services. As expected nearly every SDPs in private and NGO sectors charged their patients for the services provided compared to only few (11%) of the SDPs in government sector. (See Annex 23)
The above result showed that most of the exemption of user fees for services provided in Nepal is mostly applicable for the public sector facilities and some of the NGO facilities and very few of the private sector facilities, nonetheless generally limited to family planning services.
Table 3-62: Issues for which user fee charged and exemptions for user fees – services provided by type of facility Percentage HIV Care Total Facility Post care Family Antenatal Newborn of sick sample charging Delivery natal (e.g. Characteristics planning care care children size patients services care HTC services services services under (N) services and 5 years ART) Type of Facility % N Sub Health Post 95.0% 97.5% 97.5% 82.5% 65.0% 35.0% 27.5% 40 10.2% 394 Health Post 87.0% 95.7% 95.7% 73.9% 30.4% 13.0% 13.0% 23 9.7% 238 Primary Health 75.0% 100.0% 100.0% 87.5% 62.5% 37.5% 37.5% 8 22.2% 36 Care Center Government 100.0% 100.0% 100.0% 75.0% 50.0% 37.5% 25.0% 8 44.4% 18 Hospital Sangini outlet 11.4% 0.0% 0.0% 0.0% 0.0% 5.7% 0.0% 35 89.7% 39 Medical centers/ 41.2% 11.8% 11.8% 11.8% 11.8% 17.6% 5.9% 17 89.5% 19 Poly clinic Private hospitals 0.0% 14.3% 28.6% 0.0% 0.0% 14.3% 0.0% 7 87.5% 8 /PSSN FPAN/Marie stopes/NGO 50.0% 37.5% 0.0% 0.0% 0.0% 0.0% 0.0% 8 72.7% 11 Hospital Total 59.6% 56.8% 55.5% 44.5% 30.1% 19.9% 13.7% 146 19.1% 763 Note: *The charge incurred by the patients in government facility is mostly for registration, few for abortion services and after hour charges
Facility Charging Patients and Exemptions of User Fees- Services provided by a Qualified Health Care Provider
Regarding the fee charged for services provided by the health care provider in the SDPs a small number of (only 3%) of public SDPs claimed to charge their patients most of them leaning towards hospitals (about 22%), PHCCs (about 19%). Almost all of the private sector facilities and more than 50% of the NGOs claimed to charge their patients for the services offered by the qualified health care provider. The exemptions of the services were particularly applicable for family planning methods and maternal health medicines made available by a qualified health care provider in public facilities. Unlike the government hospitals, the exemptions in user fee is made in small amount of private SDPs, mostly for child health medicines except in case of sangini outlets where exemption is typically made for family planning methods. Similarly for NGOs the exemptions in family planning methods offered by the qualified health care provider was high. (Refer Table 3-63)
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Relatively few of the SDPs in rural area paid for the charges for the services provided by the qualified health care provider and in the same way most of the exemptions for the user fees were made for family planning methods and maternal health medicines in rural area. (See Annex 24)
Table 3-63: Issues for which user fee is charged and exemptions for user fees for services provided by a qualified health care provider by type of facility Percentage Total Facility charging Family Maternal Child health sample patients Characteristics planning health medicines size(N) methods medicines Type of Facility % N Sub Health Post 100.0% 83.3% 50.0% 6 1.5% 394 Health Post 75.0% 100.0% 50.0% 4 1.7% 238 Primary Health Care 85.7% 85.7% 28.6% 7 19.4% 36 Center Government Hospital 75.0% 75.0% 25.0% 4 22.2% 18 Sangini outlet 22.6% 3.2% 9.7% 31 79.5% 39 Medical centers/ Poly 16.7% 5.6% 22.2% 18 94.7% 19 clinic Private hospitals /PSSN 0.0% 28.6% 57.1% 7 87.5% 8 FPAN/Marie stopes/NGO 42.9% 14.3% 14.3% 7 63.6% 11 Hospital Total 36.9% 27.4% 23.8% 84 11.0% 763
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PART 4: SURVEY FINDINGS FOR EXIT INTERVIEW The client interview provides an opportunity to incorporate the views of the clients regarding the experiences with the services provided by the health facilities. The chapter of the report focuses on the results of the exit interview and as a result discusses information from the exit interview for client’s perception regarding various aspects of service delivery; and clients’ estimation of the cost of FP. These client survey interviews were conducted as a regular process of program monitoring. It is necessary to be cautious when interpreting the results of exit interview because these are the opinions of men and women who had received services, so may not be representative of the general population. Also, clients’ satisfaction is difficult to measure as it is affected by client’s expectation and knowledge. Clients commonly underreport dissatisfaction, especially at exit interviews given that they are conducted at health facilities or they need to seek services from the same facilities in future as well.
4.1 Background Characteristics of Clients
The background characteristics of the clients are taken to obtain the general profile of the clients attending the different health facilities. This chapter presents the general characteristics of the clients collected through client exit interviews in terms of their age and sex distribution, marital status, education and their visits to SDP. The analyses are based on total of 3823 clients interviewed and the data are assembled according to type of facility, development region, residence and management of the facility.
3.9.2. Sex and Age distribution
Sex distribution
Table 4-1 clearly showed the dominancy of female clients (95%) in all type of health facilities surveyed. The highest number of clients were interviewed from central and eastern development region and least from the mid west region. Likewise, analysis based on development region also showed the greater number of female clients in the entire development region. Similarly, on the basis of residence of the clients, more clients were interviewed from the rural areas than the urban are and large number of female clients were observed in both the urban and rural areas. Relatively more of the male clients were interviewed in private (17%) and NGO (17%) sector facilities compared to 3% of male clients interviewed in government facilities.
Table 4-1: Sex distribution of clients according to type of facility, region, residence and management of the SDP Percentage Characteristics Total sample size (N) Male Female Type of Facility Sub Health Post 3.7% 96.3% 1929 Health Post 3.2% 96.7% 1164 Primary Health Care Center 3.9% 96.1% 179 District Hospital 6.9% 93.1% 175 Private Hospital/PSSN 23.1% 76.9% 39 Sangini outlet 12.1% 87.9% 190 Medical Centre/Polyclinic 25.3% 74.7% 87 FPAN/Marie stope/ 15.0% 85.0% 60 NGO hospitals Region Eastern Development Region 3.9% 96.1% 974 Central Development Region 4.6% 95.3% 983
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Percentage Characteristics Total sample size (N) Male Female Western Development Region 6.8% 93.2% 676 Mid-Western Development 3.2% 96.8% 562 Far-Western Development 7.0% 93.0% 628 Region Residence Urban 9.4% 90.6% 629 Rural 4.1% 95.8% 3194 Management Government 3.7% 96.3% 3447 Private 17.1% 82.9% 316 NGOs 15.0% 85.0% 60
Total 5.0% 95.0% 3823
Age distribution
Of the total clients interviewed, a large number of the clients aged between 25 to 29 and 30 to 34 years were found to visit health facilities for family planning services followed by nearly one fourth of the clients of the age group 15 to 24 years. In contrast, clients above 45 years of age were the lowest to be interviewed. Compared to government facilities more of the clients of age group 15 to 24 years were interviewed from the private sector facilities. (Refer Table 4-2)
Table 4-2: Age distribution of clients according to type of facility, region, residence and management of the SDP Age group Total sample Characteristics 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50+ size (N) Type of Facility Sub Health Post 3.0% 18.1% 28.5% 24.6% 16.3% 7.9% 1.5% .1% 1929 Health Post 3.8% 18.8% 29.9% 21.5% 16.1% 8.2% 1.7% .1% 1164 Primary Health Care Center 1.7% 22.3% 31.3% 26.3% 11.7% 5.6% 1.1% 179 Government Hospital 4.0% 17.7% 30.9% 21.7% 20.0% 4.6% 1.1% 0.0% 175 Private Hospital/PSSN 0.0% 17.9% 30.8% 28.2% 12.8% 10.3% 0.0% 0.0% 39 Sangini outlet 5.3% 24.2% 34.2% 21.6% 10.0% 3.7% 1.1% 190 Medical Centre/ Poly Clinic 0.0% 20.7% 41.4% 25.3% 9.2% 2.3% 1.1% 0.0% 87 FPAN/Marie stope/ 3.3% 20.0% 33.3% 20.0% 15.0% 6.7% 0.0% 1.7% 60 NGO hospitals Region Eastern Development 3.1% 19.7% 30.4% 22.9% 14.6% 8.1% 1.1% .1% 974 Region Central Development 4.1% 15.5% 28.2% 20.2% 18.6% 11.3% 1.9% .2% 983 Region Western Development 2.1% 17.9% 27.2% 26.2% 19.1% 5.6% 1.9% 676 Region Mid-Western Development 3.7% 19.6% 32.4% 28.1% 11.6% 3.9% .7% 562 Region Far-Western Development 3.0% 23.6% 32.2% 22.0% 12.6% 5.1% 1.4% .2% 628 Region Residence
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Age group Total sample Characteristics 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50+ size (N) Urban 3.2% 19.2% 34.0% 21.3% 15.7% 5.7% .8% 0.0% 629 Rural 3.3% 18.8% 29.0% 23.8% 15.6% 7.7% 1.6% .1% 3194 Management Government 3.2% 18.6% 29.2% 23.5% 16.2% 7.7% 1.5% .1% 3447 Private 3.2% 22.5% 35.8% 23.4% 10.1% 4.1% .9% 0.0% 316 NGOs 3.3% 20.0% 33.3% 20.0% 15.0% 6.7% 0.0% 1.7% 60
Total 3.2% 18.9% 29.8% 23.4% 15.6% 7.4% 1.5% .1% 3823
3.9.3. Marital Status In overall the marital status of almost all of the clients (about 98.9%) interviewed were currently married or in union except for about 1% of the clients who were under the category of never married and formerly married (divorced/separated/widowed). (Refer Table 4-3)
Table 4-3: Marital status of clients according to type of facility, region, residence and management of the SDP Marital Status Total Characteristics Never Married or Currently married Formerly married sample in union or in union (divorced/Separated/widow) size (N) Type of Facility Sub Health Post .6% 99.3% .1% 1929 Health Post 1.0% 98.9% .1% 1164 Primary Health Care .6% 98.9% .6% 179 Center Government Hospital 2.3% 97.1% .6% 175 Private Hospital/PSSN 5.1% 94.9% 0.0% 39 Sangini outlet 2.6% 97.4% 190 Medical Centre/ Poly Clinic 4.6% 95.4% 0.0% 87 FPAN/Marie stope/ 5.0% 95.0% 0.0% 60 NGO hospitals Region Eastern Development 1.3% 98.7% 974 Central Development .8% 98.9% .3% 983 Western Development 1.0% 99.0% 676 Mid-Western Development 1.1% 98.8% .2% 562 Far-Western Development 1.4% 98.6% 628 Residence Urban 2.4% 97.5% .2% 629 Rural .9% 99.0% .1% 3194 Management Government .8% 99.0% .1% 3447 Private 3.5% 96.5% 0.0% 316 NGOs 5.0% 95.0% 0.0% 60
Total 1.1% 98.8% .1% 3823
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3.9.4. Education
The educational status of the clients was assessed based on four levels (never attending school, primary, lower secondary and higher levels). In general, more than half of the surveyed clients (60%) have not attended school which comprises both illiterate and literate clients with informal education. More of such clients were interviewed from sub- health post followed by health post. Furthermore, such clients were found to reside mostly in central development region and rural areas. More of clients with education level higher than secondary were found to attend private SDPs compared to government SDPs as well as in urban area. Additionally, at least primary level of education was found to be greatest in terms of formal level of education. (Refer Table 4-4)
Table 4-4: Education level of clients according to type of facility, region, residence and management of the SDP Percentage Total
Lower Secondary and sample Characteristics Not Attended School Primary secondary higher level size (N) Type of Facility Sub Health Post 65.2% 8.9% 15.3% 10.6% 1929 Health Post 59.7% 10.7% 17.7% 11.9% 1164 Primary Health Care 58.1% 11.2% 14.0% 16.8% 179 Center Government Hospital 45.7% 13.1% 16.0% 25.1% 175 Private Hospital/PSSN 30.8% 10.3% 30.8% 28.2% 39 Sangini outlet 26.8% 13.7% 24.7% 34.7% 190 Medical Centre/Poly Clinic 37.9% 9.2% 17.2% 35.6% 87 FPAN/Marie stope/ 41.7% 13.3% 25.0% 20.0% 60 NGO hospitals Region Eastern Development 60.9% 6.3% 17.8% 15.1% 974 Region Central Development 70.0% 7.5% 11.7% 10.8% 983 Region Western Development 55.9% 14.8% 20.3% 9.0% 676 Region Mid-Western Development 49.1% 8.9% 22.8% 19.2% 562 Region Far-Western Development 51.3% 16.1% 14.3% 18.3% 628 Region Residence Urban 45.8% 14.0% 18.6% 21.6% 629 Rural 61.6% 9.3% 16.5% 12.6% 3194 Management Government 62.0% 9.9% 16.1% 12.1% 3447 Private 30.4% 12.0% 23.4% 34.2% 316 NGOs 41.7% 13.3% 25.0% 20.0% 60
Total 59.0% 10.1% 16.8% 14.0% 3823
3.9.5. Frequency of visit to SDP for family planning services
Regarding the frequency of visits to clients to the SDPs, a large number of clients visited the SDP once in every three months (72%) and some even preferred to the visit once a month. More of the clients interviewed in the urban area
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visited the health facilities once a month compared to the clients in the rural areas. Similarly nearly 1/4th of the clients in private and NGO sector visited the SDP once a month, which was relatively higher than the clients in government SDPs.
Table 4-5: Frequency of visits to SDPs by clients according to type of facility, region, residence and management of the SDP Percentage Total Once in At least once a Once in every sample Characteristics every three yearly Others month two months size (N) months Type of Facility Sub Health Post 20.0% 4.2% 73.2% .5% 2.1% 1929 Health Post 19.5% 4.1% 72.0% .7% 3.7% 1164 Primary Health Care 16.2% 2.2% 78.2% .6% 2.8% 179 Center Government Hospital 18.9% 6.9% 64.0% 4.6% 5.7% 175 Private Hospital/PSSN 35.9% 2.6% 56.4% 5.1% 0.0% 39 Sangini outlet 14.7% 2.6% 70.5% 12.1% 190 Medical Centre/ Poly 33.3% 2.3% 51.7% 12.6% 0.0% 87 Clinic FPAN/Marie stope/ 25.0% 3.3% 60.0% 11.7% 0.0% 60 NGO hospitals Region Eastern Development 18.4% 5.9% 74.6% .3% .8% 974 Region Central Development 13.6% 2.8% 75.9% 1.3% 6.3% 983 Region Western Development 24.7% 3.3% 69.1% .1% 2.8% 676 Region Mid-Western 15.5% 6.4% 73.7% .5% 3.9% 562 Development Region Far-Western 30.9% 1.9% 61.3% 1.4% 4.5% 628 Development Region Residence Urban 21.1% 3.7% 68.2% 1.0% 6.0% 629 Rural 19.7% 4.1% 72.3% .7% 3.2% 3194 Management Government 19.6% 4.2% 72.6% .8% 2.8% 3447 Private 22.5% 2.5% 63.6% 11.4% 0.0% 316 NGOs 25.0% 3.3% 60.0% 11.7% 0.0% 60
Total 19.9% 4.1% 71.6% .8% 3.6% 3823 *Others include: Not sure when required; during camps; not so often
4.2 Clients’ Perception of Family Planning Service Provision Clients’ satisfaction is considered as one of the desired outcomes of health care and it is directly related with utilization of health services. Thus, clients’ perception or the satisfaction level over the services provided by the facility is considered as the valuable feedback on the services provided by the SDPs such as cost, the helpfulness of support staff, treatment received and the physical setting of services however the results cannot be taken as the robust outcome. This chapter presents clients perspective of family planning service provider adherence to technical issues,
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organization, interpersonal and outcome aspect; categorized based on type of facility, development regions, their residence and management of the facility. This is purely perspective of the clients who were interviewed on the day of survey and they might not necessarily represent all the clients visiting the facility and it may not necessarily reflect the actual situation of the SDPs. 3.10.1. Provider Adherence to Technical Aspects
About 99% of the clients, on an average (with a lowest of 95% for Primary Health Care Center), who were offered the family planning services, stated that they were provided with the method of their choice. A similar percentage (98.9%) agreed that client’s preference and wishes were taken into consideration and approx. about 96% of them reported that the date of return to SDP for checkups or additional supplies was explained to them.
However, comparatively, quite a low percentage of respondents (74.3%) reported that they were taught how to use the method, the lowest being in Medical Centers/Poly Clinics (46%) as well as relatively low in overall private sector compared to NGO and government sector SDPs. Majority of clients (89.4%) overall, reported having received information for occurrences of any serious complication on using family planning services, however, the percentage was quite low particularly, in the case of private sector SDPs. In addition, almost all the clients as many as 99% also stated that they made their own decision to use FP service. Nevertheless, very small number of clients, merely 5% stated that they had to return from the SDP due to the lack of FP services or due to the lack of maternal/RH medicines when needed, which was stated slightly more in government SDPs. (Refer Table 4-6 and 4-7)
Also, all the statements asked to the clients in the prospective of technical aspects of the SDP were found to be positive and more or less equally distributed across all development regions. On an average, clients interviewed from rural area received more information from the FP service provider compared to those from urban areas. More of the clients from government facilities had positive responses towards the facilities’ efficacy towards the technical aspect; compared to those of the private ones. (See Annex 25 and Annex 26)
Table 4-6: Clients perspective of FP service provider’s adherence to technical aspects by clients Percentage
bout bout
up
Characteristics - Total sample size
(N) Provided with method of of method with Provided choice their clients took Provider into wishes and preference consideration the to use how taught Client method common the about told Client method the of effects side a Client informed Provider be regarding done can what method the of effects side the about client informed Provider any case in to do what occur complications serious to return date given Client check for to SDP supplies /or additional and Type of Facility Sub Health Post 99.1% 99.1% 75.9% 92.6% 91.3% 90.9% 97.9% 1929 Health Post 98.8% 99.2% 76.5% 95.2% 94.2% 91.7% 98.0% 1164 Primary Health Care Center 95.0% 96.1% 73.2% 88.3% 87.2% 83.8% 95.5% 179 Government Hospital 100.0% 99.4% 78.9% 90.3% 87.4% 86.3% 93.7% 175 Private Hospital/PSSN 100.0% 100.0% 66.7% 82.1% 79.5% 84.6% 76.9% 39 Sangini outlet 100.0% 98.4% 60.0% 78.9% 77.4% 77.4% 83.2% 190 Medical Centre/ Poly Clinic 100.0% 97.7% 46.0% 72.4% 72.4% 70.1% 71.3% 87 FPAN/Marie stope/NGO 100.0% 98.3% 63.3% 90.0% 91.7% 88.3% 88.3% 60 hospitals Total 98.9 98.9 74.3 91.8 90.6 89.4 95.9 3823
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Table 4-7: Clients perspective of FP service provider’s adherence to technical issues Percentage Returned from SDP Made decision Returned from SDP due to Total Characteristics due to lack of FP to use FP lack of Maternal / RH sample services needed services Medicines when needed size (N) Type of Facility Sub Health Post 4.8% 98.9% 5.1% 1929 Health Post 4.8% 99.1% 3.5% 1164 Primary Health Care Center 8.4% 98.1% 8.4% 179 Government Hospital 4.0% 86.3% 4.6% 175 Private Hospital/PSSN 5.1% 100.0% 5.1% 39 Sangini outlet 2.2% 100.0% 1.6% 190 Medical Centre/ Poly Clinic 4.6% 92.0% 5.7% 87 FPAN/Marie stope/NGO 1.7% 98.3% 1.7% 60 hospitals Total 4.8% 99.0% 4.6% 3823
3.10.2. Organization Aspect
Regarding the organization aspect, some of the inquiry about the cleanliness, privacy and satisfaction with the time allocated were done to the clients. Majority of clients, as many as 90% in average showed their satisfaction over the cleanliness of the health facility, privacy at the exam room as well as time allocated to their case. Also, only about 9% of the clients stated that they had to wait long to receive the service, which is relatively less when compared to 22% of the clients in baseline data. Within the government facilities more of the clients in the government hospitals perceived waiting time being too long compared to PHCCs, SHPs and HPs. (Refer Table 4-8). Also, relatively more of the clients in private and NGOs perceived waiting time as long compared to government. Similarly more of the clients (12%) in urban SDPs complained about waiting time being too long compared to clients in rural SDPs (8%). (Refer Annex 27)
Table 4-8: Clients perspective of FP service provider’s adherence to organizational aspects Percentage
Client satisfied Client satisfied with Client perceived Client satisfied with Total with the privacy the time that was Characteristics waiting time as the cleanliness of sample at the exam allotted to his/her too long the health facility size (N) room case Type of Facility Sub Health Post 8.5% 96.5% 90.7% 99.3% 1929 Health Post 6.6% 96.5% 96.7% 99.6% 1164 Primary Health Care 15.6% 91.6% 97.2% 97.2% 179 Center Government Hospital 20.0% 94.3% 98.3% 98.9% 175 Private 7.7% 97.4% 94.9% 97.4% 39 Hospital/PSSN Sangini outlet 11.6% 98.4% 96.3% 98.4% 190 Medical Centre /Poly 13.8% 98.9% 97.7% 98.9% 87 Clinic FPAN/Marie 16.7% 98.3% 93.3% 100.0% 60 stope/NGO hospitals Total 9.2 96.4 93.7 99.2 3823
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3.10.3. Inter-Personal Aspect
The evaluation of inter personal aspect of the staffs of the SDPs were also done. For this clients were inquired about how they were treated by the staffs and were they satisfied by the attitude of the health provider in general. Almost all of the clients (98%) stated that they were treated with courtesy and respect by the staff as well as nearly every client indicated that they were satisfied with the attitude of the health provider towards them. Slightly more of the clients from urban area perceived better inter-personal aspects of the health facility staffs. (Refer Annex 28)
Table 4-9: Clients perspective of FP service provider’s adherence to inter-personal aspects Percentage Client indicated he/she was treated Client satisfied with the attitude of Total Characteristics with courtesy and respect by staff the health provider towards him/her sample size at the SDP generally (N) Type of Facility Sub Health Post 98.0% 99.5% 1929 Health Post 97.9% 99.5% 1164 Primary Health Care 94.9% 96.0% 179 Center Government Hospital 98.9% 98.9% 175 Private 97.4% 97.4% 39 Hospital/PSSN Sangini outlet 97.9% 98.9% 190 Medical Centre/ Poly 100.0% 100.0% 87 Clinic FPAN/Marie 100.0% 98.3% 60 stope/NGO hospitals
Total 98.0 99.3 3823
3.10.4. Outcome Aspect
For measuring the outcome aspect of SDPs, few indicators such as client’s satisfaction over the services received, client’s willingness to continue visiting the SDP in future as well as recommend the SDP they visited to relatives or friends were considered.
When asked about the satisfaction over the services they received nearly all of the clients showed their satisfaction and no notable difference in proportion of such clients were observed in accordance to type of facility or regions or residence or management of the facility. Likewise in terms of understanding their willingness to visit the SDP in the future and recommending the SDP to others, as many as 99% and 96% of the clients stated that they will continue visiting the SDP in the future. (Refer Table 4-10)
Relatively less of the clients in NGO sector facilities compared to government and private facilities stated that they would recommended the SDP to other relative or friends, though all of the clients interviewed in the NGO sector were satisfied with the services received. Across the entire development region, the clients were satisfied with the services they received and a large number of them stated in all the regions stated that they will continue their service as well as recommend the SDP to others. Slightly more of the clients from urban areas were satisfied with the services they were getting from the SDPs compared to the rural clients. (Refer Annex 29)
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Table 4-10: Clients perspective of FP service provider’s adherence to outcome aspects Percentage Total Client will continue Client satisfied with Client would recommend this sample size Characteristics visiting this SDP in the service received SDP to relatives or friends (N) future Type of Facility Sub Health Post 99.0% 99.0% 97.2% 1929 Health Post 99.4% 99.0% 96.6% 1164 Primary Health Care 95.0% 98.3% 92.7% 179 Center Government Hospital 100.0% 100.0% 98.3% 175 Private Hospital/PSSN 100.0% 97.4% 97.4% 39 Sangini outlet 99.5% 97.9% 93.2% 190 Medical Centre/ Poly 100.0% 97.7% 93.1% 87 Clinic FPAN/Marie stope/NGO 100.0% 100.0% 86.7% 60 hospitals
Total 99.1 98.9 96.4 3823
Thus, looking at the technical aspects, organization aspects, inter-personal aspects as well as outcome aspects of the SDPs from the perception of the clients receiving the services, in overall high positive responses from the clients were observed regarding the family planning services they received in the SDPs. It was particularly encouraging to see that the clients made their own decision to use FP services and that they did not have to return from the SDP due to the lack of FP services or any RH medicines when needed. Similar findings were observed in the baseline survey 2013/14 where clients had a highly affirmative response rate for the services provided by the government facilities.
On the whole conducting client interviews as the client exited the facility ensured highly positive response rate. Thus, such indications of positive client satisfaction can be taken as valuable feedback in terms of services provided by SDPs however they cannot be treated as sole or the adequate evidences or information to confirm the effectiveness of the services provided by the SDP.
4.3 Clients’ Appraisal of Cost of Family Planning Services 3.11.1. Payment for Family Planning Service
Table 4-11 below presents the payment made by clients for different family planning services at all level health facilities. The data showed that 94.2% of the clients of the private facilities were found to be paying for the services as opposed to a mere 2.9% in the government facilities. The percentage of clients paying in government facilities was observed to be relatively lower than the found in baseline data (3.6%). Major chunk of the payment made in the government driven facilities was made under registration i.e. for card payment. During the baseline survey also, the clients were observed to be paying for cards i.e. registration process only in government facilities. In case of private facilities, clients were found to be paying for more for laboratory tests / x-ray followed by registration and some of the clients also claimed to pay for contraceptives services. Only private sector facilities charged for the consultation fees compared to government and NGOs.
In case of NGOs, 35% of the clients paid for the services. Majority of the clients (83%) were found to be paying for the services in the Central Development Region. Likewise, when compared residence wise the data showed that 31.2% of the urban clients paid for the services in contrast to just 7% by the rural residents. The maximum average amount paid by the clients from the urban areas was NPR. 318.3 for laboratory services, whereas rural clients paid more for contraceptives. The clients interviewed were found to pay NRs. 5 to 8 for cards in the government managed
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facilities whereas the private facilities have been reported to charge as high as NRs. 200 on an average to the clients. Table 4-11: Clients reporting paying for FP service and average amount paid Percent of Average amount paid (in national currency) Total clients Contraceptive Total Contraceptive Characteristics sample reporting Laboratory received from Consulta Paying Card purchased size (N) paying test/x-ray service -tion fee Clients from pharmacy for service provider Type of Facility Sub Health Post 1929 2.3% 5.0 0.0 60.0 0.0 0.0 44 Health Post 1164 2.0% 5.0 0.0 0.0 20.0 0.0 23 Primary Health Care 179 6.1% 5.0 0.0 0.0 0.0 0.0 11 Center Government Hospital 175 13.1% 8.0 0.0 30.0 40.0 0.0 23 Private Hospital/PSSN 39 86.4% 200.0 450.0 46.3 45.0 200.0 33 Sangini outlet 190 98.9% 44.4 10.0 53.8 49.1 0.0 188 Medical 87 93.1% 43.3 60.0 53.7 47.5 88.3 81 Centre/Polyclinic FPAN/Marie 60 35.0% 5.0 50.0 66.9 36.7 0.0 21 stope/NGO hospitals Region Eastern Development 974 11.2% 8.2 41.7 42.8 0.0 109 Region Central Development Region 983 8.2% 83.0 372.0 45.5 53.6 133.3 81 Western Development 676 7.5% 5.0 75.0 47.1 65.0 51 Region Mid-Western Development Region 562 19.2% 6.6 10.0 47.9 56.8 0.0 108 Far-Western 628 11.9% 9.1 50.0 83.5 39.5 0.0 75 Development Region Residence Urban 629 31.2% 41.3 318.3 60.6 44.7 116.3 196 Rural 3194 7.1% 5.6 30.0 47.3 51.0 0.0 228 Management Government 3447 2.9% 5.6 45.0 33.3 0.0 101 Private 321 94.2% 76.8 311.7 53.1 48.3 116.3 302 NGOs 55 38.2% 5.0 50.0 66.9 36.7 0.0 21
Total 3823 11.1% 17.0 246.3 54.0 47.6 116.3 424
3.11.2. Mode of Transportation, Distance Travelled and Cost of Transportation
Table 4-12 shows different modes of transportation preferred by the clients to reach the facilities as well as the average distance travelled and the average cost incurred during travel. It is clear from the data that a majority of the clients interviewed (92.4%) walk to the SDPs and rest (merely 8%) used any kind of vehicle to travel to the SDP preferably bicycles (4.5%). In line with the baseline study, the higher percentage of clients walked to the lower level of facilities assuming that the lower levels were more reachable within a community.
Government run facilities had a maximum (93.3%) of clients walking to the facilities while the private and NGOs had relatively lesser client population who walked to the facilities. However, these facilities had a better reach to other
Page | 71 different modes of transportation like bicycles, motorcycles, bus, taxi and private vehicles than the government facilities. About 94.3% of the rural clients reported that they walked to the SDPs whereas for urban clients, the percentage was just 81.1%. This indicated that people generally took services from nearby facilities for the family planning issues unless needed.
The average distance travelled and costs of travelling were estimated only for the clients who used any kind of vehicle to visit the SDP (clients walking to the SDP were ignored from the study). As mentioned above, the proportion of clients using vehicles for travelling to the SDPs were less (302 out of 3823 clients), thus the analysis of average distance and cost for travelling was done for small population of clients only . The results showed that average distance travelled to reach the facilities was highest for private hospitals (11 kms) whereas the shortest distance travelled was 3.4kms for the sub health posts. The cost of travel was also proportionately higher for the travel to private hospitals and the lowest to the shortest distance for SHPs. Government facilities showed lesser distance travelled by the clients as they have a better reach at the sub-district level, whereas the private SDPs depicted maximum travelling on the part of the clients with subsequent higher cost incurred. Maximum distance travelled by a client was 6.7 kms in the central development region and the highest amount paid was 87.0 for the same region. Residence based comparison shows that urban clients travel more, i.e. 5.4 kms and accordingly pay more on an average NRS. 58.5 for the travel. (Refer Table 4-12)
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Table 4-12: Clients by mode of transportation, distance travelled and cost of transportation Percentage Average Average Distance travel cost* Total No. using Characteristics Mode of transportation Total sample size travelled (km)* (to and from vehicles Walked Bicycle Motorcycle Bus/taxi Private vehicle (N) SDP) Type of Facility Sub Health Post 95.3% 3.6% .3% .7% .1% 1929 3.4 11.2 90 Health Post 94.2% 4.0% .9% .9% .2% 1164 5.5 26.2 68 Primary Health Care Center 82.7% 8.4% 5.0% 3.9% .0% 179 4.3 66.8 31 Government Hospital 76.0% 6.9% 5.1% 12.0% .0% 175 6.4 84.7 42 Private Hospital/PSSN 84.6% .0% 10.3% 5.1% .0% 44 11.0 86.7 6 Sangini outlet 80.5% 9.5% 7.4% 2.6% .0% 190 3.8 55.4 37 Medical Centre/Polyclinic 83.9% 4.6% 4.6% 6.9% .0% 58 6.5 79.2 14 FPAN/Marie stope/NGO 76.7% 11.7% 6.7% 5.0% .0% 55 3.0 39.3 14 hospitals Region Eastern Development Region 93.0% 4.1% .7% 1.7% .4% 974 3.5 25.7 68 Central Development Region 94.2% 1.5% 2.1% 2.1% .0% 983 6.7 87.0 57 Western Development Region 86.8% 8.3% 2.7% 2.2% .0% 676 4.1 35.2 89 Mid-Western Development Region 92.3% 5.9% .9% .9% .0% 562 4.3 21.6 43 Far-Western Development Region 92.8% 4.3% 1.4% 1.4% .0% 628 5.5 41.8 45 Residence Urban 81.1% 8.6% 4.6% 5.6% .2% 629 5.4 58.5 119 Rural 94.3% 3.7% 1.0% 1.0% .1% 3194 4.3 31.1 183 Management Government 93.3% 4.1% 1.0% 1.5% .1% 3447 4.7 36.5 231 Private 82.2% 6.7% 6.7% 4.3% .0% 326 5.2 64.5 57 NGOs 76.7% 11.7% 6.7% 5.0% .0% 55 3.0 39.3 14
Total 92.1% 4.5% 1.6% 1.8% .1% 3823 4.7 41.9 302 Note: *Asked to the clients who used vehicle (excluding the clients who walked to the SDP)
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3.11.3. Time Spent
Average Time Spent
The time spent by the clients in the SDP has also become one of the important part of the management strategies of the almost all the health facilities. In this study, the interval from travelling from the place of residence of the client, waiting for and receiving services as well as travelling from the SDP to the place of residence was estimated as the total time spent by the clients in any SDP. In average, a total of approximately 50 minutes were spent by the clients for travelling to and from the place of residence to the SDP and approximately nine minutes to get service from the SDPs. This somewhat indicated that the clients did not have to dedicate much time for receiving the services from the SDP. This result is also consistent with the high satisfaction level of the clients in terms of waiting for the services they receive from the facility. Also, further comparing with the baseline data, similar results could be seen where on an average a maximum of one hour was spent in to and fro travel and 13 minutes on average was reported by clients for waiting to receive services in the government SDPs.
The maximum time in travel was spent by the clients of government hospitals and comparatively lesser time was spent in travelling to private sector facilities (half an hour maximum). The least travel time was reported by the clients of western development regions i.e. average of 35 minutes however similar time was spent for waiting for receiving services across all the development regions. Relatively more time on average were spent on two way travel by the clients of the rural areas compared to the urban. (Refer Table 4-13)
Table 4-13: Average time spent by client for family planning services Average Time Spent (minutes) Total sample
size (N) Characteristics Travelling to and from the place Waiting for and of residence to the SDP Receiving Services Type of Facility Sub Health Post 45.8 8.0 1929 Health Post 54.5 9.3 1164 Primary Health Care Center 51.1 9.8 179 Government Hospital 69.2 11.9 175 Private Hospital/PSSN 24.4 8.7 39 Sangini outlet 34.7 8.6 190 Medical Centre/Polyclinic 23.1 6.9 87 FPAN/Marie stope/NGO hospitals 48.2 9.4 60 Region Eastern Development Region 50.3 9.5 974 Central Development Region 51.1 8.4 983 Western Development Region 35.4 8.4 676 Mid-Western Development Region 53.3 8.0 562 Far-Western Development Region 52.3 8.9 628 Residence Urban 44.1 9.6 629 Rural 49.6 8.5 3194 Management Government 50.2 8.7 3447 Private 32.7 8.5 316 NGOs 45.9 9.4 60 Total 48.7 8.7 3823
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Activities Clients would have engaged in during the Time Spent Receiving FP Services
Further the clients were also inquired about the various activities they would have engaged themselves, during the time spent for receiving the services from the SDP including the travel. Such responses were distributed according to age and gender in the Table 4-14 below. The results showed that maximum of the clients (70%) would have engaged themselves in household chores, majority of them being the female clients i.e. 71.3% compared to 43% male clients. Several of the clients (21%) would have been engaged in working on household farms (the percentage being same irrespective of the gender). A small number of clients would have been engaged in other activities such as trading and other professional or labor works. And less than one percent of the clients (particularly male) stated that they would be sitting leisure or doing some recreational activities in their house. . In terms of age, majority of clients of all the age groups except clients of 50+ year’s age group (only 25%) stated that they would be engaged in household chores. More of the clients from 50+ year’s age group would have been engaged in working on the household farm, trading and doing some labor job. Further, the clients of age group from 30 to 39 years would also have engaged themselves in household farm besides doing household chores.
Table 4-14: Clients by activities they would have engaged in during the time spent receiving FP services Percentage of Respondents Total Respondents Household Working on Employed Employed Clerical or sample Background Selling in the Others chores household as unskilled as skilled professional size (N) Characteristics market/trading * farm laborer laborer work Sex Male 42.9% 28.3% 13.6% 4.2% 5.2% 3.7% 2.1% 191 Female 71.3% 20.9% 4.5% .3% .6% 1.7% .7% 3632 Age 15-19 74.2% 18.5% 4.0% 1.6% 1.6% 124 20-24 73.0% 17.3% 6.1% .4% .6% 1.8% .8% 723 25-29 72.1% 17.2% 5.3% .8% 1.1% 2.6% .9% 1141 30-34 67.9% 23.6% 5.5% .3% 1.0% 1.1% .6% 895 35-39 66.1% 27.1% 3.2% .3% .8% 1.8% .7% 598 40-44 65.2% 30.1% 3.2% .4% .4% .4% .4% 282 45-49 75.0% 19.6% 3.6% 1.8% 56 50+ 25.0% 25.0% 25.0% 25.0% 4 Total 69.9% 21.3% 5.0% .5% .9% 1.8% .7% 3823 *Others include activities like sitting leisure, doing recreational activities (Watching TV, reading)
Clients by persons indicated to have performed activities on their behalf
When inquired about the person who were assigned to perform their activities mentioned in Table 4-14 above while they were receiving the services in the SDP, a large number of the clients (60%) stated that their family members did job in behalf of them as well as significant proportion (36%) of the clients had nobody to do the job on their behalf. Only a small number (3%), particular higher for male clients (7%) had co-workers to perform the activities on their behalf. (Refer Table 4-15)
Hardly any of the clients (i.e. 17 out of the 3823) had to pay to persons who performed activities on their behalf. For such cases only, average amount of money paid was calculated in accordance to each activities and each person. The result showed that, an average of NRs 300 was paid for family member, NRs. 200 for coworkers for doing household chores. For working on farm average of NRs. 250 and NRs. 305 was paid to the family members and co- workers respectively. Also average of NRs.500 (which was the maximum amount paid) was paid to hired labor for selling in the market and also average of NRs 200 was paid for doing some clerical or professional work on their behalf to the co-worker. (Refer Table 4-16)
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Table 4-15: Clients by persons indicated to have performed activities on their behalf Person who performed activities on behalf of client Respondents Background Family Total sample Co-worker Nobody Others Characteristics Member size (N) Sex Male 55.5% 7.3% 36.6% .5% 191 Female 61.3% 2.7% 35.9% 0.0% 3632 Age 15-19 65.3% 2.4% 32.3% 0.0% 124 20-24 57.8% 3.3% 38.9% 0.0% 723 25-29 58.5% 3.6% 37.9% 0.0% 1141 30-34 61.9% 3.0% 35.1% 0.0% 895 35-39 64.2% 2.2% 33.4% .2% 598 40-44 66.7% 1.8% 31.6% 0.0% 282 45-49 67.9% 0.0% 32.1% 0.0% 56 50+ 100.0% 0.0% 0.0% 0.0% 4 Total 61.1% 3.0% 36.0% .0% 3823 *Others include: Hired labor
Table 4-16: Average amount paid to persons on behalf of clients by activities performed while client was away receiving FP services Average amount paid to persons (in NRs.) Total Total Family Co- Sample Activities Others Average Member worker Size amount Household Chores 300.0 200.0 250.0 2
Working on HH Farm 250.0 305.6 295.5 11
Selling in the market/trading 500.0 500.0 1
Clerical or professional work 200.00 200.0 3
Total 266.7 273.1 500.0 285.3 17
3.11.4. Source of Funds for Family Planning
The various sources of funds through which the clients paid for family planning services were also analyzed in this survey in accordance to background characteristics of the respondents such as sex and age. However, the distribution in accordance to the marital status of the clients was ignored for the study as almost all of the clients were married or in union status.
Table 4-17 showed that in case of male clients, nearly all of them (about 94%) paid for the services themselves, however in case of female clients though large number of them (67%) paid themselves still significant amount i.e. 32% made their spouses pay for the services they received. Looking at the same indicator age wise, the result showed that most of the clients irrespective of their age group paid themselves however the significant amount of clients of age group 20 to 24 years, 40 to 44 years made their spouses pay for the services they receive. In general very negligible amount of clients made their family member other than their spouses pay for the services in the SDPs. This somewhat indicated that most of the clients preferred paying themselves.
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Table 4-17: Clients by source of funds used to pay for FP services Source of funds used to pay for FP services Respondents Background Family member other Total sample size Client (Self) Spouse Characteristics than spouse (N) Sex Male 93.5% 6.5% 0.0% 62 Female 67.4% 32.0% 1.4% 362 Age 15-19 68.8% 31.3% 0.0% 16 20-24 63.9% 35.1% 2.1% 97 25-29 73.5% 26.5% .7% 147 30-34 67.7% 31.3% 1.0% 96 35-39 87.5% 10.4% 2.1% 48 40-44 68.8% 37.5% 0.0% 16 45-49 66.7% 33.3% 0.0% 3 50+ 100.0% 0.0% 0.0% 1 Total 71.2% 28.3% 1.2% 424
Further, the average amount paid by the clients for each source of their funding was also estimated and distributed according to sex and age of the respondents. Since significant number of clients paid themselves, it was observed that maximum average amount paid by the male client i.e. NRs. 48 and females paid average of NRs. 36. In terms of age distribution, maximum average amount when the clients paid themselves was from the age group 25 to 29 (i.e. NRs 43) and 45 to 49 years (i.e. NRs 50). In case of payments made by the spouse of the clients, the clients of age group 40 to 44 years paid the highest for the FP services provided i.e. around NRS. 171. Very few of the clients made their relatives pay and the average amount paid was also comparatively low i.e. around NRs. 20. (Refer Table 4-18)
Table 4-18: Average amount paid from each source by background characteristics of clients Average amount from each source of funds used to pay
for FP services (in NRS.) Total sample size Respondents Background Family member (N) Characteristics Client (Self) Spouse other than spouse Sex Male 48.1 51.3 0.0 62 Female 36.2 69.8 20.0 362 Age 15-19 29.1 44.0 0.0 16 20-24 35.8 47.6 32.5 97 25-29 42.6 60.9 5.0 147 30-34 39.6 95.9 5.0 96 35-39 32.1 18.8 22.5 48 40-44 39.1 171.7 0.0 16 45-49 50.0 35.0 0.0 3 50+ 20.0 0.0 0.0 1 Total 38.5 69.2 20.0 424
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PART 5: Survey findings for indicators from NHSP II logical framework
The main objective of this survey was to assess the service availability, distribution and stock-out of essential lifesaving RH commodities, including contraceptives, and other key issues related to family planning service delivery at public, private and NGO sectors health facilities across the country. In addition, this survey also collected necessary data to monitor progress on selected health system related indicators from NHSP II logical framework (only at the public sector health facilities). Data related to following indicators in the NHSP-2 Logical Framework were collected:
1. OC 2.6 Percentage of clients satisfied with their health care providers at public facilities 2. OP 1.3 Percentage of HFOMCs /HDC with at least 3 female members and at least 2 members from Dalit or Janajati 3. OP 3.1 Percentage of sanctioned posts that are filled Doctors at PHCCs Doctors at District Hospitals Nurses at PHCCs Nurses at District Hospitals 4. OP 3.2 Percentage of hospitals that have at least 1 obstetrician-gynaecologist or MDGP, 5 SBA trained nurses and 1 anaesthetist or anaesthetist assistant 5. OP 4.5 Percentage of districts that have at least one facility providing all CEONC signal functions 24/7 6. OP 4.6 Percentage of PHCCs that provide all BEONC signal functions 7. OP 4.7 Percentage of health posts that are birthing centres providing deliveries 24/7 8. OP 4.8 Percentage of safe abortion sites with long acting family planning services 9. OP 4.9 Percentage of HPs with at least five FP methods 10. OP 8.1 Percentage of health facilities that have undertaken social audits as per MoHP guideline in the last fiscal year
Major findings:
3.11.5. OC 2.6 Percentage of clients satisfied with their health care providers at public facilities
The majority (99.30%) of clients were satisfied with the attitude of the health provider towards him/her in general. This exceeds the targets set by NHSP-2 for 2013 (74%) and 2015 (80%) (Table 4-19). This result also shows increasement over the previous STS surveys.
3.11.6. OP 1.3 Percentage of HFOMCs /HDC with at least 3 female members and at least 2 members from Dalit or Janajati
This indicator reflects the Representation of disadvantaged groups in HFOMC/HDCs. Of the total surveyed public facilities, 60.1% had at least 3 female members; 31.2% had at least 2 janajati members and 44.5% had at least 2 dalit members in HFOMC/HDCs. Overall, 7.6% of the HFOMCs/HDCs had at least three female members and two Dalit and two Janajati members (Table 4-19). Findings from previous STS report shows a significant difference; however the difference is due to the fact that previous STS report has reported the percentage of health facilities with at least three females and at least two Dalit and Janjati members in HFOMCs and HDCs whereas this report has
Page | 78 shown the percentage of health facilities with at least three females and at least two Dalit and two Janjati members. (Table 4-19). Table 5-19: Major findings for NHSP2 indicators
NHSP2 indicators reported Data (2014 STS 2012 STS 2013 2015 SN Code STS2011(%) by STSs survey) (%) (%) Target (%)
% of clients satisfied with their health care provider 1. OC at public facilities (Client 99.30% 96 90 89 80 2.6 satisfied with the attitude of the health provider towards him/her generally)
% health facility operation and management committees (HFMOCs/Hospital development management committees (HDMCs) with at least 2. OP 1.3 3 female members 60.10%
2 janajati members 31.20%
2 dalit members 44.50% At least 3 female members and at least 2 Janjati and Dalit members At least 3 female members and at least 2 Janjati and 2 7.60% 42 49 72 100 Dalit members % of sanctioned posts that are filled
Doctors at PHCCs 66.70% 50 23 23 90 Doctors at district hospitals 66.70% 69 56 47 90 Nurses( 3. OP sisters/metrons/nursing 88.9% 74 59 39 90 3.1 inspectors/staff nurse/ANM) at PHCCs Nurses( sisters/metrons/nursing inspectors/staff 93.3% 83 83 55 90 nurse/ANM) at district hospitals % of district hospitals that have at least one doctor of medicine general 26.70% 44 21 0 practitioner (MDGP) or Obstetrician/Gynecologist (Obs/Gyn) % of district hospitals that have five nurses ( 4. OP 3.2 sisters/metrons/nursing inspectors/staff 0.00% 94 50 11 nurse/ANM) (SBA trained) (this criteria was only fulfilled in PHCCs and Zonal hospital) % of district hospitals that have one Anaesthesist or 26.67% 13 21 22 assistant anaesthesist
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% of districts with at least one public facility providing all Comprehensive Emergency Obstetric and Neonatal Care (CEONC) 7 districts out 5. OP signal functions of 15 (i.e. 39 62 100 76 4.5 Comprehensive EmONC (or 47%) CEmONC) included all 7 BEmONC functions including: · Cesarean delivery · Blood transfusion
% of PHCCs providing all Basic Emergency Obstetric 31.40% and Neonatal Care
84.27 (maternal 7. OP % of HPs with birthing health facility 79 98 97 ≥80 4.7 center with delivery services) % of public facilities with 18.8% safe abortion facilities (N= 686) % of public facilities with 8. OP safe abortion facilitie 4.8 providing post-abortion family planning services 65.1% NA 56 91 ≥90 (only facilities having safe abortion services included) (N=129)
OP % of HPs with at least five 9. 20.60% 13 8 18 60 4.9 family planning methods
% of PHCCs with 10. OP 41.70% 4.12 laboratory diagnosis service (culture facility)
3.11.7. OP 3.1 Percentage of sanctioned posts that are filled by Doctors at PHCCs; Doctors at District Hospitals; Nurses at PHCCs; Nurses at District Hospitals
This survey found that 66.7% of the sanctioned posts in PHCCs and 66.7% of the sanctioned posts in districts hospitals were filled by Doctors. Similarly, 88.9% of the sanctioned posts in PHCCs and 93.3% of the sanctioned posts at district hospitals were filled by Nurses (sisters/metrons/nursing inspectors/staff nurse/ANM). Compared to past STS surveys, this result shows an improvement in the fulfillment of the sanctioned post. (Table 4-19).
3.11.8. OP 3.2 Percentage of hospitals that have at least 1 obstetrician-gynaecologist or MDGP, 5 SBA trained nurses and 1 anaesthetist or anaesthetist assistant
26.70% of district hospitals had at least one doctor of medicine general practitioner (MDGP) or Obstetrician/Gynecologist (Obs/Gyn). Similarly, 26.67% of district hospitals had one Anaesthesist or assistant
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anaesthesist. However, none of the district hospitals had SBA trained five nurses (sisters/metrons/nursing inspectors/staff nurse/ANM) (this criterion was only fulfilled in PHCCs and Zonal hospital). (Table 4-19).
3.11.9. OP 4.5 Percentage of districts that have at least one facility providing all CEONC signal functions 24/7
7 districts out of 15 (i.e. 47%) had at least one public facility providing all CEONC signal functions. (Table 4-19). Comprehensive EmONC (or CEmONC) included all 7 BEmONC functions including Cesarean delivery and Blood transfusion.
3.11.10. OP 4.6 Percentage of PHCCs that provide all BEONC signal functions 31.40% of PHCCs provided all BEmONC signal functions Basic Emergency Obstetric and Neonatal Care. (Table 4- 19). The BEmONC signal functions included: assisted vaginal delivery, administering parental antibiotics (IV/IM injection), administering uterotonic drugs, administering anticonvulsants/sedatives (MGSO4 injection), manually removing the placenta, removing the retained products if incomplete abortion (MVA), and neonatal resuscitation (e.g. with bag and mask).
3.11.11. OP 4.7 Percentage of health posts that are birthing centres providing deliveries 24/7 84.27 % of HPs had birthing center (maternal health facility with delivery services). The finding has exceeded the targets set by NHSP-2 for 2015 (≥80 %). (Table 4-19).
3.11.12. OP 4.8 Percentage of safe abortion sites with long acting family planning services Of the 686 public facilities surveyed, 18.8% of the public facilities had safe abortion facility. Among the facilities having safe abortion services, 65.1% of the facilities provided post-abortion family planning services. The findings have failed to achieve the target set for 2015 (≥90%). (Table 4-19).
3.11.13. OP 4.9 Percentage of HPs with at least five FP methods
20.60% of HPs provided at least five family planning methods. The target set for 2015 (60 %) has not been achieved. (Table 4-19).
3.11.14. OP 8.1 Percentage of health facilities that have undertaken social audits as per MoHP guideline in the last fiscal year Under the Local Authority Financial Administration Regulations, 2007, GoN committed to making social audits mandatory for all programmes within four months of the completion of each FY. However, this is yet to be fully implemented. In 2009, the FHD, DoHS, developed a social audit model linked to the Aama Programme; in the same year, the MD, DoHS, also developed a social audit with broader scope, covering all health service provision. In 2012, the DoHS, under the leadership of the PHCRD, harmonized the two sets of social audit guidelines and developed comprehensive social audit guidelines for the health sector. These specified that health facilities from SHPs to district hospitals and urban health clinics should undertake social audits. The new guidelines were piloted in two districts and implemented in an additional 20 districts in 2011/12. D(P)HOs are expected to develop action plans to ensure that social audits are operational in 30% of health facilities in their district by 2015. Of the total 686 public health facilities surveyed, 60.9% of the facilities had undertaken social audits in last fiscal year (year 2070/71); Whereas, 51.5% of them had undertaken social audits as per MOHP guidelines. (Table 4- 20). The percentage of public health facilities undertaking social audits in the year 2070/71 has also exceeded the
Page | 81 target set for 2015 (25%). Compared to previous STS, there has been significant increase in the proportion of facilities undertaking social audits as well as the facilities that had undertaken social audits as per MOHP guidelines.
Table 5-20: Health facilities that have undertaken social audits as per MoHP guideline OP % of public Type of Public health Total STS2011 STS 2012 STS 2015 8.1 health facilities facilities facilities that sample (%) (%) 2013 Target that have have size (%) (%) undertaken undertaken social audits in social audits the year Sub Health 57.9% 394 2070/71 Post Health Post 62.6% 238 Primary 80.6% 36 Health Services centre District 66.7% 15 Hospital Zonal 66.7% 3 Hospital Total 60.9% 686 27 14 15 25 % of health Sub Health 49.2% facilities that Post have Health Post 51.7% undertaken Primary 66.7% social audits Health as per MOHP Services guidelines in centre the last fiscal District 66.7% year (year Hospital 2070/71) Zonal 66.7% Hospital Total 51.5% 686 31 14 15
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PART 6: CONCLUSION & RECOMMENDATIONS 5.1 Summary of Findings
General Information about the Facilities
This survey covered representive sample of all types of SDPs in government (SHPs, HPs, PHCCs and Hospitals), private (Sangini/SEWA/ PSSN outlets, private hospitals/nursing homes) and NGO sector (Outlets of FPAN and Marie stoppe and Hospitals run by Missions and NGOs), located in all the five development regions and all three ecological belt. In Nepal, in addition to the public sector, private and NGO sector plays a substantial role in providing RH services, consequently the facilities surveyed under this study are managed by different sectors. In terms of geographic distribution of the SDPs, proportionate sample facility was taken from all five development regions: Eastern, Central and Western, Mid-Western and Far-Western region. However, the proportion of the sample facility taken from Eastern, Central and Western development regions are nearly equal and fewer sample facilities were taken from Mid-Western and Far-Western region. This is due to the reason that comparatively there are few facilities in these two regions which provide reproductive health services, mostly due to the lack of proper infrastructure which makes most of the areas in these regions highly inaccessible, limiting the availability of the RH services. This survey covers 84.4 % of the total facility in the rural areas and 15.6 % of the facility in the urban area.
Modern Contraceptives Offered by Facilities
Family planning services was provided by all types of SDPs surveyed. Contraception methods such as male condoms, oral contraceptive pills and injectables were made available in regular basis in all the facilities in the government, private and NGO sector. However, methods such as IUCDs and Implants were typically provided by government hospitals, PHCCs, Private hospitals and NGO sector facilities. Sterilization services such as Minilap and Vasectomy were limited to some of the government hospitals, private hospitals and NGO sector facilities. In few PHCCs and health posts the sterilization services were provided but through scheduled seasonal or mobile outreach services. Majority of the private and NGO sector facilities provided EC service in a very regular basis compared to the government facilities where the availability were mostly limited to hospitals only. Similarly, few FPAN/Marie stopes were able to provide the female condoms in a regular basis, however no government facilities made available such services.
The most offered contraception methods by any SDP or the most popular methods were short term hormonal (such as oral contraceptive pills, and injectables) and non-hormonal family planning services (such as male condoms). However, the least popular ones were the permanent method (minilap and vasectomy) and female condoms. Also the high availability of EC in all kinds of government private and NGO hospitals showed a possibility that individuals may opt to use EC to prevent pregnancies rather than using other certain contraception methods.
Almost all (98.8 %) ofthe primary level care SDPs (i.e. SHP, HP and PHCC) offered at least three modern contraceptives. All the FPAN/Marie stopes surveyed and majority of sangini outlets i.e. 95% offered at least three contraceptives. SDPs offering at least three modern contraceptives were almost equally distributed in all regions as well as in urban and rural setting. Also, no significant percentage difference was observed in government, private and NGO sector as well as in SDPs categorized according to distance from nearest warehouse/source of supplies.
All the tertiary level care government hospitals and majority of secondary level care government hospitals (86.7%) offer at least five modern contraceptives. 20.60% of HPs provided at least five family planning methods. Further, almost all (94.7%) of the medical centres/polyclinics, half of the private hospitals and one third of NGO hospitals
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offered at least five contraceptives. In terms of development regions, SDPs offering at least five modern contraceptives were almost equally distributed among central, western and mid-western regions but higher proportion of SDPs in urban areas offered five methods of modern contraception. Government facility seemed to better equip to provide at least five contraception methods compared to NGOs and private sector facilities.
The main reasons for not providing the IUDs, Implants and other permanent contraception methods by the SDPs to the clients were predominantly due to lack of trained staffs to provide the services. Other reasons include lack of experience among trained staffs, lack of equipments and few reported low client demand for the contraceptive in case of IUDs. This showed that more of the staffs should be provided family planning trainings. The major reasons for not offering Emergency contraception services were low demand at the SDP, delays or no supply by the main source to resupply and lack of trained staff to provide such services.
Availability of Maternal and RH Medicines
All seventeen maternal and RH medicines including seven essential drugs were available in almost all level of facilities expect for Ampicillin. Ampicillin was available at only 25% of the overall surveyed facilities. Drugs such as Azithromycin, Cefixime, Methyldopa, and Benzathine benzyl penicillin were scarcely available compared to the other drugs and their availability was mostly limited to hospitals in case of public facilities. Availability of seven essential life saving maternal and RH medicines included two mandatory medicines (MgSO4 and Oxytocin). Oxytocin was made available in almost all the government hospitals, PHCCs, HPs and majority of SHPs. Apart from government sector, the availability of Oxytocin was most prevalent in private hospitals and in almost all NGO sector facilities. Magnesium Sulphate was available in almost all of HPs, PHCCs, government hospitals and majority of SHPs. Also, the prevalence of MgSO4 drugs was observed higher in private hospitals. In case of government facilities, misoprostol was available mostly in hospitals (almost half of the government hospitals) and PHCCs (43%). Comparing to the baseline data of 2013/14, the availability of misoprostol in all levels of government facilities have increased. In overall compared to 18% of the government facilities providing misoprostol in 2013/14, the figure has increased to about 22% in 2014/15 survey. Tetanus toxiod was observed to be available at almost all the government hospitals and PHCCs, more than 65% of HPs and nearly half of the SHPs.
Overall about 41% of the SDPs were found to have the seven (including 2 essential) life-saving maternal or reproductive health medicines. Also, majority of private hospitals, half of medical centers/polyclinics, about 44% of the sangini outlets and merely 20% of the NGOs facilities made available seven essential drugs. The SDPs with provision of seven life saving drugs were mostly concentrated in Mid-Western Regions and urban areas. More of the SDPs in private sectors made available seven essential drugs compared to government and NGO sector facilities.
The main reasons for non availability of the essential drugs at the SDPs were delays on the part of the district store /warehouse to re-supply this SDP. In case of misoprostol along with above mentioned reasons, poor quality issues were also reported due to which the medicine was returned. For medicines such as magnesium sulphate, oxytocin and gentamicin along with delays in the main source, low or no demand/need for the medicine at the SDP was also noted as the main reason for their unavailability.
Incidence of ‘No Stock-Out’ of Modern Contraceptives
The SDPs having stock out of any of the modern contraceptives during the time of survey is low (i.e. nearly 87% of the SDPs were in no stock out condition). The most suffered from stock out at the time of survey were the PHCCs and zonal hospitals where about 25% and 33% of the SDPs respectively experienced stock out of any of the six contraception methods. In terms of private sector facilities, most stocks outs of any of the seven contraceptives at the time of the survey were observed for private hospitals.
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Male condoms, oral pills and injectables were in stock in nearly all of the SDPs. All the contraceptive methods expect implants were completely in stock at the government hospitals. The contraceptive least in stock in PHCCs, SHPs and HPs was emergency contraceptives as well as IUCDs in SHPs. For the private hospitals IUCDs and implants suffered most of the stock outs at the time of the survey and rest five of the contraceptives were in stock in majority of the private and NGO sector SDPs. The SDPs in far western region experienced the most stock outs at the time of survey. Similarly no major difference in stock out in SDPs of urban/rural settings was observed. Also, the SDPs at the distance of about 31-40 kms experienced the most stock outs. Compared to the government facility, higher stock out situation was observed in NGO and private sector facilities.
The no stock out situation in past six months was observed in overall 83% of the SDPs. In terms of government facilities, the PHCCs experienced the most stock outs. All of the private hospitals and NGO facilities did not experience any stock out in last six months. The most stock outs in last six months were found for emergency contraception and implants. All of the six contraceptives were observed to be in stock in private hospitals and NGO facilities. The SDPs in Far western region have experienced more of the stock outs in past 6 months. Similarly no major difference in stock outs in urban and rural settings or with respect to distance was observed. The most prominent reason for stock out of male condoms, oral contraception and injectables was due to the delay on the part of the main source/warehouse to resupply the SDP with the contraceptives. The stock outs of IUCDs and implants were more related to the lack of services due to unavailability of experienced/ trained staffs to provide such contraceptives. For emergency contraceptives, the issue of expiration date was reported as one of the major reasons for stock out.
Supply Chain, Including Cold Chain
Health facility in-charges were mainly responsible for ordering medical supplies in most SDPs in all development region and geographical area. In private sector facilities, along with health facility in charge, pharmacists were also responsible for ordering the medical supplies. In FPAN/marie stopes/NGO hospital, proprietors of the SDPs were also main person responsible for ordering the medical supplies.
Majority of SDPs practiced pull system, where the staff member of the facility made request based on calculation of quantity needed to provide uninterrupted services over a certain period of time. Regional/district warehouse was the major source of medical supplies for all SDPs at government sector in all regions. For private sector SDPs, most of the purchases were made from private sources and some from the local medical stores. The NGO sector had various major sources of supplies such as central medical stores, NGOs, few from local medical stores as well as private sources.
The frequency of resupply of medical supplies was done once in every three months in all level government facilities except in hospitals where the frequency of supplies was done once every month or less by all the tertiary level facilities. Also in most of the sangini outlets, medical centres/polyclinics, private hospitals/PSSN and FPAN/Marie stope/NGO hospitals the resupplies were mainly done once every one month or less. The frequency of resupplies was done more often (once a month or fewer periods) in health facilities in Mid-western development region and in urban area. The responsibility for transportation of supplies at all government SDPs was mainly done by district warehouse except in hospitals where the central/regional warehouse was equally responsible for transportation of supplies. In most of the private sector, the facility itself had the responsibility for the transportation of the supplies. However in case of NGO, facility itself or the medical suppliers were responsible for transporting the supplies.
Among the government facilities, majority of hospitals and PHCC had the electric fridge available in their SDPs to store the cold chain medicines/ supplies. However, the situation was worst in HP and SHPs where only 30% of HP and 12% of SHPs had fridge to store the cold chain medicines. Likewise 50% of sangini outlets, about 64% of FPAN/Marie stopes/NGO hospitals, majority of 74% of medical centers/polyclinics and all of the private hospitals/PSSN had electric fridge available to store the cold chain medicines. The availability of fridge was higher in the SDPs in the urban area and SDPs managed by private and NGO sector. The availability of fridge was lower
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in the SDPs in Eastern and Mid-western region. Further, the source of power for fridges in most of the SDPs (90%) was electricity from national grid.
Staff Training and Supervision
The National Health Training Centre (NHTC) is responsible for training human resources within Nepal’s health system. It offers several trainings each year depending on training requirements identified by the different program units. The staffs trained to provide family planning services was observed to be high in all the type of health facilities. Though the majority of SDPs had staffs trained to provide family planning services, the proportion of staffs trained in insertion and removal of implant and IUCD contraceptives was relatively low. Majority of government hospitals and primary health care centers had trained staffs in both implants and IUCD however; the percentage of staffs trained in both implants and IUCD were relatively low particularly for sub health posts. Majority of the SDPs in private and NGO sectors had staffs trained in both IUCD and Implant. The percentage of SDPs with staff trained in implants and IUCD were found to slightly higher in urban areas as compared to the rural areas.
In majority of SDPs; the supervisory visits were undertaken once in a three months period except in some of the SHPs and HPs where most of the supervisory visits were undertaken annually. In some of the hospitals supervisions was done every six monthly and in few, the supervision was not done at all. More of the private SDPs were not supervised compared to government and NGO sector facilities. In terms of supervisory visits, there was no notable difference in SDPs in urban and rural areas, where both had supervisory visits once in three months. The issues mostly included in the supervisory visits were to check the data completeness, quality, and timely reporting and also drug stock out and expiry. For the government hospitals, supervisory visits mainly looked into other aspects such as supervision of vaccine services, OPD register and ANC/PNC services.
Availability of Guidelines, Check-lists and Job aids
The availability of family planning guidelines was reported by about 66% of the facilities and it was verified in nearly half of the facilities (48%). In public sector, the availability and verification of the family planning guidelines was higher in PHCCs and Government Hospitals. However only few percentages of sangini outlets and Medical centres/polyclinic and more than half of the private hospitals/PSSN and FPAN/Marie stopes/NGO verified the availability of such guidelines. The availability of family planning guidelines was reported in most of the SDPs in eastern development region and rural areas.
The availability of antenatal/postnatal job aids were reported in nearly three-fifth of the SDPs among which availability was verified in in nearly two-fifth of the SDPs. In sangini outlets, the availability verification was null. Stratification in terms of development regions and urban and rural scenarios showed that in eastern development region and in the rural areas availability verification was reported in most of the SDPs.
Ministry of Health and Population (MoHP) have provided waste disposal guidelines to all health facilities; but the availability was verified in only 13.4% of the SDPs. The verification of the waste disposal guideline was also highest for the NGO sector SDPs. The comparative study of the data in five development regions and of urban and rural scenarios showed that the availability of waste disposal guidelines was observed to be highest for mid western development region and urban settings.
Use of Information Communication Technology (ICT) and Waste Disposal
The means of information and communication technologies used at majority of SDPs were mobile telephone. Similarly computer, landline telephone and Internet were also used in most SDPs for communication. Computers and internet facilities were highly used in private hospitals, NGO sector and by the SDPs in the urban settings. Majority of the SDPs reported that the ICT they used were staff members’ personal item. apart from ICTs being acquired as the staff
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members personal item, more of the SDPs in urban setting have received the ICT from the government as well as HDP/HFOMC/proprietor of the company compared to the rural SDPs. More of the NGO sector facilities have received the ICT from the proprietor of the company. Apparently, the main purpose for which the ICT was used in majority of SDPs was for routine communication. The use of ICT was mostly done for patient registration, clinical consultation and health worker training in NGO sector.
Burning was the most common method of waste disposal in most of the SDPs in all development regions; followed by burial in special dump pits, and use of incinerators. In case of government facilities, use of incinerators were mostly common in hospitals. Similarly the use of incinerators was the primary source of waste disposal method in NGO sector facilities. In rural areas, burning was used as the primary method of waste disposal whereas in urban areas, in addition to burning, the use of incinerators and burying in special dump pits were also common.
Charges for User Fees for Services provided by SDPs including Qualified Health Care Provider
Very few of SHPs and HPs i.e. about 10% and about 44% of thegovernment hospitals reported that they charge their patients for the services provided. Whereas majority of the private and NGO sector facilities charge their patients for the services provided to them. In government facilities, the patients are charged for registration fee only for the services they have taken in the SDP. Almost all the government facilities exempted the fees for family planning services, antenatal care services, delivery services as well as post natal care services. The exemptions for user fee, particularly for family planning services, were limited to some of the medical centers/ polyclinics and FPAN/maries topes and NGO hospitals. The frequency of claims for charging the fees, especially in public facilities, though very small may stand against the policy of providing free health services in particularly in government facilities.
Majority of the public health facilities did not charge their patients for the services provided by the health care provider where as Almost all of the private sector facilities and more than 50% of the NGOs claimed to charge their patients for the services offered by the qualified health care provider. However, exemptions of the services were applicable particularly for family planning methods and maternal health medicines made available by a qualified health care provider in public facilities. Compared to urban area, relatively very few of the SDPs in rural area charged their patients for the services provided by the qualified health care provider and had provision of exemptions for the user fees for family planning methods and maternal health medicines in rural area.
Client Exit Interview
The questionnaire was administered to a total of 3823 clients , of which, 95% were female, about half of the clients were between the age group 25 to 34 years, about 59% of the clients had never attended school, 99% were married or in union. The population of literate clients was more confined in private sector SDPs.
Measuring client or patient satisfaction was considered as one of the important parts of this study as results from these can be quite helpful in developing appropriate management strategies of any health facilities. In this research, client’s perception or the satisfaction level over the services received in any facility was taken as valuable feedback for measuring the effectiveness of the services nevertheless; such responses could not be taken as the ultimate outcome or result for evaluating the services provided by the SDPs. Client’s perceptions was measured regarding the technical aspects, organization aspects, inter-personal aspects as well as outcome aspects of the SDPs. In overall, high positive responses from the clients were observed regarding the family planning services they received in the SDPs. It was particularly encouraging to see that the clients made their own decision to use FP services and that they did not have to return from the SDP due to the lack of FP services or any RH medicines when needed. More of the clients from government facilities had positive responses towards the facilities’ efficacy towards the technical aspect; this might be due to the high expectations of more literate clients in private facilities than the illiterate population in government facilities.
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In general, conducting client interviews as the client exits the facility ensures highly affirmative response rate. Thus, such indications of positive client satisfaction do not necessarily provide adequate evidences or information to confirm the effectiveness of the services provided by the SDP. In most of the cases, clients with no base for comparison i.e. with no such experience of better quality services may also be satisfied with the services that is ineffective. Also the exit interview excludes the clients who have not returned to the facility because they were not satisfied with their experience in those SDPs, which might also increase the number of positive evidences of effectiveness of the SDPs.
In terms of clients assessment regarding the cost they had to pay for the family planning services, compared to 94.2% of the clients of the private facilities, hardly any of the clients from the government facilities had to pay for the services they received. Very few who paid for the services was largely for registration i.e. for card payment i.e. the average amount of NRs. 5 to 8 for cards in the government managed facilities. Likewise, when compared residence wise, the data showed that 31.2% of the urban clients paid for the services in contrast to just 7% by the rural residents. This difference might be attributed to the fact that urban clients received the services from many private sector facilities or hospitals. In case of source of funding made by the clients, nearly all of the male clients (about 94%) paid themselves, however for female clients though large number of them (67%) paid themselves still considerable amount i.e. 32% made their spouses pay for the services they received. Since significant number of clients paid themselves, it was observed that maximum average amount paid by the male client i.e. NRs. 48 and females paid average of NRs. 36.
In terms of accessibility to SDPs, most of the clients walked to the health facility that was highest for lower level of health facility mostly located in remote areas. About 94.3% of the rural clients reported that they walked to the SDPs whereas for urban clients, the percentage was just 81.1%. This indicated that people generally took services from nearby facilities for the family planning issues unless needed. Comparatively, Government facilities showed lesser distance travelled by the clients as they have a better reach at the sub-district level, whereas the private SDPs depicted maximum travelling on the part of the clients with subsequent higher cost incurred.
Traveling by means of motorbikes/bus/taxi (10%) was also popular among the surveyed clients especially in urban areas. On an average approximately 50 minutes was spent in travelling to and from the place of residence of client to the SDP for the clients who received their services from the government facilities. This is similar to the findings of baseline and also a certain extent resembles the M&E Framework of NHSP II (OC1.1), where about 61.8% of the population were living within 30 minutes travel time to a health or sub-health post.
In average maximum of one hour was spent by the clients for travelling to and from the place of residence to the SDP and also waiting for receiving services by the clients, which to some extent indicated that the clients did not have to dedicate much time for receiving the services. The results also showed that maximum of the clients (70%) would have engaged themselves in household chores during the time spent receiving FP services, majority of them being the female clients i.e. 71.3%. Further, a large number of the clients (60%) stated that their family members did job on their behalf when they had to spend their time for receiving the services as well as significant proportion (36%) of the clients had nobody to do the job on their behalf. Hardly any of the clients (i.e. 17 out of the 3823) had to pay to persons who performed activities on their behalf.
5.2 Recommendations This survey covered reprehensive sample from all types of SDPs in government, private and NGO sectors covering all ecological regions. However, the survey could not be conducted in all 75 districts which are limited to 15 districts and less number of NGO/ private sector was included. At the same time the participation was low in Mid-Western and Far-Western region due to the lack of proper infrastructure which makes most of the areas in these regions highly inaccessible, limiting the availability of the RH services. There is an emerging need to expand survey in most districts and involve more of the private sectors to generate comprehensive data.
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It was also felt necessary that the relevant authority should keep updated list of SDPs, specifically for private and NGO sectors as many of such facilities were found to be permanently closed or shifted. Additionally as per national RH strategy, the provision of family planning service and availability of RH medicines is dependent on level of SDPs and there is no clear classification of private/ NGO sector SDPs, it was considered essential that government has clear classifications of private/ NGO sector SDPs too.
Contraceptives Offered by Types of Facilities
The national RH strategy and guideline has no provision of Emergency Contraception (EC) for public health facilities but the higher availability of EC in private and NGO SDPs showed a possibility that EC is one of the promising options to prevent unwanted pregnancies. Thus, it is recommended that further studies should be conducted to assess the feasibility and acceptability of these commodities among general population to inform possibilities of provision of these methods through the national FP program.
From the survey findings, it can also be recommended that the Government and other stakeholders give particular emphasis to the provision of long acting methods of contraception at all levels, as the proportion of SDPs offering these services was found to be relatively lower. Additionally, the government is in the process of upgrading all SHP into HP, a special emphasis must be placed to provision of these long acting contraceptives in terms of availability of commodities and staff trainings. As the lack of skilled staff was identified as the main barrier to service of long acting contraceptives, Government must also conduct mandatory training for such methods for service providers with periodic refreshers training. The provisions of permanent methods of contraception (vasectomy and minilap) were relatively lower for all types of SDPs, including the public hospitals. Thus government, private and NGO sectors should take necessary actions to increase the proportion of SDPs providing these methods. For those SDPs who have provided FP and RH services as per the national protocol, the Government and its stakeholder should focus on maintaining the existing services to ensure continuity of quality of services at all levels.
Availability of Maternal and RH Medicines
The availability of seven essential life saving maternal and RH medicines were low in all types of SDPs, particularly Ampicillin and some of other antibiotics, in spite of Government’s commitment to include more medicine in the essential drug list and free supply by this year 2015. The survey showed that the main reasons for non availability of the essential drugs specifically for magnesium sulphate, oxytocin and gentamicin at the SDPs were delays on the part of the district store /warehouse to re-supply and quality issues were also reported. The role of Logistic Management Division and Family Health Division is vital in ensuring reproductive health commodity security, thus, a close co- ordination and communication between these divisions, the warehouses and the service delivery points is recommended for maintenance of adequate stock of essential life saving RH commodities. In case of misoprostol, poor quality of drugs due to which the medicine was returned was identified as one of the prominent reasons for its stock out, thus drug procurement should emphasize primarily on drug quality. For the quality and uninterrupted services, centre level of coordination should be maintained by the stakeholder to Logistic Management Division, Department of Health Services (LMD, DoHS) to ensure the availability of commodities to all level of health facilities in the greater frequencies.
The overall findings suggest that there are gaps in the service delivery, availability of the RH medicine and FP commodities at all level of SDP which is more prominent at low level and rural SDPs. As the target for stagnant contraceptive prevalence rate (CPR) which is one of indicators for Millennium Development Goal (MDG) and government commitment to provide essential drug is actual challenges. The government needs to adopt forward looking practical approach to improve supply chain and to deliver quality services equitably.
Availability of Cold Chain
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Since the practices of improper storage of the cold chain medicines may adversely affect their quality, the availability of cold chain equipment not limiting to refrigerators should be made universally available in all health facilities. Predominantly for the government managed SDPs (SHPs and HPs), where the availability seemed less compared to other private and NGO sector facilities, the availability of at least one functional electric refrigerator should be made obligatory. Also, high dependence on the national grid for the power supply for refrigerators in most of the SDPs does not indicate the continuous power supply due to the problem of high interrupted power supply in Nepal, so back up power supply such as generators or solar powered fridges should be highly encouraged for providing 24/7 uninterrupted supply to the fridges storing essential medicines.
Use of Information Communication Technology (ICT) and Waste Disposal
To achieve result oriented activities, including, training, availability of RH medicines and FP commodities ICT play a major role for communication. The means of information and communication technologies used at majority of SDPs were mobile telephone at present. Similarly computer, landline telephone and internet were also used in most SDPs for communication facilities particularly in private hospitals, NGO sectors and by the SDPs in the urban settings. The use of ICT should not only be limited to personal communication but its use should be expanded to greater horizon for patient registration, clinical consultation and health worker training and report writing. As the use of latest communication technology was low in government facilities, government should focus on building communication infrastructure and encourage service provider to take maximum benefits from these technology for the purpose of reporting, recording and stocking at minimum.
Different ways of waste disposal in SDPs were practiced most commonly burning followed by burial in special dump pits, and use of incinerators. It is also equally important to evaluate the impact of such open burnings on the environment and on the health of local communities. Training for the proper waste disposal method of waste management according to the type of SDPs is essential since there are guidelines produced by MoHP, which were either not available or not been implemented at present.
Staff Training and Supervision
Training on family planning services, particularly, FP training in insertion and removal of implant and IUCD contraceptives was found relatively low and was also identified as the key barrier to provision of these services, building the capacity of health workers at the service delivery points is essential. Thus proper planning of basic and refresher training for these professionals on family planning; particularly on long-acting and permanent methods are recommended.
At all level of SDPs; the supervisory visits were undertaken irregularly, less frequently and particularly HPs where most of the supervisory visits were undertaken annually. Such supervision should be in more frequent and in regular basis to assure quality service. For the government hospitals, supervisory visits mainly looked into other aspects such as supervision of vaccine services, OPD register and ANC/PNC services. The issues mostly included in the supervisory visits were to check the data completeness, quality, and timely reporting and also drug stock out and expiry. Thus the purpose of supervision must be expanded to cover maximum areas of health care including availability of modern contraceptives and essential drugs.
Charges for User fees
It is important to ensure free RH commodities and FP services for the public. Since the exemptions of user fees were observed to be mostly limited to public SDPs only; it is also necessary to analyze the effect of such exemptions in user fees, not only in terms of percentage increase in patient flow and quality of services provided by the public SDPs but also in terms of its effect on other private sectors, where due to the unavailability or quality degradation of some of services in public sector may have led to the patients turning towards the private sector. Though the satisfaction level of the clients seemed to be high for the overall services provided by the SDPs, however it is crucial also to understand
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the satisfaction level of the patients as well as the health care workers in terms of consequences caused by the exemption services such as lack of planning, insufficient resources (drug shortages), effectiveness of such exemptions. For this a proper monitoring system for the utilization of these resources must be made by the government.
Client Exit Interview
The clients coming to the health facilities were almost exclusively women, also observed in the previous surveys. Although this is a common finding at health facilities, awareness program on RH and FP methods should focus on increasing male participation and engagement.
Most of the clients interviewed comprised of those never attended schools particularly in the government sector, program should be enhanced to encourage eligible individuals and couples, including those who are educated, to use family planning services, available for free at public sector health.
Some of the results from the exit interviews were quite encouraging such as clients made their own decision to use FP services and that they did not have to return from the SDP due to the lack of FP services or any RH medicines when needed, such results can be extensively utilized for developing other strategic initiatives.
The higher positive response rate in terms of measuring the various outcome indicators were found to coming from clients of government facilities. Thus, the strategic planning for health sector should not be confined to the government health sector alone; it should necessarily involve various private health sectors also.
In general, conducting client interviews as the client exits the facility ensured a highly affirmative response rate; however such indications of positive client satisfaction cannot be necessarily taken as adequate evidences or information to confirm the effectiveness of the services provided by the SDP. Thus, more effective evaluation measures should be designed such as the robust outcomes can be generated.
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ANNEX
Annex 1: WHO list for life saving medicines for maternal/RH medicines Facilities Priority life-saving medicines for women: For major causes of sexual and reproductive health related mortality and morbidity Post-partum hemorrhage Prevention Obstetric hemorrhage is the world’s leading cause of maternal Oxytocin: injection 10 IU in 1=ml ampoule mortality causing estimated 127000 maternal deaths annually. Misoprostol: tablet 200 micrograms (when Postpartum hemorrhage is the most common type. oxytocin is not available or cannot safely be used) Treatment Oxytocin: (as above) Sodium chloride: injectables solution 0.9% isotonic or Sodium lactate compound solution: inject able( Ringer’s lactate) for infusion Severe pre-eclampsia and eclampsia Severe pre-eclampsia and eclampsia18 Pre-eclampsia and eclampsia are major health problems in Magnesium sulfate: injection 500 mg/ml in 10-ml developing countries. Every year, eclampsia is associated with ampoule an estimated 50000 maternal deaths worldwide. Calcium gluconate injection ( for treatment of magnesium toxicity ): 100mg/ml in 10-ml ampoule Management of severe hypertension19 Hydralazine: powder for injection 20mg (hydrochloride) in ampoule or tablet 25 mg; 50 mg (hydrochloride) Methyldopa: tablet 250 mg Maternal sepsis Ampicillin: powder for injection 500 mg; 1g (as a Infection can follow an abortion or childbirth and is a major sodium salt) in vial cause of death. Sepsis that is not related to unsafe abortion Gentamicin: injection 40 mg/ml in 2-ml vial accounts for up to 15% of maternal deaths in developing Metronidazole: injection 500 mg in 100-ml vial countries. Provision of safe abortion services and/or the management of Misoprostol: tablet 200 micrograms incomplete abortion and miscarriage Mifepristone + misoprostol*: tablet 200 Unsafe abortion complications can lead to death associated mg+tablet 200 micrugrams (where permitted with hemorrhage and sepsis. The majority of unsafe abortions under national law) take place in developing countries. In 2008, it was estimated *requires close medical supervision that 21.6 million unsafe abortions were performed worldwide- the majority of these in developing countries. Each year, 47000 women due to complications of unsafe abortion. Sexually transmitted infection Uncomplicated genital Chlamydial infections Nearly a million people acquire sexually transmitted infection, Azithromycin: capsule 250 mg; 500 mg or oral including the human immunodeficiency virus (HIV), every day. liquid 200 mg/5 ml After pregnancy –related causes, sexually transmitted infections Gonococcal infection- uncomplicated anogenital are the second most important cause of healthy life lost in infection women. The result of infection includes acute symptoms, chronic Cefixime: capsule 400mg infection, and serious delayed consequences such as infertility, Syphilis25 ectopic pregnancy, cervical cancer, and the untimely deaths of Benzathine benzylpenicillin: powder for injection infants and adults. Many sexually transmitted infections affect 900 mg benzylpenicillin in 5-ml vial; 1.44 g the outcome of pregnancy and some are passed to unborn and benzyl penicillin in 5-ml vial newborn babies. Management of preterm labour Inhibition of uterine contractions29 The incidence of preterm birth is approximately 6-7% of all Nifedipine: immediate release capsule 10 mg
Page | 93 births. Preterm birth is the leading cause of neonatal mortality Improvement of fetal lung maturity both in developed and developing countries, accounting for an Dexamethasone: injection 4 dexamethasone estimated 24% of neonatal deaths. phosphate (as disodium salt) in 1-ml ampoule or Betamethasone: injection 6mg/ml (3 mg/ml betamethasone sodium phosphate + 3 mg/ml betamethason acetate ) in an aqueous vehicle Prevention of tetanus in mother and newborn Tetanus toxoid Maternal and neonatal tetanus have been among the most common lethal consequences of unclean deliveries and umbilical cord care practices. WHO estimates that in 2008, 59000 newborns died from neonatal tetanus.
Thus, According to the WHO Priority life-saving medicines, for women and children, 2012; the priority medicines are: i) Oxytocin, ii) Misoprostol, iii) Sodium chloride, iv) Sodium lactate compound solution, v) Magnesium sulphate, vi) Calcium gluconate, vii) Hydralazine, viii) Methyldopa, ix) Ampicillin, x) Gentamicin, xi) Metronidazole, xii) Mifepristone, xiii) Azithromycin, xiv) Cefixime, xv) BenzathineBenzylpenicillin, xvi) Nifedipine, xvii) Dexamethasone, xviii) Betamethasone, and ixx) Tetanus toxoid.
Please note that although there are 19 individual medicines on the WHO list; a) Sodium chloride and Sodium lactate compound solution are alternates; and that b) Dexamethasone is an alternate to Betamethasone. This therefore applies to this survey; hence the reference to 17 components maternal/RH medicines.
Annex 2: Core team for the project Resource Person Affiliation Dr. Jaya Kumar Gurung Executive Director, NDRI Dr. Basu Dev Pandey Team Leader, NDRI Mr. Naveen Shrestha Technical Expert, NDRI Ms. Saruna Ghimire Technical Expert, NDRI Ms. Sona Shakya Researcher, NDRI Ms. Rupa Bhandari Admin and finance officer
Annex 3: Selection of districts using systematic random sampling Development Eco-region S.N Districts Random number Region 1 Bajura Mountain 2 Bajhang 3 Darchula 3 1 Doti Far-Western 2 Dadeldhura Hills 3 Baitadi 3 4 Achham 1 Kailai Terai 2 Kanchanpur 2 1 Humla 2 Mugu Mountain 3 Kalikot 3 4 Jumla 5 Dolpa 1 Dailekh Mid-Western 2 Jajarkot 2 3 Pyuthan Hills 4 Rolpa 5 Rukum 6 Salyan 7 Surkhet
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1 Dang Terai 2 Banke 2 3 Bardiya 1 Manang 1 Mountain 2 Mustang 1 Arghkhanchi 2 Baglung 3 Gorkha 4 Gulmi 5 Kaski Hills 6 Lamjung Western 7 Myagdi 8 Palpa 9 Parbat 9 10 Syangja 11 Tanahun 1 Nawalparasi Terai 2 Rupendehi 3 Kapilbastu 3 1 Sindhupalchowk 1 Mountain 2 Dolakha 3 Rasuwa 1 Bhaktapur 2 Kathmandu 3 Lalitpur 4 Dhading 4 Hills 5 Kavre 6 Makawanpur Central 7 Nuwakot 8 Ramechap 9 Sindhuli 1 Dhanusa 2 Mahottari 3 Sarlahi Terai 4 Rautahat 4 5 Bara 6 Parsa 7 Chitwan 1 Taplejung 1 Mountain 2 Sankhuwasava 3 Solukhumbu 1 Bhojpur 1 2 Dhankuta 3 Ilam 4 Panchthar Hills Eastern 5 Terathum 6 Udayapur 7 Okhaldhunga 8 Khotang 1 Jhapa 2 Morang 3 Saptari 3 4 Siraha 5 Sunsari Total 15 districts selected
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Annex 4: Distribution of number of SDPs for selected districts per developmental region and ecological belt Primary Secondary Tertiary
Develo Instituti Urban Teachin Regional/ Eco- Health Health Sub- Distric Zonal pment District onal Health Health g District Sub- Total region Clinic Center PHCC Health t Hospit Region Clinic Center Post Hospita Hospital regional Post Clinic al l Hospital
Mountain Taplejung 2 21 29 1 53 EDR Hill Bhojpur 3 21 39 1 1 65 Terai Saptari 1 1 4 30 82 1 1 120 Sindhupalch Mountain 1 1 3 25 50 1 1 82 owk CDR Hill Dhading 1 2 2 33 16 1 55 Terai Rautahat 4 23 70 1 98 Mountain Manang 10 3 1 14 WDR Hill Parbat 2 26 26 1 1 56 Terai Kapilbastu 3 25 48 1 1 78 Mountain Kalikot 1 17 11 1 30 MWDR Hill Jajarkot 2 16 16 1 35 Terai Banke 1 3 20 24 1 1 1 51 Mountain Darchula 1 19 21 1 42 FWDR Hill Baitadi 2 20 45 1 68 Terai Kanchanpur 1 3 14 4 1 23 Total 4 1 3 1 35 320 484 4 2 12 1 3 870
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Annex 5: Detailed field plan and facility allocation to each field researchers FAR-WESTERN DEVELOPMENT REGION - MOUNTAIN Supervisors- Nidhu Ram Dangal/ Team Leader -Suraj Baniya Health Facilities Sample No. of Exit No. of Districts Health Facilities Selected SDPs Enumerators type size interview facilities Secondary 1 DISTRICT HOSPITAL 10 Ustav Dhungel PHCC 1 GOKULESHWOR PHC 5 Ustav Dhungel BYASH HP 5 Ustav Dhungel DETHALA HP 5 Ustav Dhungel GULJAR HP 5 Ustav Dhungel 10 HIKILA HP 5 Ustav Dhungel HUTI HP 5 Ustav Dhungel KHALANGA HP DARCHULA 5 Ustav Dhungel KHAR HP 5 Ustav Dhungel HP 14 LATINATH HP 5 Ustav Dhungel MALIKARJUN HP 5 Sadkishya Maharjhan PASTI HP 5 Sadkishya Maharjhan RITHACHAUPATA HP 5 Sadkishya Maharjhan SARMOLI HP 5 Sadkishya Maharjhan SHIKHAR HP 5 Sadkishya Maharjhan SUNSERA HP 5 Sadkishya Maharjhan 11 Public BHAGWATI SHP 5 Sadkishya Maharjhan (Government) BOHARIGAUN SHP 5 Sadkishya Maharjhan BRAHAMADEV SHP 5 Sadkishya Maharjhan DADAKOT SHP 5 Sadkishya Maharjhan DATTU SHP 5 Sadkishya Maharjhan Darchula DHAP SHP DHAP 5 Sita Khadka DHARI SHP 5 Sita Khadka DHAULAKOT SHP 5 Sita Khadka DHULIGARHA SHP 5 Sita Khadka SHP 18 GWANI SHP 5 Sita Khadka 10 KATAI SHP 5 Sita Khadka KHANDESWORI SHP 5 Sita Khadka KHARKADA SHP 5 Sita Khadka PIPALCHAURI SHP 5 Sita Khadka RANISHIKHAR SHP 5 Sita Khadka SITOLA SHP 5 Suraj Baniya TAPOBAN SHP 5 Suraj Baniya UKU SHP 5 Suraj Baniya Darchula Sangini Outlet 1 5 Suraj Baniya Sangini Outlets 3 Darchula Sangini Outlet 2 5 Suraj Baniya Private Darchula Sangini Outlet 3 5 Suraj Baniya 10 Medical Centers/ Polyclinic 1 Darchula Medical Centers/ Polyclinic1 5 Suraj Baniya Private Hospitals/ PSSN 1 Darchula Private Hospitals/ PSSN 1 5 Suraj Baniya Darchula Outlets of FPAN and Marie Outlets of FPAN and Marie 5 Suraj Baniya NGOs 2 stoppe/ NGO hospitals1and 2 stoppe/ NGO hospitals Darchula Outlets of FPAN and Marie 5 Suraj Baniya
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stoppe/ NGO hospitals2 Total 41 210
FAR-WESTERN DEVELOPMENT REGION - HILL Supervisors- Nidhu Ram Dangal/ Team Leader -Sabitri Sunwar Health Facilities Sample No. of Exit No. of Districts SDPs Selected SDPs Enumerators type size interview facilities Secondary 1 District hospital_Baitadi 10 Bigan Lama KESHARPUR PHC 5 Bigan Lama PHCC 2 PATAN PHC 5 Bigan Lama BASANTAPUR HP BAITADI 5 Bigan Lama BASULING HP 5 Bigan Lama 10 DURGASTHAN HP 5 Bigan Lama GIREGADA HP 5 Bigan Lama HADAKOT HP 5 Bigan Lama JOSHIBUNGA HP 5 Bigan Lama KULAU HP 5 Bigan Lama HP 15 NWADEU HP 5 Samrit Gurung RIM HP BAITADI 5 Samrit Gurung RUDRESWOR HP 5 Samrit Gurung SALENA HP 5 Samrit Gurung SHANKARPUR HP BAITADI 5 Samrit Gurung 10 SHIVALING HP 5 Samrit Gurung SHREEKOT HP BAITADI 5 Samrit Gurung THALAKANDA HP 5 Samrit Gurung AMCHAUR SHP 5 Samrit Gurung Public Baitadi BARAKOT SHP 5 Samrit Gurung (Government) BHAUNALI SHP 5 Sangita Tamang BHUMESWOR SHP 5 Sangita Tamang BIJAYAPUR SHP 5 Sangita Tamang BUMIRAJ SHP 5 Sangita Tamang CHAUKHAM SHP 5 Sangita Tamang 10 DASHARATHCHANDA SHP 5 Sangita Tamang DEULEK SHP 5 Sangita Tamang DILASAINI SHP 5 Sangita Tamang SHP 35 DURGABHABANI SHP 5 Sangita Tamang GAJARI SHP 5 Sangita Tamang GUJAR SHP 5 Amit Silwal GURUKHOLA SHP 5 Amit Silwal HATRAJ SHP 5 Amit Silwal JAGANATH SHP, BAITADI 5 Amit Silwal KATAUJPANI SHP 5 Amit Silwal 10 KOTILA SHP BAITADI 5 Amit Silwal KOTPETARA SHP 5 Amit Silwal MAHADEVSTHAN SHP BAITADI 5 Amit Silwal MAHAKALI SHP 5 Amit Silwal
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FAR-WESTERN DEVELOPMENT REGION - HILL MAHARUDRA SHP 5 Amit Silwal MALLADEHI SHP 5 Rabin Pokhrel NWALI SHP 5 Rabin Pokhrel PANCHESWOR SHP 5 Rabin Pokhrel RAULESWOR SHP 5 Rabin Pokhrel SHIGAS SHP 5 Rabin Pokhrel 10 SHIKHARPUR SHP 5 Rabin Pokhrel SHIVBANATH SHP 5 Rabin Pokhrel SIDDHAPUR SHP 5 Rabin Pokhrel SILANGA SHP 5 Rabin Pokhrel SITAD SHP 5 Rabin Pokhrel SREEKEDAR SHP 5 Sabitri Sunwar TRIPURASUNDARI SHP 5 Sabitri Sunwar UDAYADEB SHP 5 Sabitri Sunwar Baitadi Sangini Outlet 1 5 Sabitri Sunwar Sangini Outlets 3 Baitadia Sangini Outlet 2 5 Sabitri Sunwar Private Baitadi Sangini Outlet 3 5 Sabitri Sunwar 10 Medical Centers/ Polyclinic 1 Baitadi Medical Centers/ Polyclinic1 5 Sabitri Sunwar Private Hospitals/ PSSN 1 Darchula Private Hospitals/ PSSN 1 5 Sabitri Sunwar Baitadi Outlets of FPAN and Marie stoppe/ 5 Sabitri Sunwar Outlets of FPAN and Marie NGO hospitals1 NGOs 2 stoppe/ NGO hospitals Baitadi Outlets of FPAN and Marie stoppe/ 5 Sabitri Sunwar NGO hospitals2 Total 60 305
FAR-WESTERN DEVELOPMENT REGION - TERAI Supervisors- Nidhu Ram Dangal/ Team Leader -Bipin Singh No. of Exit No. of Districts SDPs Selected SDPs Enumerators interview facilities Tertiary 1 Kanchanpur Mahakali Zonal Hospital 10 Sabina Swar BELDANDI PHC 5 Sabina Swar PHCC 3 DODHARA PHC 5 Sabina Swar 6 SHREEPUR PHC 5 Sabina Swar HP_Kanchanpur 5 Sabina Swar CHANDANI HP 5 Sabina Swar Public DAIJEE HP 5 Sabina Kafle Kanchanpur (Government) DEKHATBHULI HP 5 Sabina Kafle JHALARI HP 5 Sabina Kafle HP 15 6 JIMUWA HP 5 Sabina Kafle KRISHNAPUR HP KANCHANPUR 5 Sabina Kafle PARASAN (TRIBHUVANBASTI) HP 5 Sabina Kafle PARASAN HP 5 Sanod Poudyal 7 PIPALADI HP 5 Sanod Poudyal
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FAR-WESTERN DEVELOPMENT REGION - TERAI RAIKWAR BICHAWA HP 5 Sanod Poudyal RAMPUR BILASIPUR HP 5 Sanod Poudyal RAUTELI BICHAWA HP 5 Sanod Poudyal SHANKARPUR HP KANCHANPUR 5 Sanod Poudyal BAISE BICHAWA HP 5 Sanod Poudyal KALIKA SHP KANCHANPUR 5 Rajan Kumar Shah LAXMIPUR SHP KANCHANPUR 5 Rajan Kumar Shah SHP 5 PITAMBER SHP 5 Rajan Kumar Shah 6 SUDA SHP 5 Rajan Kumar Shah SHP_Kanchanpur 5 Rajan Kumar Shah Kanchanpur Sangini Outlet 1 5 Rajan Kumar Shah Sangini Outlets 3 Kanchanpura Sangini Outlet 2 5 Bipin Singh Kanchanpur Sangini Outlet 3 5 Bipin Singh Private Medical Centers/ 1 Kanchanpur Medical Centers/ Polyclinic1 5 Bipin Singh Polyclinic Private Hospitals/ 1 Darchula Private Hospitals/ PSSN 1 5 Bipin Singh 6 PSSN Kanchanpur Outlets of FPAN and Marie 5 Bipin Singh Outlets of FPAN and stoppe/ NGO hospitals1 NGOs Marie stoppe/ NGO 2 Kanchanpur Outlets of FPAN and Marie hospitals 5 Bipin Singh stoppe/ NGO hospitals2 Total 31 160
MID-WESTERN DEVELOPMENT REGION - MOUNTAIN Supervisors- Nava Raj Thapa/ Team Leader -Nabina Paiju Health Sample No. of Exit No. of Districts Health Facilities Selected SDPs Enumerators Facilities type size interview facilities Secondary 1 District hospital, Kalikot 10 Prativa Bhandari PHCC 1 KUMALGAUN PHC 5 Prativa Bhandari BHARTA HP 5 Prativa Bhandari CHILKHAYA HP 5 Prativa Bhandari DHOLAGOHE HP 5 Prativa Bhandari GELA HP 5 Prativa Bhandari 11 JUBITHA HP 5 Prativa Bhandari Public Kalikot KOTBADA HP 5 Prativa Bhandari (Government) HP 13 LALUTANTIKOT HP 5 Prativa Bhandari MALKOT HP 5 Prativa Bhandari PHUKOT HP 5 Prativa Bhandari RAMANAKOT HP 5 Anuja Timilisina RANCHULI HP 5 Anuja Timilisina 11 SIPKHANA HP 5 Anuja Timilisina SUKATIYA HP 5 Anuja Timilisina
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MID-WESTERN DEVELOPMENT REGION - MOUNTAIN BADALKOT SHP 5 Anuja Timilisina CHHAPRA SHP 5 Anuja Timilisina MUGRAHA SHP 5 Anuja Timilisina MUMRAKOT SHP 5 Anuja Timilisina NANIKOT SHP 5 Anuja Timilisina SHP 11 ODANKU SHP 5 Anuja Timilisina PAKHA SHP 5 Anuja Timilisina PHOIMAHADEV SHP 5 Nabina Paiju RAKU SHP 5 Nabina Paiju RUPSA SHP 5 Nabina Paiju THIRPU SHP 5 Nabina Paiju Sangini Outlet 1 5 Nabina Paiju Sangini Outlets 3 Sangini Outlet 2 5 Nabina Paiju Private Sangini Outlet 3 5 Nabina Paiju 11 Medical Centers/ Polyclinic 1 Medical Centers/ Polyclinic1 5 Nabina Paiju Private Hospitals/ PSSN 1 Private Hospitals/ PSSN 1 5 Nabina Paiju Outlets of FPAN and Marie 5 Nabina Paiju Outlets of FPAN and Marie stoppe/ NGO hospitals1 NGOs 2 stoppe/ NGO hospitals Outlets of FPAN and Marie 5 Nabina Paiju stoppe/ NGO hospitals2 Total 33 170
MID-WESTERN DEVELOPMENT REGION - Hills Supervisors- Nava Raj Thapa/ Team Leader -Gyannath Bhattarai Actual No. of Districts SDPs Sample size sample Selected SDPs Exit Enumerators Mandays size interview Secondary 1 DISTRICT HOSPITAL, JAJARKOT 10 Nirajan Chapai GARKHAKOT PHC 5 Nirajan Chapai PHCC 2 LIMSA PHC 5 Nirajan Chapai ARCHHANI HP 5 Nirajan Chapai DALLI HP 5 Nirajan Chapai DASHERA HP 5 Nirajan Chapai 12 DHIME HP 5 Nirajan Chapai Public Jajarkot JHAPRA HP 5 Nirajan Chapai (Government) HP 11 KARKIGAUN HP 5 Nirajan Chapai MAJHAKOT HP 5 Nirajan Chapai RAGDA HP 5 Nirajan Chapai SAKALA HP 5 Nirajan Chapai SIMA HP 5 Shiva Sharki THALARAIKAR HP 5 Shiva Sharki 12 SHP 15 BAHUNTHANA SHP 5 Shiva Sharki
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MID-WESTERN DEVELOPMENT REGION - Hills BHAGAWATITOL SHP 5 Shiva Sharki DAHA SHP 5 Shiva Sharki DANDAGAUN A SHP 5 Shiva Sharki DANDAGAUN B SHP 5 Shiva Sharki JAGATIPUR SHP 5 Shiva Sharki JUNGATHAPACHAUR SHP 5 Shiva Sharki KORTRANG SHP 5 Shiva Sharki LAHAI SHP 5 Shiva Sharki NAYAKWADA SHP 5 Shiva Sharki PAINK SHP 5 Gyannath Bhattarai PAJARU B SHP 5 Gyannath Bhattarai PUNAMA SHP 5 Gyannath Bhattarai SALMA SHP 5 Gyannath Bhattarai SUWANAULI SHP 5 Gyannath Bhattarai Sangini Outlet 1 5 Gyannath Bhattarai Sangini Outlets 3 Sangini Outlet 2 5 Gyannath Bhattarai 12 Private Sangini Outlet 3 5 Gyannath Bhattarai Medical Centers/ Polyclinic 1 Medical Centers/ Polyclinic1 5 Gyannath Bhattarai Private Hospitals/ PSSN 1 Private Hospitals/ PSSN 1 5 Gyannath Bhattarai Outlets of FPAN and Marie stoppe/ 5 Gyannath Bhattarai Outlets of FPAN and Marie NGO hospitals1 NGOs 2 stoppe/ NGO hospitals Outlets of FPAN and Marie stoppe/ 5 Gyannath Bhattarai NGO hospitals2 Total 36 185
MID-WESTERN DEVELOPMENT REGION - TERAI Actual No. of Exit Districts SDPs Sample size sample Selected SDPs Enumerators Mandays interview size Supervisors- Nava Raj Thapa/ Team Leader -Gita Bhattarai Tertiary 1 Zonal Hospital- Bheri 10 Rashmi Dhungana District clinic-INSTITUTIONAL CLINIC Secondary 1 10 Rashmi Dhungana AND TRANING CENTRE (BZH) BAGESWARI PHC 5 Rashmi Dhungana PHCC 3 BANAKATAWA PHC 5 Rashmi Dhungana 8 LAXMANPUR PHC 5 Rashmi Dhungana Public Banke HIRMINIYA HP 5 Rashmi Dhungana (Government) KACHANAPUR HP 5 Rashmi Dhungana KALAPHATA HP 5 Rashmi Dhungana HP 13 KOHALPUR HP 5 Krishna Gamal MAHADEVPURI HP 5 Krishna Gamal 8 NEPALGUNG HP 5 Krishna Gamal PARASPUR HP 5 Krishna Gamal
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MID-WESTERN DEVELOPMENT REGION - TERAI PIPARHAWA HP 5 Krishna Gamal SAIGAUN HP 5 Krishna Gamal SITAPUR HP BANKE 5 Krishna Gamal SONPUR HP 5 Krishna Gamal UDARAPUR HP 5 Sushma Sharma UDAYAPUR HP BANKE 5 Sushma Sharma BANAKATTI SHP 5 Sushma Sharma BASUDEVAPUR SHP 5 Sushma Sharma 8 BEJAPUR SHP 5 Sushma Sharma BELAHARI SHP 5 Sushma Sharma BELBHAR SHP 5 Sushma Sharma BETAHANI SHP 5 Sushma Sharma BINAUNA SHP 5 Srijana B.C CHISAPANI SHP BANKE 5 Srijana B.C GANAPUR SHP 5 Srijana B.C HOLIYA SHP 5 Srijana B.C 8 INDARPUR SHP 5 Srijana B.C SHP 22 KAMDI SHP 5 Srijana B.C KHAJURAKHURDA SHP 5 Srijana B.C KHASKARKADO SHP 5 Srijana B.C KHASKUSMA SHP 5 Bhavishara Shahi MANIKAPUR SHP 5 Bhavishara Shahi MATAHIYA SHP 5 Bhavishara Shahi PURAINA SHP 5 Bhavishara Shahi 8 PURAINI SHP 5 Bhavishara Shahi RADHAPUR SHP 5 Bhavishara Shahi RAJHENA SHP 5 Bhavishara Shahi RANIYAPUR SHP 5 Bhavishara Shahi Sangini Outlet 1 5 Gita Bhattarai Sangini Outlets 3 Sangini Outlet 2 5 Gita Bhattarai Private Sangini Outlet 3 5 Gita Bhattarai Medical Centers/ Polyclinic 1 Medical Centers/ Polyclinic1 5 Gita Bhattarai Private Hospitals/ PSSN 1 Private Hospitals/ PSSN 1 5 Gita Bhattarai 7 Outlets of FPAN and Marie stoppe/ 5 Gita Bhattarai Outlets of FPAN and Marie NGO hospitals1 NGOs 2 stoppe/ NGO hospitals Outlets of FPAN and Marie stoppe/ 5 Gita Bhattarai NGO hospitals2 Total 47 245
WESTERN DEVELOPMENT REGION - MOUNTAIN Health Sample No. of Exit No. of Districts Health Facilities Selected SDPs Enumerators Facilities type size interview facilities Supervisors- Sudina Maharjan/ Team Leader -Uttam Nepal Manang Public Secondary 1 District hospital, Manang 10 Subash Karel 10
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WESTERN DEVELOPMENT REGION - MOUNTAIN (Government) BHRAKA HP 5 Subash Karel CHAME HP 5 Subash Karel DHARAPANI HP MANANG 5 Subash Karel GHYARU HP 5 Subash Karel KHANGSAR HP 5 Subash Karel HP 10 MANANG HP 5 Subash Karel NARKHOLA HP 5 Subash Karel TACHAI HP 5 Subash Karel TANKI MANANG HP 5 Subash Karel THOCHE HP 5 Uttam Nepal HUMDE SHP 5 Uttam Nepal SHP 2 PISANG SHP 5 Uttam Nepal Sangini Outlet 1 5 Uttam Nepal Sangini Outlets 3 Sangini Outlet 2 5 Uttam Nepal 10 Private Sangini Outlet 3 5 Uttam Nepal Medical Centers/ Polyclinic 1 Medical Centers/ Polyclinic1 5 Uttam Nepal Private Hospitals/ PSSN 1 Private Hospitals/ PSSN 1 5 Uttam Nepal Outlets of FPAN and Marie Outlets of FPAN and Marie stoppe/ NGO hospitals1 5 Uttam Nepal NGOs 2 stoppe/ NGO hospitals Outlets of FPAN and Marie stoppe/ NGO hospitals2 5 Uttam Nepal Total 20 105
WESTERN DEVELOPMENT REGION -HILLS Health Facilities Sample No. of Exit Districts Health Facilities Selected SDPs Enumerators No. of facilities type size interview Supervisors- Sudina Maharjan/ Team Leader -Swarawati Adhikari Secondary 1 District hospital, Parbat 10 Teji Shara Thapa LUNKHU DEURALI PHC 5 Teji Shara Thapa PHCC 2 THULIPOKHARI PHC 5 Teji Shara Thapa ARTHAR DANDAKHARKA HP 5 Teji Shara Thapa 8 BAHAKITHANTI HP 5 Teji Shara Thapa BASKHARKA HP 5 Teji Shara Thapa BHANGARA HP 5 Teji Shara Thapa CHITRE HP 5 Teji Shara Thapa DEUPURKOT HP 5 Anupam Kunwar Public Parbat DEURALI HP PARBAT 5 Anupam Kunwar (Government) FALEBAS DEVISTHAN HP 5 Anupam Kunwar HP 19 HOSRANGDI HP 5 Anupam Kunwar HUWAS HP 5 Anupam Kunwar 9 KUSHMA (PANG) HP 5 Anupam Kunwar KYANG HP 5 Anupam Kunwar LIMITHANA HP 5 Anupam Kunwar MAJHPHANT MALLAJ HP 5 Anupam Kunwar NAGLIWANG HP 5 Sushant Ghimire 9 RAMJA DEURALI HP 5 Sushant Ghimire
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WESTERN DEVELOPMENT REGION -HILLS SALIJA HP 5 Sushant Ghimire SARAUKHOLA HP 5 Sushant Ghimire TILAHAR HP 5 Sushant Ghimire BACHCHHA SHP 5 Sushant Ghimire BALAKOT SHP 5 Sushant Ghimire BANOU SHP 5 Sushant Ghimire BEHULIBANS SHP 5 Sushant Ghimire BHOKSING SHP 5 Selina Khadki BHORLE SHP 5 Selina Khadki BHUKTANGLE SHP 5 Selina Khadki BIHADIBARACHAUR SHP 5 Selina Khadki BITALAWAPIPALTARI SHP 5 Selina Khadki 9 DURLUNG SHP 5 Selina Khadki FALAMKHANI SHP 5 Selina Khadki SHP 23 FULEBAS KHANIGAUN SHP 5 Selina Khadki KATUWACHAUPARI SHP 5 Selina Khadki KHURKOT SHP 5 Bibek Risal KURGHA SHP 5 Bibek Risal MUDIKUWA SHP 5 Bibek Risal PAKHAPANI SHP PARBAT 5 Bibek Risal PAKUWA SHP 5 Bibek Risal 9 TAKLAK SHP 5 Bibek Risal THANAMAULO SHP 5 Bibek Risal THAPATHANA SHP 5 Bibek Risal TRIBENI SHP PARBAT 5 Bibek Risal URAM POKHARA SHP 5 Swarawati Adhikari Sangini Outlet 1 5 Swarawati Adhikari Sangini Outlets 3 Sangini Outlet 2 5 Swarawati Adhikari Sangini Outlet 3 5 Swarawati Adhikari Private Medical Centers/ 1 Medical Centers/ Polyclinic1 5 Swarawati Adhikari Polyclinic 8 Private Hospitals/ 1 Private Hospitals/ PSSN 1 5 Swarawati Adhikari PSSN Outlets of FPAN and Marie 5 Swarawati Adhikari Outlets of FPAN and stoppe/ NGO hospitals1 NGOs Marie stoppe/ NGO 2 Outlets of FPAN and Marie hospitals 5 Swarawati Adhikari stoppe/ NGO hospitals2 Total 52 265
WESTERN DEVELOPMENT REGION -TERAI Supervisors- Sudina Maharjan/ Team Leader -Roslin Karki Health Sample No. of Exit No. of Districts Health Facilities Selected SDPs Enumerators Facilities type size interview facilities Kapilbastu Public Secondary 2 PRITHIV BIR HOSPITAL, KAPILBASTU 10 Santosh Nepal 8
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WESTERN DEVELOPMENT REGION -TERAI (Government) INSTITUTIONAL CLINIC (TAULIHAWA)-District Clinic 10 Santosh Nepal BANGANGA PHC 5 Santosh Nepal PHCC 2 MAHARAJGANJ PHC 5 Santosh Nepal BAIDAULI HP 5 Santosh Nepal BARAKULPUR HP 5 Santosh Nepal BHAGWANPUR HP 5 Santosh Nepal BITHUWA HP 5 Santosh Nepal DHARMPANIYA HP 5 Sujata Karki GOTIHAWA HP 5 Sujata Karki HARDAUNA HP 5 Sujata Karki JAYANAGAR HP 5 Sujata Karki HP 16 KRISHNANAGAR HP 5 Sujata Karki 10 KUSHAHAWA HP 5 Sujata Karki PAKADI HP 5 Sujata Karki PATHARDEIYA HP 5 Sujata Karki PIPARA HP KAPILBASTU 5 Sujata Karki SAURAHA HP 5 Sujata Karki SISAWA HP 5 Sarita Kharki UDAYAPUR HP KAPILBASTU 5 Sarita Kharki ABHIRAWA SHP 5 Sarita Kharki AJIGARA SHP 5 Sarita Kharki BALARAMWAPUR SHP 5 Sarita Kharki 10 BASANTAPUR SHP KAPILBASTU 5 Sarita Kharki BASKHOR SHP 5 Sarita Kharki BHALWAR SHP 5 Sarita Kharki BHALWARI SHP 5 Sarita Kharki BHILMI SHP 5 Sarita Kharki BISHUNPUR SHP 5 Sudharshan Thapa BUDHI SHP 5 Sudharshan Thapa CHANAI SHP 5 Sudharshan Thapa DHANKAULI SHP 5 Sudharshan Thapa SHP 40 DOHANI SHP 5 Sudharshan Thapa 10 DUMARA SHP 5 Sudharshan Thapa FULIKA SHP 5 Sudharshan Thapa GANESHPUR SHP 5 Sudharshan Thapa GAURI SHP KAPILBASTU 5 Sudharshan Thapa GUGAULI SHP 5 Sudharshan Thapa HATHIHAWA SHP 5 Bhawana Bhandari JAHADI SHP 5 Bhawana Bhandari JAWABHARI SHP 5 Bhawana Bhandari KAJARHAWA SHP 5 Bhawana Bhandari 10 KHURHURIYA SHP 5 Bhawana Bhandari MAHENDRAKOT SHP 5 Bhawana Bhandari MAHUWA SHP 5 Bhawana Bhandari
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WESTERN DEVELOPMENT REGION -TERAI MANPUR SHP KAPILBASTU 5 Bhawana Bhandari MOTIPUR SHP KAPILBASTU 5 Bhawana Bhandari NANDANAGAR SHP 5 Bhawana Bhandari PARSOHIYA SHP 5 Prasidha Raj Neupane PATARIYA SHP 5 Prasidha Raj Neupane PURUSOTTAMPUR SHP 5 Prasidha Raj Neupane RAJPUR SHP KAPILBASTU 5 Prasidha Raj Neupane RAMNAGAR SHP KAPILBASTU 5 Prasidha Raj Neupane 10 SHIVANAGAR SHP 5 Prasidha Raj Neupane SHIVAPUR SHP 5 Prasidha Raj Neupane SIHOKHOR SHP 5 Prasidha Raj Neupane SIRSIHAWA SHP 5 Prasidha Raj Neupane SOMDIHA SHP 5 Prasidha Raj Neupane TITIRKHI SHP 5 Roslin Karki VIDHYANAGAR SHP 5 Roslin Karki Sangini Outlet 1 5 Roslin Karki Sangini Outlets 3 Sangini Outlet 2 5 Roslin Karki Private Sangini Outlet 3 5 Roslin Karki 9 Medical Centers/ Polyclinic 1 Medical Centers/ Polyclinic1 5 Roslin Karki Private Hospitals/ PSSN 1 Private Hospitals/ PSSN 1 5 Roslin Karki Outlets of FPAN and Marie Outlets of FPAN and Marie stoppe/ NGO hospitals1 5 Roslin Karki NGOs 2 stoppe/ NGO hospitals Outlets of FPAN and Marie stoppe/ NGO hospitals2 5 Roslin Karki Total 67 345
CENTRAL DEVELOPMENT REGION - MOUNTAIN Supervisors- Renu Wasti/ Team Leader -Kiran Raj Dahal No. of Health Sample No. of Districts Health Facilities Selected SDPs Exit Enumerators Facilities type size facilities interview Secondary 1 District Hospital (Sindhupalchowk) 10 Aliza Shrestha BARHABISE (RAMCHE) PHC 5 Aliza Shrestha PHCC 3 JALBIRE PHC 5 Aliza Shrestha MELAMCHI PHC 5 Aliza Shrestha BADEGAU HP 5 Aliza Shrestha 10 BHIMTAR HP 5 Aliza Shrestha BHOTASIPA HP 5 Aliza Shrestha Public Sindhupalchowk BHOTECHAUR HP 5 Aliza Shrestha (Government) DEVISTHAN HP SINDHUPALCHOK 5 Aliza Shrestha HP 19 FULPINGDANDAGAU HP 5 Aliza Shrestha FULPINGKATTI HP 5 Deepa Maharjhan KARTHALI HP 5 Deepa Maharjhan KUNCHOK HP 5 Deepa Maharjhan 10 LISANKHU HP 5 Deepa Maharjhan NAWALPUR HP NAWALPUR 5 Deepa Maharjhan
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CENTRAL DEVELOPMENT REGION - MOUNTAIN PISKAR HP 5 Deepa Maharjhan SANGACHOK HP 5 Deepa Maharjhan SELANG HP 5 Deepa Maharjhan SIPAPOKHARE HP 5 Deepa Maharjhan TALRAMARANG HP 5 Deepa Maharjhan TATOPANI HP SINDHUPALCHOK 5 Isha Karmacharya TEKANPUR HP 5 Isha Karmacharya THAMPALDHAP HP 5 Isha Karmacharya ATTARPUR SHP 5 Isha Karmacharya BARAMCHI SHP 5 Isha Karmacharya 10 BARHABISE SHP 5 Isha Karmacharya BARUWA SHP 5 Isha Karmacharya BATASE SHP SINDHUPALCHOK 5 Isha Karmacharya BHOTENAMLANG SHP 5 Isha Karmacharya CHOUKATI SHP 5 Isha Karmacharya DHUSKUN SHP 5 Narayan Prashan Budhathoki DUBACHOUR SHP 5 Narayan Prashan Budhathoki FULPINGKOT SHP 5 Narayan Prashan Budhathoki GATI SHP 5 Narayan Prashan Budhathoki GHORTHALI SHP 5 Narayan Prashan Budhathoki 10 GHUMTHANG SHP 5 Narayan Prashan Budhathoki GUMBA SHP 5 Narayan Prashan Budhathoki GUNSAKOT SHP 5 Narayan Prashan Budhathoki HAGAM SHP 5 Narayan Prashan Budhathoki HAIBUNG SHP 5 Narayan Prashan Budhathoki ICHOK SHP 5 Meera Bishowkarma SHP 40 JETHAL SHP 5 Meera Bishowkarma JYAMIRE SHP SINDHUPALCHOK 5 Meera Bishowkarma KADAMBAS SHP 5 Meera Bishowkarma KIWOOL SHP 5 Meera Bishowkarma 10 KUBHINDE SHP 5 Meera Bishowkarma LANGARCHE SHP 5 Meera Bishowkarma MAHANKAL SHP SINDHUPALCHOK 5 Meera Bishowkarma MANKHA SHP 5 Meera Bishowkarma MARMING SHP 5 Meera Bishowkarma PALCHOK SHP 5 Bishnu Devi Pariyar PANGRETAR SHP 5 Bishnu Devi Pariyar PETKU SHP 5 Bishnu Devi Pariyar PIPALDANDA SHP 5 Bishnu Devi Pariyar SANUSIRUWARI SHP 5 Bishnu Devi Pariyar 10 SIKHARPUR SHP 5 Bishnu Devi Pariyar SYAULEBAZAR SHP 5 Bishnu Devi Pariyar THAKANI SHP 5 Bishnu Devi Pariyar THANPALKOT SHP 5 Bishnu Devi Pariyar
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CENTRAL DEVELOPMENT REGION - MOUNTAIN THOKARPA SHP 5 Bishnu Devi Pariyar THULOSIRUBARI SHP 5 Kiran Raj Dahal THUMPAKHAR SHP 5 Kiran Raj Dahal YAMUNADANDA SHP 5 Kiran Raj Dahal Sangini Outlet 1 5 Kiran Raj Dahal Sangini Outlets 3 Sangini Outlet 2 5 Kiran Raj Dahal Sangini Outlet 3 5 Kiran Raj Dahal Private Medical Centers/ 1 Medical Centers/ Polyclinic1 5 Kiran Raj Dahal 10 Polyclinic Private 1 Private Hospitals/ PSSN 1 5 Kiran Raj Dahal Hospitals/ PSSN Outlets of FPAN and Marie stoppe/ Outlets of FPAN 5 Kiran Raj Dahal and Marie NGO hospitals1 NGOs 2 stoppe/ NGO Outlets of FPAN and Marie stoppe/ 5 Kiran Raj Dahal hospitals NGO hospitals2 Total 70 355
CENTRAL DEVELOPMENT REGION - HILLS Supervisors- Renu Wasti/ Team Leader -Menuka Adhikari No. of Health Sample No. of Districts Health Facilities Selected SDPs Exit Enumerators Facilities type size facilities interview District Hospital, Dhading 10 Susmita Bhandari Secondary 2 INSTITUTIONAL (MCH) CLINIC, DDH 5 Susmita Bhandari GAJURI PHC 5 Susmita Bhandari PHCC 2 SALYANTAR PHC 5 Susmita Bhandari 8 AGINCHOK HP 5 Susmita Bhandari BENIGHAT HP 5 Susmita Bhandari BUDHATHUM HP 5 Susmita Bhandari CHAINPUR (SALBAS) HP 5 Susmita Bhandari DARKHA HP 5 Prakash Panta DHOLA HP 5 Prakash Panta Public DHUSSA HP 5 Prakash Panta Dhading (Government) JHARLANG HP 5 Prakash Panta JOGIMARA HP 5 Prakash Panta 9 HP 25 JYAMRUNG HP 5 Prakash Panta KATUNJE HP DHADING 5 Prakash Panta KEWALPUR HP 5 Prakash Panta KHALTE HP 5 Prakash Panta Madikot HP 5 Pratima Pathak MAHADEVBESI HP 5 Pratima Pathak MAHADEVSTHAN HP DHADING 5 Pratima Pathak 9 MURALI BHANJYANG HP 5 Pratima Pathak NALANG HP 5 Pratima Pathak
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CENTRAL DEVELOPMENT REGION - HILLS NAUBISE HP 5 Pratima Pathak PHULKHARK HP 5 Pratima Pathak SALANG HP 5 Pratima Pathak SATYADEVI (BHOGATENI) HP 5 Pratima Pathak SEMJONG HP 5 Suruchi Pandey SUNAULA BAZAR HP 5 Suruchi Pandey Chatra deurali HP 5 Suruchi Pandey BASERI SHP 5 Suruchi Pandey BHUMESTHAN SHP 5 Suruchi Pandey 9 DHUWAKOT SHP 5 Suruchi Pandey GOGANPANI SHP DHADING 5 Suruchi Pandey GUMDI SHP 5 Suruchi Pandey JEEWANPUR SHP 5 Suruchi Pandey KIRANCHOK SHP 5 Bishnu Bhatta KUMPUR SHP 5 Bishnu Bhatta SHP 16 MARPAK SHP 5 Bishnu Bhatta MULPANI SHP DHADING 5 Bishnu Bhatta REEGAUN SHP 5 Bishnu Bhatta 9 SALYANKOT SHP 5 Bishnu Bhatta SANGKOSH SHP 5 Bishnu Bhatta TASARPU SHP 5 Bishnu Bhatta THAKRE SHP 5 Bishnu Bhatta TRIPURESWOR SHP 5 Menuka Adhikari Sangini Outlet 1 5 Menuka Adhikari Sangini Outlets 3 Sangini Outlet 2 5 Menuka Adhikari Private Sangini Outlet 3 5 Menuka Adhikari 8 Medical Centers/ Polyclinic 1 Medical Centers/ Polyclinic1 5 Menuka Adhikari Private Hospitals/ PSSN 1 Private Hospitals/ PSSN 1 5 Menuka Adhikari Outlets of FPAN and Marie Outlets 1 5 Menuka Adhikari NGOs 2 stoppe/ NGO hospitals Outlets 2 5 Menuka Adhikari Total 52 265
CENTRAL DEVELOPMENT REGION - TERAI Supervisors- Renu Wasti/ Team Leader -Doma Tshering Lama No. of Health Sample No. of Districts Health Facilities Selected SDPs Exit Enumerators Facilities type size facilities interview Secondary 1 GAUR HOSPITAL, RAUTAHAT 10 Sabina Shrestha CHANDRANIGAHAPUR PHC 5 Sabina Shrestha Public GANGAPIPARA PHC 5 Sabina Shrestha Rautahat PHCC 4 10 (Government) KATAHARIYA PHC 5 Sabina Shrestha RAJPUR FARHADAWA PHC 5 Sabina Shrestha HP 12 AURAIYA HP 5 Sabina Shrestha
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CENTRAL DEVELOPMENT REGION - TERAI BARIYARPUR HP RAUTAHAT 5 Sabina Shrestha BISHRAMPUR HP BISHRAMPUR 5 Sabina Shrestha DHARAMPUR HP 5 Sabina Shrestha GARUDABAIRIYA HP 5 Sabina Shrestha HAJMINIYA HP 5 Rupesh Shrestha KHESARHIYA HP 5 Rupesh Shrestha MATIAUNA (DUMARIYA) HP 5 Rupesh Shrestha PATAURA HP 5 Rupesh Shrestha SAKHUWA DHAMAURA HP 5 Rupesh Shrestha 10 SANTAPUR (DOSTIYA) HP 5 Rupesh Shrestha SARUATHA HP 5 Rupesh Shrestha AJAGABI SHP 5 Rupesh Shrestha BADHARWA SHP 5 Rupesh Shrestha BAHUWA MADANPUR SHP 5 Rupesh Shrestha BAIRIYA SHP 5 Kopila Khadka BANJARAHA SHP 5 Kopila Khadka BASBITI JINGADIYA SHP 5 Kopila Khadka BHALOHIYA (PIPRA) SHP 5 Kopila Khadka BHASEDAWA SHP 5 Kopila Khadka 10 BHEDIYAHI SHP 5 Kopila Khadka BISUNPURWA MANPUR SHP 5 Kopila Khadka BRAHMAPURI SHP RAUTAHAT 5 Kopila Khadka DEBAHI SHP 5 Kopila Khadka DHARHARI SHP 5 Kopila Khadka FATUHAMAHESHPUR SHP 5 Pritima Sanjel FATUWAHARSAHA SHP 5 Pritima Sanjel GADHO (BHAGAWANPUR) SHP 5 Pritima Sanjel SHP 56 GAMHARIYAPARSA SHP 5 Pritima Sanjel HADIRYAPALTUWA SHP 5 Pritima Sanjel 10 IHARBARI SHP 5 Pritima Sanjel INARUWA SHP INARUWA 5 Pritima Sanjel JATAHARA SHP 5 Pritima Sanjel JETHRAHIYA SHP 5 Pritima Sanjel JHUNKHUNWA SHP 5 Pritima Sanjel JINGADAWA BELBICHWA SHP 5 Amogha Shrestha JOWAHA (JOKAHA) SHP 5 Amogha Shrestha KAKANPUR SHP 5 Amogha Shrestha KARKACH KARMAIYA SHP 5 Amogha Shrestha KARUNIYA SHP 5 Amogha Shrestha 10 LAXMINIYA SHP RAUTAHAT 5 Amogha Shrestha LAXMIPUR BELBICHAWA SHP 5 Amogha Shrestha LOKAHA SHP 5 Amogha Shrestha MADHOPUR SHP 5 Amogha Shrestha MALAHI SHP 5 Amogha Shrestha
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CENTRAL DEVELOPMENT REGION - TERAI MATHIYA SHP 5 Suchana Phuyal MATSARI SHP 5 Suchana Phuyal MITHUAWA SHP 5 Suchana Phuyal MUDWALAWA SHP 5 Suchana Phuyal PACHARUKHI SHP 5 Suchana Phuyal 10 PATHARABUDHA RAMPUR SHP 5 Suchana Phuyal PAURAI SHP 5 Suchana Phuyal PIPARA POKHARIYA SHP 5 Suchana Phuyal PIPRA BHAGWANPUR SHP 5 Suchana Phuyal PIPRA RAJBARA SHP 5 Suchana Phuyal POTHIYAHI SHP 5 Tara Khatri PRATAPPUR PALTUWA SHP 5 Tara Khatri RAJDEVI SHP 5 Tara Khatri RAJPURTULSI SHP 5 Tara Khatri RAMOLIBAIRIYA SHP 5 Tara Khatri 10 RAMPURKHAP SHP 5 Tara Khatri SAKHUAWA SHP 5 Tara Khatri SANGRAMPUR SHP RAUTAHAT 5 Tara Khatri SANTPUR (MATIAUN) SHP 5 Tara Khatri SARMUJAWA SHP 5 Tara Khatri SIMARA BHAWANIPUR SHP 5 Doma Tshering Lama TEJAPAKAR SHP 5 Doma Tshering Lama TENGRAHA SHP 5 Doma Tshering Lama Sangini Outlet 1 5 Doma Tshering Lama Sangini Outlets 3 Sangini Outlet 2 5 Doma Tshering Lama Sangini Outlet 3 5 Doma Tshering Lama Private Medical Centers/ 1 Medical Centers/ Polyclinic1 5 Doma Tshering Lama 10 Polyclinic Private Hospitals/ 1 Private Hospitals/ PSSN 1 5 Doma Tshering Lama PSSN Outlets of FPAN and Marie stoppe/ NGO Outlets of FPAN 5 Doma Tshering Lama and Marie hospitals1 NGOs 2 stoppe/ NGO Outlets of FPAN and Marie stoppe/ NGO 5 Doma Tshering Lama hospitals hospitals2 Total 80 405
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EASTERN DEVELOPMENT REGION - MOUNTAIN Supervisors- Smirti Thapa/ Team Leader -Manju KC Health Sample No. of Exit No. of Districts Health Facilities Selected SDPs Enumerators Facilities type size interview facilities Secondary 1 DISTRICT HOSPITAL, TAPLEJUNG 10 Sher Bahadhur Thapa DHUNGESAGHU PHC 5 Sher Bahadhur Thapa PHCC 2 TELLOK PHC 5 Sher Bahadhur Thapa EKHABU HP 5 Sher Bahadhur Thapa KHEWANG HP 5 Sher Bahadhur Thapa 9 LIMKHIM HP 5 Sher Bahadhur Thapa MEHELE HP 5 Sher Bahadhur Thapa HP 8 SABLAKHU HP 5 Sher Bahadhur Thapa SANWA HP 5 Sher Bahadhur Thapa THECHAMBU HP 5 Bhawana Khatiwada THUMBEDIN HP 5 Bhawana Khatiwada AMBEGUDIN SHP 5 Bhawana Khatiwada ANGKHOP SHP 5 Bhawana Khatiwada CHAKSIBOTE SHP 5 Bhawana Khatiwada 10 CHOKPUR SHP 5 Bhawana Khatiwada DOKHU SHP 5 Bhawana Khatiwada Public Taplejung (Government) DUMMRISE SHP 5 Bhawana Khatiwada HANGDEVA SHP 5 Bhawana Khatiwada HANGPANG MEHELE SHP 5 Bhawana Khatiwada KALIKHOLA SHP 5 Sijan Shrestha KHAMLUNG SHP 5 Sijan Shrestha LIMBUDIN SHP 5 Sijan Shrestha SHP 29 LINGTEP SHP 5 Sijan Shrestha LIWANG SHP TAPLEJUNG 5 Sijan Shrestha 10 MAMANKHE SHP 5 Sijan Shrestha NALBU SHP 5 Sijan Shrestha NANKHOLYANG SHP 5 Sijan Shrestha NIGHURADIN SHP 5 Sijan Shrestha PAPUNG SHP 5 Sijan Shrestha PEDANG SHP 5 Prajeena Maharjan PHAKUMBA SHP 5 Prajeena Maharjan 9 PHAWAKHOLA SHP 5 Prajeena Maharjan PHURUMBU SHP 5 Prajeena Maharjan
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EASTERN DEVELOPMENT REGION - MOUNTAIN SANGHU SHP 5 Prajeena Maharjan SANTHAKRA SHP 5 Prajeena Maharjan SAWADIN SHP 5 Prajeena Maharjan SOBUWA SHP 5 Prajeena Maharjan SURUMAKHIM SHP 5 Prajeena Maharjan TAPETHOK SHP 5 Manju K.C TIRINGE SHP 5 Manju K.C Sangini Outlet 1 5 Manju K.C Sangini Outlets 3 Sangini Outlet 2 5 Manju K.C Private Sangini Outlet 3 5 Manju K.C 9 Medical Centers/ Polyclinic 1 Medical Centers/ Polyclinic1 5 Manju K.C Private Hospitals/ PSSN 1 Private Hospitals/ PSSN 1 5 Manju K.C Outlets of FPAN and Marie stoppe/ 5 Manju K.C Outlets of FPAN and Marie stoppe/ NGO hospitals1 NGOs 2 NGO hospitals Outlets of FPAN and Marie stoppe/ 5 Manju K.C NGO hospitals2 Total 47 240
EASTERN DEVELOPMENT REGION - HILLS Supervisors- Smirti Thapa/ Team Leader -Manju KC Health Sample No. of Exit No. of Districts Health Facilities Selected SDPs Enumerators Facilities type size interview facilities Secondary 1 DISTRICT HOSPITAL, BHOJPUR 10 Suman Ghimire GHORETAR PHC 5 Suman Ghimire PHCC 3 MULPANI PHC BHOJPUR 5 Suman Ghimire PYAULI PHC 5 Suman Ghimire BAIKUNTHE HP 5 Suman Ghimire 10 BASINGTHARPUR HP 5 Suman Ghimire BASTEEM HP 5 Suman Ghimire Public BOYA HP 5 Suman Ghimire Bhojpur (Government) CHARAMBI HP 5 Suman Ghimire CHHINAMAKHU HP 5 Suman Ghimire HP 21 DOBHANE HP 5 Duraj Badhaur Dhimal GOGANE HP 5 Duraj Badhaur Dhimal HELAUCHHA HP 5 Duraj Badhaur Dhimal 10 KEEMALUNG HP 5 Duraj Badhaur Dhimal KOT HP 5 Duraj Badhaur Dhimal KULUNG HP 5 Duraj Badhaur Dhimal
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EASTERN DEVELOPMENT REGION - HILLS NEPALEDADA HP 5 Duraj Badhaur Dhimal OKHRE HP 5 Duraj Badhaur Dhimal PANGCHA HP 5 Duraj Badhaur Dhimal PATLEPANI HP 5 Duraj Badhaur Dhimal SANGPANG HP 5 Khadka Raj Thapa TAKSAR HP TAKSAR 5 Khadka Raj Thapa WALANGKHA HP 5 Khadka Raj Thapa YAKU HP 5 Khadka Raj Thapa YOO HP 5 Khadka Raj Thapa 10 AAMTEK SHP 5 Khadka Raj Thapa ANNAPURNA SHP 5 Khadka Raj Thapa BHAISIPANKHA SHP 5 Khadka Raj Thapa BHULKE SHP 5 Khadka Raj Thapa CHAMPE SHP 5 Khadka Raj Thapa CHAUKIDADA SHP 5 Binita Subedi CHYANGRE SHP 5 Binita Subedi DEURALI SHP BHOJPUR 5 Binita Subedi DEWANTAR SHP 5 Binita Subedi DUMMANA SHP 5 Binita Subedi 10 GADITAR (ANNAPURNA) SHP 5 Binita Subedi GUPTESHWOR SHP 5 Binita Subedi HOMTANG SHP 5 Binita Subedi JARAYOTAR SHP BHOJPUR 5 Binita Subedi SHP 28 KHAIRANG SHP BHOJPUR 5 Binita Subedi KHARTAMCHHA SHP 5 Manoj Devkota KHATAMMA SHP 5 Manoj Devkota KUDAKAKAULE SHP 5 Manoj Devkota LEKHARKA SHP 5 Manoj Devkota MANE BHANJYANG SHP 5 Manoj Devkota 10 PAWALA SHP 5 Manoj Devkota SANODUMMA SHP 5 Manoj Devkota SIDDHESWOR SHP BHOJPUR 5 Manoj Devkota SINDRANG SHP 5 Manoj Devkota THIDINGKHA SHP 5 Manoj Devkota TIMMA SHP 5 Sangam Lama TIWARI BHANGYAN SHP 5 Sangam Lama 10 YANGPANG SHP 5 Sangam Lama
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EASTERN DEVELOPMENT REGION - HILLS Sangini Outlet 1 5 Sangam Lama Sangini Outlets 3 Sangini Outlet 2 5 Sangam Lama Private Sangini Outlet 3 5 Sangam Lama Medical Centers/ Polyclinic 1 Medical Centers/ Polyclinic1 5 Sangam Lama Private Hospitals/ PSSN 1 Private Hospitals/ PSSN 1 5 Sangam Lama Outlets of FPAN and Marie stoppe/ Outlets of FPAN and Marie stoppe/ NGO hospitals1 5 Sangam Lama NGOs 2 NGO hospitals Outlets of FPAN and Marie stoppe/ NGO hospitals2 5 Sangam Lama Total 60 305
EASTERN DEVELOPMENT REGION - TERAI Health Facilities No. of Exit No. of Districts Health Facilities Sample size Selected SDPs Enumerators type interview facilities Teritary 1 Saptari Zonal Hospital 10 Abishek Chaudhary BABHANGAMAKATI TOPA PHC 5 Abishek Chaudhary KADARBONA PHC 5 Abishek Chaudhary PHCC 4 KALYANPUR PHC 5 Abishek Chaudhary 8 KANCHANPUR PHC 5 Abishek Chaudhary ARNAHA HP SAPTARI 5 Abishek Chaudhary BANARJHULA HP 5 Abishek Chaudhary BARHI BIRAPUR HP 5 Abishek Chaudhary BATHNAHA HP 5 Maheshwor Yadev BISHAHARIYA HP 5 Maheshwor Yadev BRAHAMPUR HP 5 Maheshwor Yadev DUMARI HP 5 Maheshwor Yadev HANUMANNAGAR HP 5 Maheshwor Yadev 9 INARUWA PHULBADIYA HP 5 Maheshwor Yadev HP 18 ITAHARI BISHNUPUR HP 5 Maheshwor Yadev KOCHA BAKHARI HP 5 Maheshwor Yadev MAINA SAHASHRABAHU HP 5 Maheshwor Yadev PASCHIM PIPRA HP 5 Sudip Shrestha Public PATTHARGADA HP 5 Sudip Shrestha Saptari (Government) PHATTEPUR HP SAPTARI 5 Sudip Shrestha RAUTHAT HP 5 Sudip Shrestha SAKHADA HP 5 Sudip Shrestha 10 SITAPUR HP SAPTARI 5 Sudip Shrestha AURAHI SHP SAPTARI 5 Sudip Shrestha BAIRAWA SHP 5 Sudip Shrestha BANAINIYA SHP 5 Sudip Shrestha BANAULA SHP 5 Sudip Shrestha BANAULI SHP 5 Sunita Karki BASBITTI SHP SAPTARI 5 Sunita Karki BELHI CHAPENA SHP 5 Sunita Karki SHP 67 BELHI SHP SAPTARI 5 Sunita Karki BHANGAHA SHP 5 Sunita Karki 9 BHARADAH SHP 5 Sunita Karki BORIYA SHP 5 Sunita Karki DADHA SHP 5 Sunita Karki DAULATPUR SHP 5 Sunita Karki DEURI BHARUWA SHP 5 Sudip Shakya 6 DEURI SHP 5 Sudip Shakya
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EASTERN DEVELOPMENT REGION - TERAI DHANGADI SHP 5 Sudip Shakya DHARAMPUR SHP SAPTARI 5 Sudip Shakya DIGHWA SHP 5 Sudip Shakya DIMAN SHP 5 Sudip Shakya FULKAHI SHP 5 Bhanu Poudel GHOGANPUR SHP 5 Bhanu Poudel GOBARGADHA SHP 5 Bhanu Poudel HARIHARPUR SHP SAPTARI 5 Bhanu Poudel HARIPUR SHP SAPTARI 5 Bhanu Poudel 9 JAGATPUR SHP 5 Bhanu Poudel JAMUNI MADHEPURA SHP 5 Bhanu Poudel JANDOL SHP 5 Bhanu Poudel JHUTAKI SHP 5 Bhanu Poudel KABILASHA SHP 5 Himanshu Rayamaji KATAIYA SHP 5 Himanshu Rayamaji KHADAKPUR SHP 5 Himanshu Rayamaji KHOJPUR SHP 5 Himanshu Rayamaji KHOKSAR PARWAHA SHP 5 Himanshu Rayamaji 9 KO MADHEPURA SHP 5 Himanshu Rayamaji KOILADI SHP 5 Himanshu Rayamaji LAUNIYA SHP 5 Himanshu Rayamaji LOHAJARA SHP 5 Himanshu Rayamaji MADHUPATI SHP 5 Anupa Parajuli MAHADEWA SHP SAPTARI 5 Anupa Parajuli MAINAKADERI SHP 5 Anupa Parajuli MALEKPUR SHP 5 Anupa Parajuli MALETH SHP 5 Anupa Parajuli 9 MALHANIYA SHP 5 Anupa Parajuli MANRAJA SHP 5 Anupa Parajuli MAUWAHA SHP 5 Anupa Parajuli MOHANPUR SHP SAPTARI 5 Anupa Parajuli NARGHO SHP 5 Bimala Baral ODRAHA SHP 5 Bimala Baral PAKARI SHP 5 Bimala Baral PANSERA SHP 5 Bimala Baral PATERWA SHP SAPTARI 5 Bimala Baral 9 PORTAHA SHP 5 Bimala Baral PRASBANI SHP 5 Bimala Baral PURB PIPRA SHP 5 Bimala Baral RAM NAGAR SHP 5 Bimala Baral RAMPUR JAMUWA SHP 5 Bidhyapati Thakhur RUPNAGAR SHP 5 Bidhyapati Thakhur SAKARPURA SHP 5 Bidhyapati Thakhur SARSWAR SHP SAPTARI 5 Bidhyapati Thakhur SIMRAHA SINGIYON SHP 5 Bidhyapati Thakhur 10 TARAHI SHP 5 Bidhyapati Thakhur TERHAUTA SHP 5 Bidhyapati Thakhur THELIYA SHP 5 Bidhyapati Thakhur TIKULIYA A SHP 5 Bidhyapati Thakhur TIKULIYA B SHP 5 Bidhyapati Thakhur TRIKOL SHP 5 Bibek Balla 9 YOGINIYA_2 SHP SAPTARI 5 Bibek Balla
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EASTERN DEVELOPMENT REGION - TERAI Sangini Outlet 1 5 Bibek Balla Sangini Outlets 3 Sangini Outlet 2 5 Bibek Balla Private Sangini Outlet 3 5 Bibek Balla Medical Centers/ Polyclinic 1 Medical Centers/ Polyclinic1 5 Bibek Balla Private Hospitals/ PSSN 1 Private Hospitals/ PSSN 1 5 Bibek Balla Outlets of FPAN and Marie stoppe/ Outlets of FPAN and Marie stoppe/ NGO hospitals1 5 Bibek Balla NGOs 2 NGO hospitals Outlets of FPAN and Marie stoppe/ NGO hospitals2 5 Bibek Balla Total 97 490
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Annex 6: Training Schedule: (Two Days Training Schedule-14th and 15th November) Training on Conducting a Facility Based Assessment for Reproductive Health Commodities and Services
Resource Person(s): Dr. Jaya Kumar Gurung , ED, NDRI Dr. Shilu Adhikari, UNFPA Dr. Basu Dev Pandey, Team Leader, NDRI Mr. Chandramani Dhungana, UNFPA Mr. Naveen Shrestha, Technical Expert, NDRI Mr. Bhogendra Dotel, Family Health Division (FHD) Ms. Saruna Ghimire, NDRI Mr. Upendra Dhungana, Logistics Management Division, Ms. Sona Shakya, NDRI Representative (LMD) Ms. Roopa Bhandari, NDRI Ms. Basanti Thapa, NDRI DAY I: November 14, 2014 (Friday) Participants : Field Supervisor +Enumerators ( 5+85) Time Activities Resource person Opening Session: 9.30-10.00 Registration Ms. Basanti Thapa 10.00-10.15 Introduction and Welcome Dr. Jaya Kumar Gurung , ED, NDRI Brief scope, objectives and approach of research 10.15-10.30 Mr. Naveen Shrestha, NDRI survey 10.30-10.45 RH Services in Nepal Mr. Bhogendra Dotel, Family Health Division Mr. Upendra Dhungana, Logistics Management 10.45-11.00 Logistic supply management status in Nepal Division, Representative 11.00-11.15 Reproductive health services in Nepal NHSSP Representative UNFPA Representative (Dr. Shilu Adhikari/ Mr. 11.15-11.30 Brief account of Project Chandramani Dhungana) Technical Session: Questionnaire discussion: Monitoring Survey 11.30-1.00 Dr. Basu Dev Pandey/ Mr. Naveen Shrestha Model -1 1.00-2.00 Lunch Break Questionnaire discussion 2.00-4:50 Ms. Saruna Ghimire/ Mr. Naveen Shrestha Model -1 5.00 Wrap Up Dr. Jaya Kumar Gurung
DAY II: November 15, 2014 (Saturday) 10.00 -10.30 Review / question clarity of day first Mr. Naveen Shrestha Questionnaire discussion 10.30 -1.30 Dr Basu Dev Pandey/ Mr. Naveen Shrestha Model -2 1.30-2.00 Lunch break Questionnaire discussion 2.00-4.00 Ms. Saruna Ghimire/ Mr. Naveen Shrestha Model -2 • General Sampling methodology/ Field allocation 4.00-4.15 Ms. Sona Shakya and planning (group division) Participants: 5 groups , 5 Health Facilities 4.15-4.25 • Discussion on pre-test for next day SHP1, HP1, PHC1 and private /NGO sectors from KTM/ Lalitpur 4.25-4.40 General Administration/Financial Matters Ms Roopa Bhandari 5.00 • Training wrap up &Vote of Thanks Dr. Jaya Kumar Gurung
Page | 119
Form No:
Annex 7: Final questionnaire for the survey
सव��ण प्र�नावल�
2014 प्रजनन ्वा镍यस륍बꅍधी सामग्री र सेवा प्रदायक संथाको म쥍यांकनू
अꅍतवा셍ता셍 स륍बꅍधी जानकार�
िज쥍ला ……………………………… ……….……………………….………;Dk{s JolQmM ……………..……………………kb======
;Dks{ g+= ………………………..……… ;+:yfsf] 5fk ……………………..………
प्र�नकता셍को नाम ………………...... ……………………kl/ro g+=………… …………… अꅍतवा셍ता셍 �म�त………………………………… cGtjf{tf ;'?ePsf] ;do ======cGtjf{tf ;DkGg ePsf] ;do ======
प्र�नावल� 셁जु तथा स륍पादन गन�: ;'kl/j]Ifsको नाम:……………………………………………… प�रचय g+=…… ……………………………
सह� ……………………………………………………… �म�त: ………………………………………………..……
यो ��ावल�का tLg भाग छन:् भाग 1 (ख赍ड 1 देिख 5 स륍म) र भाग 2 (ख赍ड 6 देिख 14 स륍म) वा镍य सेवा �दायक संथा (Service Delivery
Point, SDP) को ला�ग, र भाग 3 (ख赍ड 15 र 16 स륍म)SDP मा सेवा �लन आउने सेवा�ाह�को एि啍जट अꅍतवा셍ता셍 (Exit Interview) को ला�ग |
भाग 1 का ��को ला�ग ��कता셍ले सो संथाको इꅍचाज셍 वा इꅍचाज셍 नभए सो �दन काय셍रत व�र� कम셍चार� भे絍न ु पन�छ. भेटप�छ ��कता셍ले उहाँलाई
अ�भवादन गन�, आ굍नो प�रचय बताउने, र आफू आउनको उ�े�य बताउनपन�छु ।
अꅍतवा셍ता셍को ससु ूिचत सहम�त को ला�ग ��कता셍ले उQरदातालाई तलका �ववरणह셁 पढेर सनाउनु ु पन� छ:
• यो सव�क्षणको ला�ग तपाइँको संथा छनौटमा परेको छ. तपाइँको संथाले �दन े प�रवार �नयोजनलगायत �जनन ् वा镍यस륍बꅍधी सामाग्री र
सेवाको बारेमा हामीले तपाइँलाई ��ह셁 सो鵍नेछ�. तपाइँको संथाले र अ셁 संथाह셁ले �दन े जानकार� वा镍य मꅍ�ालय र अ셁 साझेदार संथाह셁ले यी स�वधाकोु िथ�तको बारे ब畍नु र यी सेवालाई सधान셍ु र योजना तज셍माु गन셍 �योग गन�छन ् । • यो सव�क्षणका tLg भाग छन.् प�हलो र दो�ो भागका ��ह셁को उQर तपाइँ सेवा �दायक संथाले �दनहु नु ेछ. t];|f] भागका प्र�नह셁को उ配तर तपाइँको यस संथामा प�रवार �नयोजन सेवा �लन आएका सेवाग्राह�ह셁ले �दनुहुनेछ. t];|f] भागको एि啍जट अꅍतवा셍ता셍 उपयु啍त समयमा गन셍 तपाइँको अनुम�तको ला�ग अनुरोध गद셍छ� । • तपाइँलाई हामी आ�त पान셍 चाहꅍछ� �क तपाइँको वा हामीलाई उQर �दने यस संथाको कु नै वा镍यकम� वा सेवा�ाह�को नाम गोꥍय रािखने छ, र त镍यांकमा वा ��तवेदनमा नाम खलाइनु े छैन । • तपाइँ कुनै ��को उQर �दन अवीकार गन셍 स啍नहु ꅍछु , र कुनै प�न बेला अꅍतवा셍ता셍 समा� गन셍 स啍नहु ꅍछु . तथापी हामी आशा गछ� तपाइँले सबै ��को उ�र �दनहु नु छे , जसले गदा셍 प�रवार �नयोजन लगायत �जनन ् वा镍यस륍बꅍधी सेवालाई सधारु गन� रा��य �यासमा बल प嵍नु ेछ । • य�द कु नै ��ह셁को उQर �दन अ셁 नै 핍यि� उपय�ु ठा�ुभएको छ भने सो 핍यि�सगँ हामीलाई भेट गराई सूचना संकलन गन셍 सहयोग ग�र�दनभएमाु हामी आभार� हꅍछ�ु । • अ�हले, तपाइँलाई यो सव�क्षणस륍बꅍधीु कनै �� छ भने सो鵍न स啍नहु ꅍछु । • के हामीलाई अगा�ड ब襍न अनमु �त �दनहु ꅍछु ?
उQरदाताको अनम�तप�छु ��कता셍ले अꅍतवा셍ता셍 श셁ु गन셍 स啍छ । संथासगकोँ अꅍतवा셍ता셍को अꅍतमा (ख赍ड 1 देिख 14 स륍मको) उQरदातालाई उहाँले �दएको समय र जानकार�को ला�ग धꅍयवाद �दनसु .् 配यसप�छ उहाँबाट वा अꅍय स륍बिꅍधत अ�धकार�बाट प�रवार �नयोजनस륍बꅍधी सेवा�ाह�सगँ एि啍जट अꅍतवा셍ता셍 �लन े अनम�तु मा嵍नसु ् ।
Form No:
भाग 1 सामग्री र सेवाको उपल녍धता AVAILABILITY OF COMMODITIES AND SERVICES
ख赍ड 1: वा镍य सेवा प्रदायक संथाको प�हचान (नाम, थान, र दर�ू ) SN �ववरण 001 वा镍य सेवा प्रदायक संथाको नाम …………………………………………….………..…….………………
………………………… ……………………… . . / gu/kflnsf ……………….………………. 002 टोल वडा गा �व स िज쥍ला …………………….. 003 भूम赍डल�य िथ�त �नधा셍रण प्रणाल� (Global Positioning System) (GPS): /______°/______'_/______"/ वा镍य सेवा प्रदायक संथा पन� �ेत्र (नेपालको वग�करण अनुसार) 004 1 सहर� 2 ग्रामीण cf}iflw , , 005 यो संथालाई चा�हने वा镍य सामग्री �नय�मत 셁पमा आपू�त셍 गन� सबभꅍदा निजकको भ赍डार टोर वा संथा क�त दर�माू छः /______/ दर�ू : 1 �कलो�मटर 2 कोस ख赍ड 2: सेवा प्रदायक संथाका प्रकार र �दने सेवाह셁 ( ) 006 वा镍य सेवा प्रदायक संथाको तह उपयु啍त �वक쥍पमा �चꅍह लगाउनुस ्
1 pk :jf:Yorf}sL 2 :jf:Yorf}sL 3 kf|ylds :jfYo ;]jf s]Gb| 4 lhNnf c:ktfn 5 c+rn c:ktfn
6 pk If]lqo c:ktfn 7 If]lqo c:ktfn 8 s]lb|o c:ktfn 9 cGo c:ktfn 10 ;+lugL outlets 11 d]l8sn ;]G6/ 12 kf]nL SnLlgs 13 FPAN 14 Marie Stopes 15 PSSN (Pariwar Swastha Sewa Network) 16 अꅍय (खुलाउने) ......
007 यो संथा कसले 핍यवथापन गछ셍 ? 1 सरकार 2 �नजी 핍यि啍त/संथा 3 गैर-सरकार� संथा 4 अꅍय (खुलाउने) -olb ;+:yf lghL, u}/ ;/sf/L xf] eg] v08 #sf] k|Zg )!@ v08 $ sf] k|Zg )!^ g;f]Wg]_
के यो संथाले प�रवार �नयोजन सेवा प�न �दꅍछ? 1 �दꅍछ 2 �दंदैन 008 (य�द �दंदैन भने, ख赍ड 3 र 5 का प्र�न 012 दे�ख 015 र 020 दे�ख 025 नसो鵍ने)
के यो संथाले प्रसू�तलगायत मातवा镍यृ सेवा प�न �दꅍछ? (जतै, प्रसू�तको ला�ग मात/ृ प्रसू�त क� छ?) 009 1 �दꅍछ 2 �दंदैन (य�द �दंदैन भने, ख赍ड 4 को 016 दे�ख 019 स륍मका प्र�न नसो鵍ने)
010 s] of] ;+:yfn] सुर��त गभ셍पतन ;]jf klg lbG5 < 1 �दꅍछ 2 �दंदैन
011 के यो संथाले ue{ktg kl5 kl/jf/ lgof]hg ;]jf प�न �दꅍछ? 1 �दꅍछ 2 �दंदैन olb ;]jf lbG5 eg], of] ;+:yfn] ue{ktg kl5 kl/jf/ lgof]hgsf] s]–s] ;]jf lbG5 < s पु셁षले लगाउने क赍डम �दꅍछ �दंदैन nfu' gx'g]
v म�हलाले लगाउने क赍डम �दꅍछ �दंदैन nfu' gx'g]
u ue{ lg/f]wscf}ifwL -lkN;_ �दꅍछ �दंदैन nfu' gx'g]
3 l8kf]k|f]e]/f �दꅍछ �दंदैन nfu' gx'g]
ª cfOo';L8L (Copper T) �दꅍछ �दंदैन nfu' gx'g]
Rf O{DKnf06 (Norplant) �दꅍछ �दंदैन nfu' gx'g]
5 ldgLNofk �दꅍछ �दंदैन nfu' gx'g]
Hf Eof;]S6f]dL �दꅍछ �दंदैन nfu' gx'g]
` Comprehensive Abortion Care (CAC) �दꅍछ �दंदैन nfu' gx'g]
Page | 112
3 / ) ख赍ड : प�रवार �नयोजनका आध�नकु साधन �व�धह셁 (संथाले �दने (नोट: प्र.नं. 008 मा संथाले प�रवार �नयोजन सेवा “�दꅍछ” भꅍने उtर आएको भए मात्र सो鵍ने) �ववरण (1) (2) (3) (4) (5) (6) (7) (8) (9) प셁षले लगाउने म�हलाले लगाउने खाने च啍क� सई पाठे घरमा हा쥍ने साधन इ륍ꥍलाꅍट म�हला बꅍ鵍याकर प셁ष बꅍ鵍याकरण आकिमक गभ셍�नरोध ु ु ु Remarks क赍डम क赍डम (Pills) (Depo) (IUCD/Copper T) (Zdal) (Minilap) (Vasectomy) साधन (Emergency
Contraceptives) (एउटामा मात्र �चꅍह (एउटामा मात्र �चꅍह एउटामा मात्र �चꅍह एउटामा मात्र �चꅍह एउटामा मात्र �चꅍह एउटामा मात्र �चꅍह एउटामा मात्र �चꅍह एउटामा मात्र �चꅍह एउटामा मात्र �चꅍह 012 लगाउने) लगाउने) लगाउने) लगाउने) लगाउने) लगाउने) लगाउने) लगाउने) लगाउने) (प्रच�लत राि�ट्रय प्रोटोकल, �नद��शका, वा 1 हो, संथाले यो 1 हो, संथाले यो 1 हो, संथाले यो 1 हो, संथाले यो 1 हो, संथाले यो 1 हो, संथाले यो 1 हो, संथाले यो 1 हो, संथाले यो 1 हो, संथाले यो कानून अनसारु ) यी साधन/�व�ध साधन/�व�ध उपल녍ध साधन/�व�ध उपल녍ध साधन/�व�ध साधन/�व�ध उपल녍ध साधन/�व�ध साधन/�व�ध साधन/�व�ध उपल녍ध साधन/�व�ध उपल녍ध प्र配येक प�रवार �नयोजन उपल녍ध गराउनपन�ु गराउनुपन� हो गराउनुपन� हो उपल녍ध गराउनपन�ु गराउनुपन� हो उपल녍ध गराउनपन�ु उपल녍ध गराउनपन�ु गराउनुपन� हो गराउनुपन� हो
साधन/�व�ध संथाले हो हो हो हो 2 होइन, संथाबाट 2 होइन, संथाबाट 2 होइन, संथाबाट यो 2 होइन, संथाबाट यो 2 होइन, संथाबाट यो आ굍नो तहअनसारु 2 होइन, संथाबाट यो साधन/�व�ध यो साधन/�व�ध 2 होइन, संथाबाट साधन/�व�ध उपल녍ध गन� 2 होइन, संथाबाट 2 होइन, संथाबाट साधन/�व�ध उपल녍ध गन� साधन/�व�ध उपल녍ध गन� उपल녍ध गराउन ु पन� हो यो साधन/�व�ध उपल녍ध गन� अपे�ा उपल녍ध गन� अपे�ा यो साधन/�व�ध अपे�ा ग�रएको छै न। यो साधन/�व�ध यो साधन/�व�ध अपे�ा ग�रएको छै न। अपे�ा ग�रएको छै न। वा होइन, उ配तरदातासँग
छलफल गर� उपल녍ध गन� अपे�ा ग�रएको छै न। ग�रएको छै न। उपल녍ध गन� अपे�ा उपल녍ध गन� अपे�ा उपल녍ध गन� अपे�ा
�न�कष셍अनसार �चꅍह ग�रएको छै न। ग�रएको छै न। ग�रएको छै न। ग�रएको छै न। ु
लगाउनसु .्
(मा�थ प्र.नं. 006 मा
उ쥍ले�खत तह 奍याल
गन셍स) ु ् ( ( ( ( ( ( ( ( ( 013 एउटामा मात्र एउटामा मात्र �चꅍह एउटामा मात्र �चꅍह एउटामा मात्र �चꅍह एउटामा मात्र �चꅍह एउटामा मात्र �चꅍह एउटामा मात्र �चꅍह एउटामा मात्र �चꅍह एउटामा मात्र �चꅍह �चꅍह लगाउने) लगाउने) लगाउने) लगाउने) लगाउने) लगाउने) लगाउने) लगाउने) लगाउने) य�द उपल녍ध गराउनुपन� हो भने, के संथाले 1 छ 1 छ 1 छ 1 छ 1 छ 1 छ 1 छ 1 छ 1 छ �नय�मत 셁पमा यो 2 2 2 2 2 2 2 2 2 सु�वधा आ굍ना छै न छै न छै न छै न छै न छै न छै न छै न छै न सेवाग्राह�लाई �दइरहेको 3 3 3 3 3 3 3 3 3 छ? सो鵍न ु नपन� सो鵍न ु नपन� सो鵍न ु नपन� सो鵍न ु नपन� सो鵍न ु नपन� सो鵍न ु नपन� सो鵍न ु नपन� सो鵍न ु नपन� सो鵍न ु नपन� (�कन�क प्र.नं. 012 (�कन�क प्र.नं. 012 (�कन�क प्र.नं. 012 (�कन�क प्र.नं. 012 (�कन�क प्र.नं. 012 मा (�कन�क प्र.नं. 012 (�कन�क प्र.नं. 012 (�कन�क प्र.नं. 012 मा (�कन�क प्र.नं. 012 मा मा “होइन” भꅍने मा “होइन” भꅍने मा “होइन” भꅍने मा “होइन” भꅍने “होइन” भꅍने उ配तर छ) मा “होइन” भꅍने मा “होइन” भꅍने “होइन” भꅍने उ配तर छ) “होइन” भꅍने उ配तर छ)
उ配तर छ) उ配तर छ) उ配तर छ) उ配तर छ) उ配तर छ) उ配तर छ)
Page | 113
(1) (2) (3) (4) (5) (6) (7) (8) (9) पु셁षले लगाउने म�हलाले लगाउने खाने च啍क� सुई पाठे घरमा हा쥍ने साधन इ륍ꥍलाꅍट म�हला बꅍ鵍याकर पु셁ष बꅍ鵍याकरण आकिमक
�ववरण क赍डम क赍डम (Pills) (Depo) (IUCD/Copper T) (Zdal) (Minilap) (Vasectomy) गभ셍�नरोध
साधन (Emergency Contraceptives) 1 मु奍य स्रोत 1 मु奍य स्रोत 1 मु奍य स्रोत 1 मु奍य स्रोत 1 मु奍य स्रोत 1 मु奍य स्रोत 1 मु奍य स्रोत 1 मु奍य स्रोत 1 मु奍य स्रोत 014 संथा/भ赍डारबाट संथा/भ赍डारबाट संथा/भ赍डारबाट संथा/भ赍डारबाट संथा/भ赍डारबाट संथा/भ赍डारबाट संथा/भ赍डारबाट संथा/भ赍डारबाट संथा/भ赍डारबाट संथाले यी स�वधा ु संथालाई यो साधन संथालाई यो साधन संथालाई यो साधन संथालाई यो साधन संथालाई यो साधन संथालाई यो साधन संथालाई यो साधन संथालाई यो साधन संथालाई यो साधन उपल녍ध गराउन ु पन� आप�तू 셍 गन셍 �ढलाई आप�तू 셍 गन셍 �ढलाई भएकोले आप�तू 셍 गन셍 �ढलाई आप�तू 셍 गन셍 �ढलाई आप�तू 셍 गन셍 �ढलाई भएकोले आप�तू 셍 गन셍 �ढलाई आप�तू 셍 गन셍 �ढलाई आप�तू 셍 गन셍 �ढलाई भएकोले आप�तू 셍 गन셍 �ढलाई 013 हो, तर प्र.नं. मा भएकोले भएकोले भएकोले भएकोले भएकोले भएकोले
यो सु�वधा �दइरहेको 2 2 संथा आ फै ल े यो साधन 2 2 2 संथा आ फै ल े यो साधन 2 “छै न” भꅍने उ配तर 2 संथा आ फै ल े यो संथा आ फै ल े यो साधन 2 संथा आ फै ल े यो 2 संथा आ फै ल े यो संथा आ फै ल े यो संथा आ फै ल े यो संथा आ फै ल े यो माग गन셍 �ढलाई गरे कोले माग गन셍 �ढलाई गरे कोले , माग गन셍 �ढलाई गरे कोले साधन माग गन셍 �ढलाई साधन माग गन셍 �ढलाई साधन माग गन셍 �ढलाई आएमा न�दनकोु साधन माग गन셍 साधन माग गन셍 �ढलाई साधन माग गन셍 �ढलाई
मु奍य कारण ले奍नसु �ढलाई् गरेकोले गरेकोले गरेकोले गरेकोले गरेकोले गरेकोले 3 सेवा प्रदायक संथालाई 3 सेवा प्रदायक संथालाई 3 सेवा प्रदायक संथालाई 3 सेवा प्रदायक 3 सेवा प्रदायक 3 सेवा प्रदायक (प्र配येक �व�धको �कꅍन उपल녍ध नभएकोले �कꅍन उपल녍ध नभएकोले
3 सेवा प्रदायक �कꅍन उपल녍ध नभएकोले 3 सेवा प्रदायक 3 सेवा प्रदायक संथालाई �कꅍन संथालाई �कꅍन संथालाई �कꅍन ला�ग एउटामा उपल녍ध नभएकोले उपल녍ध नभएकोले उपल녍ध नभएकोले मु奍य कारणमा] मात्र संथालाई �कꅍन संथालाई �कꅍन संथालाई �कꅍन 4 यो साधनको ला�ग 4 यो साधनको ला�ग �चꅍह लगाउने) उपल녍ध नभएकोले उपल녍ध नभएकोले उपल녍ध नभएकोले 4 यो साधनको ला�ग 4 यो साधनको ला�ग 4 यो साधनको ला�ग 4 यो साधनको ला�ग सेवाग्राह�को माग कम सेवाग्राह�को माग कम
भएको वा माग नभएकोले सेवाग्राह�को माग कम सेवाग्राह�को माग कम भएको वा माग नभएकोले सेवाग्राह�को माग कम सेवाग्राह�को माग कम भएको वा माग भएको वा माग भएको वा माग
4 यो साधनको ला�ग भएको वा माग नभएकोले 4 यो साधनको ला�ग 4 यो साधनको ला�ग 5 k|bfg ug{ यो साधन नभएकोले नभएकोले 5 k|bfg ug{ नभएकोले यो साधन सेवाग्राह�को माग कम सेवाग्राह�को माग कम सेवाग्राह�को माग कम ता�लमप्राꥍत कम셍चार� 5 यो साधन k|bfg ug{ 5 यो साधन k|bfg ug{ ता�लमप्राꥍत कम셍चार� 5 यो साधन k|bfg ug{ भएको वा माग 7 अꅍय कारण (खुलाउने): भएको वा माग भएको वा माग नभएकोले ता�लमप्राꥍत कम셍चार� ता�लमप्राꥍत कम셍चार� नभएकोले ता�लमप्राꥍत कम셍चार�
नभएकोले नभएकोले नभएकोले 6 यो साधन k|bfg ug{ …….…………………… नभएकोले नभएकोले 6 यो साधन k|bfg ug{ नभएकोले …………………… चा�हने आव�यक उपकरण 7 अꅍय कारण 7 अꅍय कारण 6 यो साधन k|bfg ug{ 6 यो साधन k|bfg ug{ चा�हने आव�यक उपकरण 6 यो साधन k|bfg ug{ 7 अꅍय कारण नभएकोले (खुलाउने): (खुलाउने): चा�हने आव�यक चा�हने आव�यक नभएकोले चा�हने आव�यक (खुलाउने): 7 अꅍय कारण (खुलाउने): उपकरण नभएकोले उपकरण नभएकोले 7 उपकरण नभएकोले …….……………… …….………………… अꅍय कारण (खुलाउने): …….……………… ………………… ……………… …………………… …….…………………… 7 अꅍय कारण 7 अꅍय कारण 7 अꅍय कारण …………………… …….…………………… …………… (खुलाउने): (खुलाउने): ………………… (खुलाउने):
…….………………… …….………………… …….………………… …………………… ………………… …………………… 015 प्र.नं.013 को उ配तरअनसारु यो प्राथ�मक तहको संथाको ला�ग (प्र.न. 006 मा उ쥍ले�खत) 饍�वतीय र ततीयृ तहको संथाको ला�ग (प्र.न. 006 मा उ쥍ले�खत) प्र�नबारे उ配तरदातासँग छलफल गर� 1 संथाले दईवटास륍मु प�रवार �नयोजनको आध�नकु �व�ध उपल녍ध गर ाउँ छ 3 संथाले चारवटास륍म प�रवार �नयोजनको आध�नकु साधन/�व�ध उपल녍ध गर ाउँ छ एउटामा �चꅍह लगाउनसु ् 2 संथाले तीन वा तीनभꅍदा बढ� प�रवार �नयोजनको �व�ध उपल녍ध गर ाउँ छ 4 संथाले पाँच वा पाँचभꅍदा बढ� प�रवार �नयोजनको आध�नकु साधन/�व�ध उपल녍ध गर ाउँ छ
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ख赍ड 4: मात ृ वा镍य / प्रजनन ् वा镍यस륍बꅍधी औषधीको उपल녍धता / (Maternal/RH Medicines) मातवा镍यृ प्रजनन ्वा镍यस륍बꅍधी औषधी (नोट: प्र.नं. 009 मा प्रसू�तलगायत मात ृ वा镍य सेवा “�दꅍछ” भꅍने उ配तर आएको भए मात्र सो鵍ने) �ववरण (4) (1) (2) (3) Either (5) (6) (7) (8) (9) Ampicillin Azithromycin Benzathine Betamethasone Calcium Cefixime Gentamicin Hydralazine Magnesium benzylpenicillin Or gluconate sulfate Dexamethasone Or Both
(एउटामा मात्र �चꅍह (एउटामा मात्र �चꅍह (एउटामा मात्र �चꅍह (एउटामा मात्र �चꅍह (एउटामा मात्र �चꅍह (एउटामा मात्र �चꅍह (एउटामा मात्र �चꅍह (एउटामा मात्र �चꅍह (एउटामा मात्र �चꅍह 016 (प्रच�लत राि�ट्रय लगाउने) लगाउने) लगाउने) लगाउने) लगाउने) लगाउने) लगाउने) लगाउने) लगाउने) प्रोटोकल, �नद��शका, वा
कानून अनसारु , र यो तहको 1 हो, मात/ृ प्रजनन ् 1 हो, मात/ृ प्रजनन ् 1 हो, मात/ृ प्रजनन ् 1 हो, मात/ृ प्रजनन ् 1 हो, मात/ृ प्रजनन ् 1 हो, मात/ृ प्रजनन ् 1 हो, मात/ृ प्रजनन ् 1 हो, मात/ृ प्रजनन ् 1 हो, मात/ृ प्रजनन ् संथालाई उ�चत/लाग हने वा镍यस륍बꅍधी यो वा镍यस륍बꅍधी यो वा镍यस륍बꅍधी यो वा镍यस륍बꅍधी यो वा镍यस륍बꅍधी यो वा镍यस륍बꅍधी यो ु ु वा镍यस륍बꅍधी वा镍यस륍बꅍधी यो वा镍यस륍बꅍधी यो अवथामा) मात/प्रजनन ् औषधी संथाले औषधी संथाले उपल녍ध औषधी संथाले उपल녍ध औषधी संथाले औषधी संथाले औषधी संथाले ृ यो औषधी संथाले औषधी संथाले उपल녍ध औषधी संथाले उपल녍ध
वा镍यस륍बꅍधी यी प्र配येक उपल녍ध गराउनु पन� गराउनु पन� हो गराउनु पन� हो उपल녍ध गराउनु पन� हो उपल녍ध गराउनु पन� हो उपल녍ध गराउनु पन� हो उपल녍ध गराउनु पन� गराउनु पन� हो गराउनु पन� हो औष�ध संथाले उपल녍ध हो हो , गराउनु पन� हो वा होइन 2 , / 2 , / होइन मातृ प्रजनन ् होइन मातृ प्रजनन ् 2 , / 2 , / 2 , 2 / 2 / 2 / होइन मातृ प्रजनन ् होइन मातृ प्रजनन ् उ配तरदातासँग छलफल गर� 2 होइन, होइन वा镍यस륍बꅍधी यो वा镍यस륍बꅍधी यो होइन, मातृ प्रजनन ् होइन, मातृ प्रजनन ् होइन, मातृ प्रजनन ् वा镍यस륍बꅍधी यो वा镍यस륍बꅍधी यो �न�कष셍अनसार �चꅍह मात/प्रजनन ् वा镍यस륍बꅍधी यो वा镍यस륍बꅍधी यो वा镍यस륍बꅍधी यो ु मात/ृ प्रजनन ् ृ औषधी संथाले उपल녍ध औषधी संथाले उपल녍ध औषधी संथाले उपल녍ध औषधी संथाले उपल녍ध लगाउनसु .् वा镍यस륍बꅍधी औषधी संथाले उपल녍ध औषधी संथाले औषधी संथाले वा镍यस륍बꅍधी यो गराउने अपे�ा ग�रएको गराउने अपे�ा ग�रएको गराउने अपे�ा ग�रएको गराउने अपे�ा ग�रएको औषधी संथाले यो औषधी संथाले छै न। छै न। गराउने अपे�ा ग�रएको उपल녍ध गराउने अपे�ा उपल녍ध गराउने अपे�ा (मा�थ प्र.नं. 006 मा छै न छै न। उपल녍ध गराउने छै न। ग�रएको छै न। ग�रएको छै न। ) उपल녍ध गराउने उ쥍ले�खत तह 奍याल गनु셍स ् अपे�ा ग�रएको छै न। अपे�ा ग�रएको छै न।
017 (एउटामा मात्र �चꅍह (एउटामा मात्र �चꅍह (एउटामा मात्र �चꅍह (एउटामा मात्र �चꅍह (एउटामा मात्र �चꅍह (एउटामा मात्र �चꅍह (एउटामा मात्र �चꅍह (एउटामा मात्र �चꅍह (एउटामा मात्र �चꅍह य�द प्र.नं. 016 को उQर लगाउने) लगाउने) लगाउने) लगाउने) लगाउने) लगाउने) लगाउने) लगाउने) लगाउने) “हो” भएमा (अथा셍त,् 1 छ 1 छ 1 छ 1 छ 1 छ 1 छ 1 छ मात/ृ प्रजनन ् वा镍य 2 छै न 2 छै न 2 छै न 2 छै न 2 छै न 1 छ 1 छ 3 सो鵍न ु नपन� (�कन�क 2 छै न स륍बꅍधी यो औषधी 3 सो鵍न ु नपन� 3 सो鵍न ु नपन� 3 सो鵍न ु नपन� (�कन�क 3 सो鵍न ु नपन� (�कन�क 3 सो鵍न ु नपन� (�कन�क 2 छै न 2 छै न प्र.नं. 016 मा होइन भꅍने 3 सो鵍न ु नपन� (�कन�क संथाले उपल녍ध (�कन�क प्र.नं. 016 (�कन�क प्र.नं. 016 प्र.नं. 016 मा होइन भꅍने प्र.नं. 016 मा होइन भꅍने प्र.नं. 016 मा होइन 3 सो鵍न ु नपन� 3 सो鵍न ु नपन� उ配तर छ) प्र.नं. 016 मा होइन भꅍने गराउनुपन� हो भने), यो ) ) ) ( . . 016 ( . . 016 ) मा होइन भꅍने उ配तर मा होइन भꅍने उ配तर छ उ配तर छ भꅍने उ配तर छ �कन�क प्र नं मा �कन�क प्र नं मा उ配तर छ औषधी अ�हले संथाबाट छ) उ配तर छ) होइन भꅍने उ配तर छ) होइन भꅍने उ配तर छ)
उपल녍ध छ/छै न उ쥍लेख
गनु셍स.्
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(3) (4) (9) (1) (2) Betamethasone Or (5) (6) (7) (8) �ववरण Ampicillin Azithromycin Benzathine Dexamethasone Calcium gluconate Cefixime Gentamicin Hydralazine Magnesium benzylpenicillin Or Both sulfate एउटामा (मु奍य कारणमा) एउटामा (मु奍य एउटामा (मु奍य कारणमा) एउटामा (मु奍य कारणमा) एउटामा (मु奍य एउटामा (मु奍य एउटामा (मु奍य एउटामा (मु奍य कारणमा) एउटामा (मु奍य कारणमा) 018 मात्र �चꅍह लगाउनसु .् कारणमा) मात्र �चꅍह मात्र �चꅍह लगाउनसु .् मात्र �चꅍह लगाउनसु .् कारणमा) मात्र �चꅍह कारणमा) मात्र �चꅍह कारणमा) मात्र �चꅍह मात्र �चꅍह लगाउनसु .् मात्र �चꅍह लगाउनसु .् य�द यी औषधी लगाउनसु .् लगाउनसु .् लगाउनसु .् लगाउनसु .् संथाले उपल녍ध 1 मु奍य स्रोत 1 मु奍य स्रोत 1 मु奍य स्रोत 1 मु奍य स्रोत 1 मु奍य स्रोत गराउन ु पन� हो, तर संथा/भ赍डारबाट यो 1 मु奍य स्रोत संथा/भ赍डारबाट यो संथा/भ赍डारबाट यो 1 मु奍य स्रोत 1 मु奍य स्रोत 1 मु奍य स्रोत संथा/भ赍डारबाट यो संथा/भ赍डारबाट यो प्र.नं. 017 मा औषधी यो संथालाई संथा/भ赍डारबाट यो औषधी यो संथालाई औषधी यो संथालाई संथा/भ赍डारबाट यो संथा/भ赍डारबाट यो संथा/भ赍डारबाट यो औषधी यो संथालाई औषधी यो संथालाई उपल녍ध “छै न” भꅍने आप�तू 셍 गन셍 �ढलाई औषधी यो संथालाई आप�तू 셍 गन셍 �ढलाई आप�तू 셍 गन셍 �ढलाई भएकोले औषधी यो संथालाई औषधी यो संथालाई औषधी यो संथालाई आप�तू 셍 गन셍 �ढलाई भएकोले आप�तू 셍 गन셍 �ढलाई उQर आएमा, भएकोले आप�तू 셍 गन셍 �ढलाई भएकोले आप�तू 셍 गन셍 �ढलाई आप�तू 셍 गन셍 �ढलाई आप�तू 셍 गन셍 �ढलाई 2 संथा आ फै ल े यो औषधी भएकोले 2 संथा आ फै ल े यो औषधी उपल녍ध नहुनकोु भएकोले भएकोले भएकोले भएकोले माग गन셍 �ढलाई गरेकोले 2 2 2 मु奍य कारण ले奍नसु .् संथा आ फै ल े यो संथा आ फै ल े यो औषधी माग गन셍 �ढलाई गरेकोले 3 सेवा प्रदायक संथालाई संथा आ फै ल े यो 2 2 2 2 एउटामा (मु奍य औषधी माग गन셍 �ढलाई संथा आ फै ल े यो माग गन셍 �ढलाई गरेकोले संथा आ फै ल े यो संथा आ फै ल े यो संथा आ फै ल े यो �कꅍन उपल녍ध नभएकोले औषधी माग गन셍 �ढलाई 3 सेवा प्रदायक संथालाई कारणमा) मात्र �चꅍह गरेकोले औषधी माग गन셍 �ढलाई औषधी माग गन셍 �ढलाई औषधी माग गन셍 औषधी माग गन셍 �ढलाई 4 यो औषधीको ला�ग गरेकोले 3 सेवा प्रदायक संथालाई �कꅍन उपल녍ध नभएकोले लगाउनसु .् गरेकोले गरेकोले �ढलाई गरेकोले गरेकोले सेवाग्राह�को माग कम 3 सेवा प्रदायक संथालाई �कꅍन उपल녍ध नभएकोले 3 सेवा प्रदायक 4 भएको वा नभएकोले �कꅍन उपल녍ध 3 सेवा प्रदायक यो औषधीको ला�ग 3 सेवा प्रदायक 3 सेवा प्रदायक 3 सेवा प्रदायक संथालाई �कꅍन 4 5 यो औषधी प्रदान गन� नभएकोले संथालाई �कꅍन यो औषधीको ला�ग सेवाग्राह�को माग कम संथालाई �कꅍन संथालाई �कꅍन संथालाई �कꅍन उपल녍ध नभएकोले ता�लमप्राꥍत कम셍चार� उपल녍ध नभएकोले सेवाग्राह�को माग कम भएको वा नभएकोले उपल녍ध नभएकोले उपल녍ध नभएकोले उपल녍ध नभएकोले
4 यो औषधीको ला�ग भएको वा नभएकोले नभएकोले 4 यो औषधीको ला�ग 5 7 सेवाग्राह�को माग कम 4 यो औषधीको ला�ग यो औषधी प्रदान गन� 4 यो औषधीको ला�ग 4 यो औषधीको ला�ग 4 यो औषधीको ला�ग अꅍय कारण (खुलाउने): सेवाग्राह�को माग कम 5 यो औषधी प्रदान गन� ता�लमप्राꥍत कम셍चार� ………………………… भएको वा नभएकोले सेवाग्राह�को माग कम सेवाग्राह�को माग कम सेवाग्राह�को माग कम सेवाग्राह�को माग कम ………………………… भएको वा नभएकोले
भएको वा नभएकोले ता�लमप्राꥍत कम셍चार� नभएकोले भएको वा नभएकोले भएको वा नभएकोले भएको वा नभएकोले ………………………… 5 यो औषधी प्रदान गन� नभएकोले 5 यो औषधी प्रदान गन� 7 ( ): ता�लमप्राꥍत कम셍चार� 5 यो औषधी प्रदान गन� अꅍय कारण खुलाउने 5 यो औषधी प्रदान गन� 5 यो औषधी प्रदान गन� 5 यो औषधी प्रदान गन� ता�लमप्राꥍत कम셍चार� 7 ( ): नभएकोले ता�लमप्राꥍत कम셍चार� अꅍय कारण खुलाउने ता�लमप्राꥍत कम셍चार� ता�लमप्राꥍत कम셍चार� ता�लमप्राꥍत कम셍चार� नभएकोले ………………………… ………………………… नभएकोले ………………………… नभएकोले नभएकोले नभएकोले 7 अꅍय कारण (खुलाउने): ………………………… 7 अꅍय कारण (खुलाउने): 7 7 7 अꅍय कारण अꅍय कारण अꅍय कारण ……………………… 7 अꅍय कारण ……………………… …… (खुलाउने): (खुलाउने): (खुलाउने): ……………………… (खुलाउने): ……………………… …………………… ………………………
…………………… …… ………………… ……………………… ………………………
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ख赍ड 4 (बाँक� : मात ृ वा镍य प्रजनन ् वा镍यस륍बꅍधी औषधीको उपल녍धता ) / / (Maternal/RH Medicines) मातवा镍यृ प्रजनन ्वा镍यस륍बꅍधी औषधी (नोट: प्र.नं. 009 मा प्रसू�तलगायत मात ृ वा镍य सेवा “�दꅍछ” भꅍने उ配तर आएको भए मात्र सो鵍ने) �ववरण (16) (10) (11) (12) (13) (14) (15) Either (17) Methyldopa Metronidazole Mifepristone Misoprostol Nifedipine Oxytocin Sodium lactate Tetanus toxoid compound solution or Sodium chloride or Both of them
(एउटामा मात्र �चꅍह (एउटामा मात्र �चꅍह (एउटामा मात्र �चꅍह (एउटामा मात्र �चꅍह (एउटामा मात्र �चꅍह (एउटामा मात्र �चꅍह (एउटामा मात्र �चꅍह लगाउने) (एउटामा मात्र �चꅍह लगाउने) 016 (बाँक�) लगाउने) लगाउने) लगाउने) लगाउने) लगाउने) लगाउने) (प्रच�लत राि�ट्रय प्रोटोकल, 1 हो, मात/ृ प्रजनन ् 1 हो, मात/ृ प्रजनन ् �नद��शका, वा कानून अनसारु , र 1 हो, मात/ृ प्रजनन ् 1 हो, मात/ृ प्रजनन ् 1 हो, मात/ृ प्रजनन ् 1 हो, मात/ृ प्रजनन ् 1 हो, मात/ृ प्रजनन ् वा镍यस륍बꅍधी यो औषधी 1 हो, मात/ृ प्रजनन ् वा镍यस륍बꅍधी यो औषधी यो तहको संथालाई उ�चत/लागु वा镍यस륍बꅍधी यो वा镍यस륍बꅍधी यो वा镍यस륍बꅍधी यो वा镍यस륍बꅍधी यो वा镍यस륍बꅍधी यो औषधी संथाले उपल녍ध गराउन ु पन� वा镍यस륍बꅍधी यो संथाले उपल녍ध गराउन ु पन� ) / हुने अवथामा मातृ प्रजनन ् औषधी संथाले औषधी संथाले औषधी संथाले औषधी संथाले संथाले उपल녍ध गराउनु हो औषधी संथाले उपल녍ध हो वा镍यस륍बꅍधी यी प्र配येक उपल녍ध गराउन पन� उपल녍ध गराउन पन� उपल녍ध गराउन पन� हो उपल녍ध गराउन पन� हो पन� हो ु गराउन पन� हो ु ु ु ु औष�ध संथाले उपल녍ध गराउन ु हो हो 2 / होइन, मातृ प्रजनन ् 2 / 2 / होइन, मातृ प्रजनन ् पन� हो वा होइन, उ配तरदातासँग होइन, मातृ प्रजनन ् 2 / होइन, मातृ प्रजनन ् वा镍यस륍बꅍधी यो औषधी 2 , / 2 , / वा镍यस륍बꅍधी यो औषधी छलफल गर� �न�कष셍अनसारु 2 होइन, वा镍यस륍बꅍधी यो 2 होइन, होइन मातृ प्रजनन ् होइन मातृ प्रजनन ् वा镍यस륍बꅍधी यो औषधी संथाले उपल녍ध गराउने संथाले उपल녍ध गराउने �चꅍह लगाउनसु .् / औषधी संथाले उपल녍ध / वा镍यस륍बꅍधी यो वा镍यस륍बꅍधी यो मातृ प्रजनन ् मातृ प्रजनन ् संथाले उपल녍ध गराउने अपे�ा ग�रएको छै न। अपे�ा ग�रएको छै न। वा镍यस륍बꅍधी यो गराउने अपे�ा ग�रएको वा镍यस륍बꅍधी यो औषधी संथाले उपल녍ध औषधी संथाले अपे�ा ग�रएको छै न। (मा�थ प्र.नं. 006 मा उ쥍ले�खत छै न। गराउने अपे�ा ग�रएको उपल녍ध गराउने अपे�ा ) औषधी संथाले औषधी संथाले तह 奍याल गनु셍स ् छै न। ग�रएको छै न। उपल녍ध गराउने उपल녍ध गराउने अपे�ा ग�रएको छै न। अपे�ा ग�रएको छै न।
(एउटामा मात्र �चꅍह (एउटामा मात्र �चꅍह (एउटामा मात्र �चꅍह (एउटामा मात्र �चꅍह (एउटामा मात्र �चꅍह (एउटामा मात्र �चꅍह (एउटामा मात्र �चꅍह लगाउने) (एउटामा मात्र �चꅍह लगाउने) 017 (बाँक�) लगाउने) लगाउने) लगाउने) लगाउने) लगाउने) लगाउने) 1 छ य�द प्र नं 016 को उQर . . 1 छ 1 छ 1 छ 1 छ 1 छ 1 छ 2 छै न “हो” भएमा अथा셍त ् ( , 2 छै न 2 छै न 2 छै न 2 छै न 2 छै न 1 छ 2 छै न 3 सो鵍न ु नपन� (�कन�क प्र.नं. मात/ृ प्रजनन ् वा镍य 3 सो鵍न ु नपन� 3 सो鵍न ु नपन� (�कन�क 3 सो鵍न ु नपन� 3 सो鵍न ु नपन� (�कन�क 3 सो鵍न ु नपन� 2 छै न 3 सो鵍न ु नपन� (�कन�क प्र.नं. 016 मा होइन भꅍने उ配तर छ) स륍बꅍधी यो औषधी संथाले (�कन�क प्र.नं. 016 प्र.नं. 016 मा होइन भꅍने (�कन�क प्र.नं. 016 प्र.नं. 016 मा होइन (�कन�क प्र.नं. 016 मा 3 सो鵍न ु नपन� (�कन�क 016 मा होइन भꅍने उ配तर छ) उपल녍ध गराउनपन� हो भने , ु ) मा होइन भꅍने उ配तर उ配तर छ) मा होइन भꅍने उ配तर भꅍने उ配तर छ) होइन भꅍने उ配तर छ) प्र.नं. 016 मा होइन भꅍने यो औषधी अ�हले संथाबाट छ) छ) उ配तर छ) उपल녍ध छ छै न उ쥍लेख / गन셍स ् ु .
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(16) (10) (11) (12) (13) (14) (15) Either (17) Methyldopa Metronidazole Mifepristone Misoprostol Nifedipine Oxytocin Sodium lactate Tetanus toxoid �ववरण compound solution or Sodium chloride or Both of them एउटामा (मु奍य कारणमा) एउटामा (मु奍य कारणमा) मात्र एउटामा (मु奍य कारणमा) एउटामा (मु奍य कारणमा) मात्र एउटामा (मु奍य कारणमा) एउटामा (मु奍य कारणमा) एउटामा (मु奍य कारणमा) 018 ) (बाँक� एउटामा (मु奍य मात्र �चꅍह लगाउनसु .् �चꅍह लगाउनसु .् मात्र �चꅍह लगाउनसु .् �चꅍह लगाउनसु .् मात्र �चꅍह लगाउनसु .् मात्र �चꅍह लगाउनसु .् मात्र �चꅍह लगाउनसु .्
कारणमा) मात्र �चꅍह य�द यी औषधी लगाउनसु .् 1 मु奍य स्रोत 1 मु奍य स्रोत संथा/भ赍डारबाट 1 मु奍य स्रोत 1 मु奍य स्रोत संथा/भ赍डारबाट 1 मु奍य स्रोत 1 मु奍य स्रोत 1 मु奍य स्रोत संथाले उपल녍ध संथा/भ赍डारबाट यो यो औषधी यो संथालाई संथा/भ赍डारबाट यो औषधी यो औषधी यो संथालाई संथा/भ赍डारबाट यो औषधी संथा/भ赍डारबाट यो संथा/भ赍डारबाट यो गराउन ु पन� हो, तर प्र.नं. 1 मु奍य स्रोत औषधी यो संथालाई आप�तू 셍 गन셍 �ढलाई भएकोले यो संथालाई आप�तू 셍 गन셍 आप�तू 셍 गन셍 �ढलाई भएकोले यो संथालाई आप�तू 셍 गन셍 औषधी यो संथालाई औषधी यो संथालाई 017 मा उपल녍ध संथा/भ赍डारबाट यो आप�तू 셍 गन셍 �ढलाई �ढलाई भएकोले �ढलाई भएकोले आप�तू 셍 गन셍 �ढलाई भएकोले आप�तू 셍 गन셍 �ढलाई भएकोले “छै न” भꅍने उQर 2 2 औषधी यो संथालाई भएकोले संथा आ फै ल े यो औषधी संथा आ फै ल े यो औषधी आएमा, उपल녍ध 2 2 2 2 आप�तू 셍 गन셍 �ढलाई माग गन셍 �ढलाई गरेकोले संथा आ फै ल े यो औषधी माग गन셍 �ढलाई गरेकोले संथा आ फै ल े यो औषधी संथा आ फै ल े यो औषधी संथा आ फै ल े यो औषधी
नहुनकोु मु奍य कारण 2 संथा आ फै ल े यो औषधी माग गन셍 �ढलाई गरेकोले माग गन셍 �ढलाई गरेकोले माग गन셍 �ढलाई गरेकोले माग गन셍 �ढलाई गरेकोले भएकोले 3 3 ले奍नसु .् माग गन셍 �ढलाई गरेकोले सेवा प्रदायक संथालाई सेवा प्रदायक संथालाई 3 3 3 3 2 संथा आ फै ल े यो �कꅍन उपल녍ध नभएकोले सेवा प्रदायक संथालाई �कꅍन उपल녍ध नभएकोले सेवा प्रदायक संथालाई सेवा प्रदायक संथालाई सेवा प्रदायक संथालाई एउटामा (मु奍य 3 औषधी माग गन셍 �ढलाई सेवा प्रदायक संथालाई �कꅍन उपल녍ध नभएकोले �कꅍन उपल녍ध नभएकोले �कꅍन उपल녍ध नभएकोले �कꅍन उपल녍ध नभएकोले कारणमा) मात्र �चꅍह 4 यो औषधीको ला�ग 4 यो औषधीको ला�ग �कꅍन उपल녍ध नभएकोले गरेकोले 4 4 4 4 लगाउनसु .् सेवाग्राह�को माग कम भएको यो औषधीको ला�ग सेवाग्राह�को माग कम भएको यो औषधीको ला�ग यो औषधीको ला�ग यो औषधीको ला�ग 4 3 सेवा प्रदायक यो औषधीको ला�ग वा नभएकोले सेवाग्राह�को माग कम भएको वा नभएकोले सेवाग्राह�को माग कम भएको सेवाग्राह�को माग कम सेवाग्राह�को माग कम
संथालाई �कꅍन सेवाग्राह�को माग कम वा नभएकोले वा नभएकोले भएको वा नभएकोले भएको वा नभएकोले 5 यो औषधी प्रदान गन� 5 यो औषधी प्रदान गन� उपल녍ध नभएकोले भएको वा नभएकोले 5 5 5 5 ता�लमप्राꥍत कम셍चार� यो औषधी प्रदान गन� ता�लमप्राꥍत कम셍चार� यो औषधी प्रदान गन� यो औषधी प्रदान गन� यो औषधी प्रदान गन� 5 4 यो औषधीको ला�ग यो औषधी प्रदान गन� नभएकोले ता�लमप्राꥍत कम셍चार� नभएकोले ता�लमप्राꥍत कम셍चार� ता�लमप्राꥍत कम셍चार� ता�लमप्राꥍत कम셍चार�
सेवाग्राह�को माग कम ता�लमप्राꥍत कम셍चार� नभएकोले नभएकोले नभएकोले नभएकोले 7 अꅍय कारण (खुलाउने): 7 अꅍय कारण (खुलाउने): भएको वा नभएकोले नभएकोले 7 अꅍय कारण (खुलाउने): 7 अꅍय कारण (खुलाउने): 7 अꅍय कारण (खुलाउने): 7 अꅍय कारण (खुलाउने): …………………………… …………………………… 7 अꅍय कारण (खुलाउने): 5 यो औषधी प्रदान गन� …………………………… …………………………… ………………………… …………………………
ता�लमप्राꥍत कम셍चार� … … ……………………… नभएकोले ……
7 अꅍय कारण (खुलाउने):
……………………… ……
019 1 छ. संथासँग ७ वटा प्राण-र�क मात/ृ प्रजनन ्वा镍य륍बꅍधी औषधी छन ् 2 छै न. संथासँग ७ वटा प्राण-र�क मात/ृ प्रजनन ्वा镍य륍बꅍधी औषधी छै नन ् प्र.नं. 017 को उ配तरअनसारु यो (Magnesium Sulfate Oxytocin) . ( (Magnesium Sulfate Oxytocin) . प्र�नबारे उQरदातासँग छलफल दइवटाु अ�नवाय셍 हुनुपन� र र बाँक�म鵍ये कु नै पाँचवटा 奍याल दइवटाु अ�नवाय셍 हुनपन�ु र र बाँक�म鵍ये कु नै पाँचवटा , Sodium chloride Sodium lactate compound , Sodium chloride Sodium lactate compound गनु셍स,् अ�न �न�कष셍 अनसारु रहोस ् र आपसमा वैकि쥍पक हुन ्भने 奍याल रहोस ् र आपसमा वैकि쥍पक हुन ्भने Dexamethasone र Betamethasone प�न आपसमा वैकि쥍पक हुन)् Dexamethasone र Betamethasone प�न आपसमा वैकि쥍पक हुन)् Page | 118
एउटामा �चꅍह लगाउनसु ्
प्र.नं.017 मा उ쥍ले�खत औषधीको टक प्रमाणीकरण (1) (3) (4) (5) (9) Medicines (2) Benzathine BetamethasoneOr Calcium (6) (7) (8) Magnesium Azithromycin DexamethasoneOr Cefixime Gentamicin Hydralazine Ampicillin benzylpenicillin Both gluconate sulfate प्र.नं. 017 को लगत �लइयो, यो लगत �लइयो, यो लगत �लइयो, यो लगत �लइयो कु नै एउटा लगत �लइयो, यो लगत �लइयो, यो लगत �लइयो, यो लगत �लइयो, यो लगत �लइयो, यो प्र配येक उQरको औषधी टकमा छ औषधी टकमा छ औषधी टकमा छ वा दवैु टकमा छ औषधी टकमा छ औषधी टकमा छ औषधी टकमा छ औषधी टकमा छ औषधी टकमा छ
ला�ग, प्र�नकता셍ले , लगत �लइयो, यो लगत �लइयो, यो लगत �लइयो, यो लगत �लइयो, यो लगत �लइयो, यो लगत �लइयो, यो संथाको टक लगत �लइयो, लगत �लइयो यो कु नै एउटा वा दवैु टकमा औषधी टकमा छै न औषधी टकमा छै न औषधी टकमा छै न औषधी टकमा छै न औषधी टकमा छै न औषधी टकमा छै न अवलोकन यो औषधी टकमा छै न औषधी टकमा छै न छै न (Physical (16) Inventory) Either (17) गरेर (10) (11) (12) (13) (14) (15) Sodium chloride Tetanus toxoid प्राꥍत त镍य ले奍ने Or Methyldopa Metronidazole Mifepristone Misoprostol Nifedipine Oxytocin Sodium lactate compound solution
लगत �लइयो, यो लगत �लइयो, यो लगत �लइयो, यो लगत �लइयो कु नै एउटा लगत �लइयो, यो लगत �लइयो, यो लगत �लइयो, यो लगत �लइयो, यो औषधी टकमा छ औषधी टकमा छ औषधी टकमा छ वा दवैु टकमा छ औषधी टकमा छ औषधी टकमा छ औषधी टकमा छ औषधी टकमा छ
लगत �लइयो, , , , , लगत �लइयो, यो कु नै एउटा वा दवैु टकमा लगत �लइयो यो लगत �लइयो यो लगत �लइयो यो लगत �लइयो यो यो औषधी टकमा छै न लगत �लइयो, यो औषधी टकमा छै न छै न औषधी टकमा छै न औषधी टकमा छै न औषधी टकमा छै न औषधी टकमा छै न औषधी टकमा छै न
ख赍ड 5: सेवा प्रदायक संथामा प�रवार �नयोजनका आध�नकु साधन/�व�धको टक-आउटको िथ�त (नोट: प्र.नं. 008 मा प�रवार �नयोजन सेवा “�दꅍछ” भꅍने उ配तर आएको भए मात्र सो鵍ने) (1) (2) (3) (4) (5) (6) (7) (8) (9)
�ववरण पु셁षले लगाउने म�हलाले लगाउने खाने च啍क� सुई पाठे घरमा हा쥍ने इ륍ꥍलाꅍट म�हला बꅍ鵍याकर पु셁ष बꅍ鵍याकरण आकिमक क赍डम क赍डम (Pills) (Depo) साधन (Zdal) (Minilap) (Vasectomy) गभ셍�नरोध
(IUCD/ साधन Copper T) (Emergency Contraceptives) (i): यो सव��ण अगा�ड गत ६ म�हनामा टक आउटको िथ�त ( ( 020 एउटामा मात्र �चꅍह एउटामा मात्र �चꅍह एउटामा मात्र �चꅍह एउटामा मात्र �चꅍह एउटामा मात्र �चꅍह एउटामा मात्र �चꅍह एउटामा मात्र �चꅍह एउटामा मात्र �चꅍह एउटामा मात्र �चꅍह लगाउनसु )् लगाउनसु )् लगाउनसु )् लगाउनसु )् लगाउनसु )् लगाउनसु )् लगाउनसु )् लगाउनसु )् लगाउनसु )् प�रवार �नयोजनका यी
प्र配येक साधन/�व�ध संथाले उपल녍ध 1.�थयो, (यो सव��ण 1.�थयो, (यो सव��ण 1.�थयो, (यो सव��ण 1.�थयो, (यो सव��ण 1.�थयो, (यो सव��ण 1.�थयो, (यो 1.�थयो, (यो सव��ण 1.�थयो, (यो सव��ण 1.�थयो, (यो सव��ण ) ) ) ) ) ) ) ) ) गराउनुपन�मा(आजभꅍदा) अगा�ड गत ६ अगा�ड गत ६ म�हनामा अगा�ड गत ६ म�हनामा अगा�ड गत ६ म�हनामा अगा�ड गत ६ सव��ण अगा�ड अगा�ड गत ६ अगा�ड गत ६ म�हनामा अगा�ड गत ६
गत ६ म�हनामा ए कै �दन म�हनामा कु नै एक कु नै एक �दन यो कु नै एक �दन यो कु नै एक �दन यो म�हनामा कु नै एक गत ६ म�हनामा कु नैम�हनामा कु नै एक �दनकु नै एक �दन यो म�हनामा कु नै एक �दन / / / / / / / / मात्र भए प�न टकमा �दन यो साधन �व�ध साधन �व�ध टकमै साधन �व�ध टकमै �थएनसाधन �व�ध टकमै �दन यो साधन �व�ध एक �दन यो यो साधन �व�ध साधन �व�ध टकमै यो साधन �व�ध Out of / नभएकोले उपल녍ध गराउन टकमै �थएन �थएन �थएन टकमै �थएन साधन �व�ध टकमै �थएन �थएन टकमै �थएन Out of Out of stock/STOCK-OUT) Out of Out of Out of Out of Out of Page | 119
? stock/STOCK- stock/STOCK- stock/STOCK- stock/STOCK- stock/STOCK- stock/STOCK- stock/STOCK- न स के क ो िथ�त �थयो टकमै �थएन OUT) OUT) OUT) OUT) Out of OUT) OUT) OUT) ( . . 006 मा�थ प्र नं मा 2.�थएन , ( stock/STOCK- यो सव��ण उ쥍ले�खत तह 奍याल . , ( . , ( . , ( OUT) . , ( . , ( . , ( 2 �थएन यो सव��ण अगा�ड) गत ६ म�हनाको 2 �थएन यो सव��ण 2 �थएन यो 2 �थएन यो 2 �थएन यो सव��ण 2 �थएन यो ) 2.�थएन , (यो गनु셍स ् अगा�ड) गत ६ म�हनाको अगा�ड) गत ६ म�हनाको सव��ण अगा�ड) गत ६ सव��ण अगा�ड) गत ६ अगा�ड) गत ६ म�हनाको सव��ण अगा�ड) गत ६ ) कु नै एक �दन प�न यो सव��ण अगा�ड गत . , ( कु नै एक �दन प�न यो साधन/�व�ध टकमै कु नै एक �दन प�न यो म�हनाको कु नै एक 2 �थएन यो म�हनाको कु नै एक �दन कु नै एक �दन प�न यो म�हनाको कु नै एक �दन ६ म�हनाको कु नै एक साधन/�व�ध टकमै साधन/�व�ध टकमै �दन प�न यो सव��ण अगा�ड) प�न यो साधन/�व�ध साधन/�व�ध टकमै प�न यो साधन/�व�ध नभएको �थएन (NO �दन प�न यो NO NO साधन/�व�ध टकमै गत ६ म�हनाको टकमै नभएको �थएन NO टकमै नभएको �थएन साधन/�व�ध टकमै नभएको �थएन ( Out of नभएको �थएन ( नभएको �थएन ( कु नै एक �दन प�न Out of stock/STOCK-OUT) Out of नभएको �थएन (NO (NO Out of Out of (NO Out of नभएको �थएन (NO stock/STOCK- stock/STOCK- यो साधन/�व�ध stock/STOCK- Out of stock/STOCK- stock/STOCK- Out of OUT) OUT) stock/STOCK- टकमै नभएको OUT) OUT) OUT) stock/STOCK- OUT) NO Out OUT) �थएन ( of stock/STOCK- OUT)
021 1 संथाले उपल녍ध गराउने एक वा एक भꅍदा बढ� साधनह셁 (यो सव��ण अगा�ड) 2 संथाले उपल녍ध गराउने सबै साधनह셁 (यो सव��ण अगा�ड) गत ६ म�हनामा प्र नं 020 को उ配तरअनसार यो प्र�नबारे . . ु गत ६ म�हनामा कु नै एक �दन यो साधन/�व�ध टकमा �थएन सबै �दन नै टकमा �थयो Q उ र दातासँग छलफल गनु셍स,् अ�न 配यसैले, यो संथाले गत ६ म�हनामा टक-आउट अनुभव 配यसैले, यो संथाले गत ६ म�हनामा टक-आउट अनुभव गरेन �न�कष셍अनुसार एउटामा �चꅍह लगाउनुस ् गय� (STOCK-OUT WITHIN THE LAST SIX MONTHS) (NO STOCK-OUT WITHIN THE LAST SIX MONTHS]
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(1) (2) (3) (4) (5) (6) (7) (8) (9)
�ववरण पु셁षले लगाउने म�हलाले लगाउने खाने च啍क� सुई पाठे घरमा हा쥍ने साधन इ륍ꥍलाꅍट म�हला बꅍ鵍याकर पु셁ष बꅍ鵍याकरण आकिमक गभ셍�नरोध क赍डम क赍डम (Pills) (Depo) (IUCD/ (Zdal) (Minilap) (Vasectomy) साधन (Emergency
Copper T) Contraceptives) 022 (एउटा मु奍य (एउटा मु奍य कारण (एउटा मु奍य (एउटा मु奍य कारण (एउटा मु奍य कारण (एउटा मु奍य कारण (एउटा मु奍य कारण (एउटा मु奍य कारण (एउटा मु奍य कारण य�द प्र.नं. कारण ले奍नसु )् ले奍नसु )् कारण ले奍नसु )् ले奍नसु )् ले奍नसु )् ले奍नसु )् ले奍नसु )् ले奍नसु )् ले奍नसु )् 021 को उ配तर 1 मु奍य स्रोत 1 मु奍य स्रोत 1 मु奍य स्रोत 1 मु奍य स्रोत 1 मु奍य स्रोत 1 मु奍य स्रोत 1 मु奍य स्रोत 1 मु奍य स्रोत 1 मु奍य स्रोत “हो” भएमा संथा/भ赍डारबाट संथा/भ赍डारबाट संथा/भ赍डारबाट संथा/भ赍डारबाट संथा/भ赍डारबाट संथा/भ赍डारबाट संथालाई संथा/भ赍डारबाट संथा/भ赍डारबाट संथा/भ赍डारबाट (अथा셍त,् यो संथालाई यो संथालाई यो साधन संथालाई यो संथालाई यो साधन संथालाई यो साधन यो साधन आप�तू 셍 गन셍 �ढलाई संथालाई यो साधन संथालाई यो साधन संथालाई यो साधन सव��ण अगा�ड साधन आप�तू 셍 गन셍 आप�तू 셍 गन셍 �ढलाई साधन आप�तू 셍 गन셍 आप�तू 셍 गन셍 �ढलाई आप�तू 셍 गन셍 �ढलाई भएकोले आप�तू 셍 गन셍 �ढलाई आप�तू 셍 गन셍 �ढलाई आप�तू 셍 गन셍 �ढलाई
गत ६ म�हनामा �ढलाई भएकोले भएकोले �ढलाई भएकोले भएकोले भएकोले भएकोले भएकोले भएकोले 2 संथा आ फै ल े यो साधन कु नै एक �दन 2 संथा आ फै ल े यो 2 संथा आ फै ल े यो साधन 2 संथा आ फै ल े यो साधन माग गन셍 �ढलाई गरेकोले 2 संथा आ फै ल े यो 2 संथा आ फै ल े यो साधन 2 संथा आ फै ल े यो साधन यो साधन/�व�ध 2 2 संथा आ फै ल े यो संथा आ फै ल े यो साधन माग गन셍 माग गन셍 �ढलाई गरेकोले माग गन셍 �ढलाई गरेकोले साधन माग गन셍 �ढलाई माग गन셍 �ढलाई गरेकोले माग गन셍 �ढलाई गरेकोले टकमा �थएन साधन माग गन셍 �ढलाई गरेकोले साधन माग गन셍 गरेकोले STOCK-OUT 3 सेवा प्रदायक संथालाई �ढलाई गरेकोले �ढलाई गरेकोले 3 3 3 3 भने), यसको सेवा प्रदायक संथालाई सेवा प्रदायक संथालाई �कꅍन उपल녍ध नभएकोले सेवा प्रदायक संथालाई सेवा प्रदायक 3 3 मु奍य कारण सेवा प्रदायक �कꅍन उपल녍ध �कꅍन उपल녍ध सेवा प्रदायक �कꅍन उपल녍ध संथालाई �कꅍन 3 सेवा प्रदायक 3 सेवा प्रदायक ले奍नस ् संथालाई �कꅍन नभएकोले नभएकोले संथालाई �कꅍन नभएकोले उपल녍ध नभएकोले ु 4 यो साधनको ला�ग संथालाई �कꅍन संथालाई �कꅍन उपल녍ध नभएकोले उपल녍ध नभएकोले उपल녍ध नभएकोले उपल녍ध नभएकोले 4 यो साधनको ला�ग 4 यो साधनको ला�ग सेवाग्राह�को माग कम भएको 4 यो साधनको ला�ग 4 यो साधनको ला�ग
सेवाग्राह�को माग कम सेवाग्राह�को माग कम वा नभएकोले 4 यो साधनको ला�ग सेवाग्राह�को माग कम सेवाग्राह�को माग कम 4 5 k|bfg ug]{ यो साधनको ला�ग यो साधन 4 4 भएको वा नभएकोले भएको वा नभएकोले सेवाग्राह�को माग कम भएको वा नभएकोले भएको वा नभएकोले यो साधनको ला�ग यो साधनको ला�ग सेवाग्राह�को माग कम ता�लमप्राꥍत कम셍चार� भएको वा नभएकोले 5 k|bfg ug]{ 5 k|bfg ug]{ सेवाग्राह�को माग भएको वा नभएकोले सेवाग्राह�को माग यो साधन नभएकोले यो साधन 5 k|bfg ug]{ 5 यो साधन k|bfg ug]{ कम भएको वा कम भएको वा 7अꅍय कारण (खलाउने): ता�लमप्राꥍत कम셍चार� यो साधन ता�लमप्राꥍत कम셍चार� ु नभएकोले नभएकोले …….……………………… नभएकोले 6 यो साधन k|bfg ug{ चा�हने ता�लमप्राꥍत कम셍चार� ता�लमप्राꥍत कम셍चार� नभएकोले
7 नभएकोले अꅍय कारण आव�यक उपकरण नभएकोले नभएकोले 6 k|bfg ug{ (खलाउने): यो साधन ु 6 यो साधन k|bfg ug{ 7 7 6 k|bfg ug{ अꅍय कारण अꅍय कारण चा�हने आव�यक उपकरण यो साधन 6 यो साधन k|bfg ug{ …….…………………… 7अꅍय कारण (खुलाउने): चा�हने आव�यक उपकरण ( ): ( ): खुलाउने … खुलाउने नभएकोले …….……………………… चा�हने आव�यक चा�हने आव�यक उपकरण नभएकोले उपकरण नभएकोले …….………………… …….………………… 7 ( ): नभएकोले …… …… अꅍय कारण खुलाउने …….……………………… 7अꅍय कारण (खुलाउने): 7अꅍय कारण (खुलाउने): 7अꅍय कारण (खुलाउने): …….…………………… …….……………………… …….………………………
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(ii): सव��णको समयमा टक-आउटको िथ�त (NO STOCK-OUT AT THE TIME OF THE SURVEY) (1) (2) (3) (4) (5) (6) (7) (8) (9)
�ववरण पु셁षले लगाउने म�हलाले लगाउने खाने च啍क� सुई पाठे घरमा हा쥍ने इ륍ꥍलाꅍट म�हला बꅍ鵍याकर पु셁ष बꅍ鵍याकरण आकिमक क赍डम क赍डम (Pills) (Depo) साधन (Zdal) (Minilap) (Vasectomy) गभ셍�नरोध
(IUCD/ साधन Copper T) (Emergency Contraceptives)
023 (एउटामा मात्र �चꅍह (एउटामा मात्र �चꅍह ((एउटामा मात्र �चꅍह (एउटामा मात्र �चꅍह (एउटामा मात्र �चꅍह (एउटामा मात्र �चꅍह (एउटामा मात्र �चꅍह (एउटामा मात्र �चꅍह (एउटामा मात्र �चꅍह लगाउने) लगाउने) लगाउने) लगाउने) लगाउने) लगाउने) लगाउने) लगाउने) लगाउने) प्र.नं. 011 अनसारु , प�रवार
�नयोजनका यी प्र配येक �व�ध संथाले आ굍नो तहअनसार ु 1 हो, यो साधन �व�ध 1 हो, यो साधन �व�ध 1 हो, यो साधन �व�ध 1 हो, यो साधन �व�ध 1 हो, यो साधन �व�ध 1 हो, यो साधन 1 हो, यो साधन �व�ध 1 हो, यो साधन �व�ध 1 हो, यो साधन �व�ध उपल녍ध गराउनपन� हो, तर ु टकमा छै न टकमा छै न (STOCK- टकमा छै न (STOCK- टकमा छै न (STOCK- टकमा छै न �व�ध टकमा छै न टकमा छै न टकमा छै न (STOCK- टकमा छै न
यो साधन अ�हले टकमा (STOCK-OUT) OUT) OUT) OUT) (STOCK-OUT) (STOCK-OUT) (STOCK-OUT) OUT) (STOCK-OUT) छै न 配यसैले सेवाग्राह�लाई �दन न स के क ो हो? 2 होइन, यो साधन 2 होइन, यो साधन 2 होइन, यो साधन अ�हले 2 होइन, यो साधन 2 होइन, यो साधन 2 होइन, यो साधन 2 होइन, यो साधन 2 होइन, यो साधन अ�हले 2 होइन, यो साधन 006 (मा�थ प्र.नं. मा अ�हले टकमै छ अ�हले टकमै छ टकमै छ अ�हले टकमै छ अ�हले टकमै छ अ�हले टकमै छ अ�हले टकमै छ टकमै छ अ�हले टकमै छ उ쥍ले�खत तह 奍याल गनु셍स)् (NO STOCK- (NO STOCK-OUT) (NO STOCK-OUT) (NO STOCK-OUT) (NO STOCK-OUT) (NO STOCK- (NO STOCK-OUT) (NO STOCK-OUT) (NO STOCK-OUT)
OUT OUT ) )
024 1 यी साधनम鵍ये कु नै वा के ह � अ�हले संथाको टकमा छै न, 配यसैले, यो सव��णको �दन 2 सबै साधन/�व�ध टकमा छ र उपल녍ध छ, 配यसैले, यो सव��णको प्र नं 020 को उ配तरअनसार यो प्र�नबारे . . ु टकमै नभएको अवथा अनुभव गरेको हो (STOCK-OUT ON DAY OF SURVEY) �दन टकमा नभएको अवथा होइन उ配तरदातासँग छलफल गनु셍स ् अ�न �न�कष셍अनुसार (NO STOCK-OUT ON THE DAY OF SURVEY ) , एउटामा �चꅍह लगाउनुस ्
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(1) (2) (3) (4) (5) (6) (7) (8) (9)
पु셁षले लगाउने म�हलाले लगाउने खाने च啍क� सुई पाठे घरमा हा쥍ने साधन इ륍ꥍलाꅍट म�हला बꅍ鵍याकर पु셁ष बꅍ鵍याकरण आकिमक गभ셍�नरोध �ववरण क赍डम क赍डम (Pills) (Depo) (IUCD/ (Zdal) (Minilap) (Vasectomy) साधन (Emergency
Copper T) Contraceptives) (एउटा मु奍य (एउटा मु奍य कारण (एउटा मु奍य (एउटा मु奍य कारण (एउटा मु奍य कारण (एउटा मु奍य कारण (एउटा मु奍य कारण (एउटा मु奍य कारण (एउटा मु奍य कारण 025 कारण ले奍नसु )् ले奍नसु )् कारण ले奍नसु )् ले奍नसु )् ले奍नसु )् ले奍नसु )् ले奍नसु )् ले奍नसु )् ले奍नसु )् प्र.नं. 022 को 1 मु奍य स्रोत 1 मु奍य स्रोत 1 मु奍य स्रोत 1 मु奍य स्रोत 1 मु奍य स्रोत 1 मु奍य स्रोत 1 मु奍य स्रोत 1 मु奍य स्रोत उ配तर “हो” भए 1 मु奍य स्रोत संथा/भ赍डारबाट संथा/भ赍डारबाट संथा/भ赍डारबाट संथा/भ赍डारबाट संथा/भ赍डारबाट संथालाई संथा/भ赍डारबाट संथा/भ赍डारबाट संथा/भ赍डारबाट (यो साधन अ�हले संथा/भ赍डारबाट संथालाई यो साधन संथालाई यो संथालाई यो साधन संथालाई यो साधन यो साधन आप�तू 셍 गन셍 �ढलाई संथालाई यो साधन संथालाई यो साधन संथालाई यो साधन टकमा छै न भने), संथालाई यो आप�तू 셍 गन셍 �ढलाई साधन आप�तू 셍 गन셍 आप�तू 셍 गन셍 �ढलाई आप�तू 셍 गन셍 �ढलाई भएकोले आप�तू 셍 गन셍 �ढलाई आप�तू 셍 गन셍 �ढलाई आप�तू 셍 गन셍 �ढलाई यसको म奍य ु साधन आप�तू 셍 गन셍 भएकोले �ढलाई भएकोले भएकोले भएकोले भएकोले भएकोले भएकोले 2 कारण ले奍नसु ् �ढलाई भएकोले संथा आ फै ल े यो साधन 2 संथा आ फै ल े यो 2 संथा आ फै ल े यो साधन 2 संथा आ फै ल े यो साधन माग गन셍 �ढलाई गरेकोले 2 संथा आ फै ल े यो 2 संथा आ फै ल े यो साधन 2 संथा आ फै ल े यो साधन 2 प्र配येक �व�धको संथा आ फै ल े यो 2 साधन माग गन셍 माग गन셍 �ढलाई गरेकोले माग गन셍 �ढलाई गरेकोले साधन माग गन셍 �ढलाई माग गन셍 �ढलाई गरेकोले माग गन셍 �ढलाई गरेकोले संथा आ फै ल े यो ला�ग एउटामा �ढलाई गरेकोले साधन माग गन셍 गरेकोले 3 सेवा प्रदायक संथालाई (म奍य कारणमा) साधन माग गन셍 �ढलाई गरेकोले ु 3 3 3 3 सेवा प्रदायक संथालाई सेवा प्रदायक संथालाई �कꅍन उपल녍ध नभएकोले सेवा प्रदायक संथालाई सेवा प्रदायक मात्र �चꅍह �ढलाई गरेकोले 3 सेवा प्रदायक �कꅍन उपल녍ध �कꅍन उपल녍ध 3 सेवा प्रदायक �कꅍन उपल녍ध संथालाई �कꅍन लगाउनसु ् 3 संथालाई �कꅍन सेवा प्रदायक नभएकोले नभएकोले संथालाई �कꅍन नभएकोले उपल녍ध नभएकोले 3 सेवा प्रदायक 4 यो साधनको ला�ग उपल녍ध नभएकोले संथालाई �कꅍन उपल녍ध नभएकोले
संथालाई �कꅍन उपल녍ध नभएकोले 4 यो साधनको ला�ग 4 यो साधनको ला�ग सेवाग्राह�को माग कम भएको 4 यो साधनको ला�ग 4 यो साधनको ला�ग
उपल녍ध नभएकोले सेवाग्राह�को माग कम सेवाग्राह�को माग कम वा नभएकोले 4 यो साधनको ला�ग सेवाग्राह�को माग कम सेवाग्राह�को माग कम 4 यो साधनको ला�ग 5 यो साधन k|bfg ug]{ भएको वा नभएकोले भएको वा नभएकोले सेवाग्राह�को माग कम भएको वा नभएकोले भएको वा नभएकोले 4 यो साधनको ला�ग 4 सेवाग्राह�को माग कम ता�लमप्राꥍत कम셍चार� भएको वा नभएकोले यो साधनको ला�ग सेवाग्राह�को माग 5 k|bfg ug]{ 5 k|bfg ug]{ भएको वा नभएकोले यो साधन नभएकोले यो साधन 5 k|bfg ug]{ सेवाग्राह�को माग 5 k|bfg ug]{ यो साधन कम भएको वा 7अꅍय कारण (खुलाउने): ता�लमप्राꥍत कम셍चार� यो साधन ता�लमप्राꥍत कम셍चार� कम भएको वा नभएकोले …….……………………… नभएकोले 6 यो साधन k|bfg ug{ चा�हने ता�लमप्राꥍत कम셍चार� ता�लमप्राꥍत कम셍चार� नभएकोले
नभएकोले 7अꅍय कारण आव�यक उपकरण नभएकोले नभएकोले नभएकोले
6 k|bfg ug{ ( ): यो साधन खुलाउने 6 यो साधन k|bfg ug{ 7अꅍय कारण चा�हने आव�यक उपकरण 6 यो साधन k|bfg ug{ 6 7 ( ): यो साधन k|bfg ug{ 7अꅍय कारण …….…………………… अꅍय कारण खुलाउने चा�हने आव�यक उपकरण … (खुलाउने): नभएकोले चा�हने आव�यक …….……………………… चा�हने आव�यक उपकरण (खुलाउने): नभएकोले उपकरण नभएकोले …….………………… 7अꅍय कारण (खुलाउने): नभएकोले …….………………… …… …… …….……………………… 7अꅍय कारण (खुलाउने): 7अꅍय कारण (खुलाउने): 7अꅍय कारण (खुलाउने): …….…………………… …….……………………… …….………………………
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प्र.नं.023 का �ववरण प्रमाणीकरण (1) (2) (3) (4) (5) (6) (7) (8) (9)
पु셁षले म�हलाले लगाउने खाने च啍क� सुई पाठे घरमा इ륍ꥍलाꅍट म�हला पु셁ष आकिमक Contraceptive लगाउने क赍डम (Pills) (Depo) हा쥍ने साधन (Zdal) बꅍ鵍याकर बꅍ鵍याकरण गभ셍�नरोध
क赍डम (IUCD/ (Minilap) (Vasectomy) साधन Copper T) (Emergency Contraceptives) प्र.नं. 023 को लगत लगत �लइयो, लगत �लइयो, लगत �लइयो, लगत लगत लगत लगत लगत �लइयो, प्र配येक उ配तरको �लइयो, यो यो औषधी टकमा यो औषधी टकमा यो औषधी �लइयो, यो �लइयो, यो �लइयो, यो �लइयो, यो यो औषधी टकमा ला�ग, औषधी टकमा छ छ टकमा छ औषधी टकमा औषधी टकमा औषधी टकमा औषधी टकमा छ
प्र�नकता셍ले छ छ छ छ छ
संथाको लगत �लइयो, लगत �लइयो, लगत लगत �लइयो, लगत लगत लगत लगत लगत �फिजकल लगत यो औषधी टकमा यो औषधी टकमा �लइयो, यो औषधी टकमा �लइयो, �लइयो, �लइयो, �लइयो, �लइयो, (Physical छै न छै न यो औषधी छै न यो औषधी यो औषधी यो औषधी यो औषधी यो औषधी Inventory) गरेर टकमा छै न टकमा छै न टकमा छै न टकमा छै न टकमा छै न टकमा छै न प्राꥍत त镍य ले奍ने
026 of] v08df xfdLcf}ifwLsf] cfk"lt{, df}Hbft (Stock) ;do, xfnsf] df}Hbft tyf Dofb ;lsPsf] cf}ifwLsf] af/]dfhfgsf/L lng]5f}F. #=df}Hbft @= olb eof] z"Go %=cGtjf{tf{ != ut !@ eg] slt (Stock- $=cGtjf{tf{ sf] ;dodf Dlxgfleq cf}ifwLsf] k6s out) sf] ;dodf s'g} Dofb df}Hbftz"Go df}Hbft cf}ifwL hDdf cf}ifwLsf] ;lsPsf] (Stock-out) z"Go -/]s8{ cjnf]sgug]{, slt df}Hbft cf}ifwL ePsf] lyof]< (Stock- :6f]/sf] ;fy} :jf:Yo ;+:yfsf] lbgsf lyof]< df}Hbft out) ePsf] cfˆg]]}cf}ifwLljt/0f sIfdfklg nflu lyof]< lyof]< x]g]{_ eof]<
#
lyof] lyPg yfxf 5}g k6s slt yfxf 5}gÖ k6s slt yfxf 5}gÖ# lyof] lyPg yfxf 5}g 5 5}g yfxf 5}g
1. Albendazole cap/tab 1 2 3 3 3 1 2 3 1 2 3
Aluminium hydroxide + 3 3 2. 1 2 3 1 2 3 1 2 3 Magnesium hydroxide tab 3. Amoxycillincap/tab 1 2 3 3 3 1 2 3 1 2 3
4. 1 2 3 3 3 1 2 3 1 2 3
Chloramphenicol 1% eye 3 3 5. 1 2 3 1 2 3 1 2 3 applicap 6. Ciprofloxacin cap/tab. 1 2 3 3 3 1 2 3 1 2 3
7. Depo-provera 1 2 3 3 3 1 2 3 1 2 3
Ferrous salt + folic acid 3 3 8. 1 2 3 1 2 3 1 2 3 cap/tab Gamma benzene 3 3 9. 1 2 3 1 2 3 1 2 3 hexachloride lotion Hyoscinebutylbromidecap/ta 3 3 10. 1 2 3 1 2 3 1 2 3 b 11. Metronidazole cap/tab 1 2 3 3 3 1 2 3 1 2 3
Oral Rehydration Solution 3 3 12. 1 2 3 1 2 3 1 2 3 (ORS) 13. Paracetamolcap/tab 1 2 3 3 3 1 2 3 1 2 3
14. Providone iodine solution 1 2 3 3 3 1 2 3 1 2 3
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026 of] v08df xfdLcf}ifwLsf] cfk"lt{, df}Hbft (Stock) ;do, xfnsf] df}Hbft tyf Dofb ;lsPsf] cf}ifwLsf] af/]dfhfgsf/L lng]5f}F. #=df}Hbft @= olb eof] z"Go %=cGtjf{tf{ != ut !@ eg] slt (Stock- $=cGtjf{tf{ sf] ;dodf Dlxgfleq cf}ifwLsf] k6s out) sf] ;dodf s'g} Dofb df}Hbftz"Go df}Hbft cf}ifwL hDdf cf}ifwLsf] ;lsPsf] (Stock-out) z"Go -/]s8{ cjnf]sgug]{, slt df}Hbft cf}ifwL ePsf] lyof]< (Stock- :6f]/sf] ;fy} :jf:Yo ;+:yfsf] lbgsf lyof]< df}Hbft out) ePsf] cfˆg]]}cf}ifwLljt/0f sIfdfklg nflu lyof]< lyof]< x]g]{_ eof]<
#
lyof] lyPg yfxf 5}g k6s slt yfxf 5}gÖ k6s slt yfxf 5}gÖ# lyof] lyPg yfxf 5}g 5 5}g yfxf 5}g Sulfamethoxazole + 3 3 15. Trimethoprimcap/tab 1 2 3 1 2 3 1 2 3 (Cotrium) 16. Vitamin A cap/tab 1 2 3 3 3 1 2 3 1 2 3
17. Zinc sulphate 1 2 3 3 3 1 2 3 1 2 3
Vaccine DPT, HepB, Hip 3 3
18. 1 2 3 1 2 3 1 2 3 (pentavalent) vial 19. Gentamycin inj. 1 2 3 3 3 1 2 3 1 2 3
20. Oxytocin Injection 1 2 3 3 3 1 2 3 1 2 3
21. Magnesium sulphate Injection, 1 2 3 3 3 1 2 3 1 2 3
Compound solution of Sodium 3 3
22. 1 2 3 1 2 3 1 2 3 lactate (Ringer’s L) cGt/jf{tf{ lng] JolQmn] dflysf] 6]an ebf{ s'g} cK7\ of/f] cj:yfef]Ug' k/]sf] jf s'g} afwfJojwfg k/]sf] ePdf ;f] s'/f pNn]v ug{'xf];\ -h:t}M b/fh÷sf]7f cGtjf{ t{f lng] lbgx¿dfaGblyof] cflb . utcfly{s jif{df -@)&)÷@)&!_ 1 df}Hbft z"Go ePsf sf/0f ;d:of k/]sf] …………………………………………… df}Hbftz"GoePsfsf/0f ;d:ofef]Ug' k¥of] sLk/]g< 2 s'g} klgcf}ifwLsf] df}Hbft z"Go gePsf ……………………………………………
!_ pknAw ;]jfx¿ -;]jf pknAw gePdf csf]{ ljj/0fdf hfg]_ 027 lgDg ;]jfx¿ o; :jf:Yo ;+:yfdfpknAw 5g\ ls 5}gg\ < pknAw t/ @$÷& pknAw @$÷& pknAw pknAw5}g 5}g 1. Normal Vaginal Delivery 1 2 3 2. Assisted vaginal delivery, vacuum extraction 1 2 3 3. Assisted vaginal delivery, forceps 1 2 3 4. Parental antibiotics (IV / IM injection) 1 2 3 5. Uterotonic drugs (e.g. Parental oxytocins, Misoprostol) 1 2 3 6. Anti-convulsants/sedatives (Magnesium Sulphate injection) (IV / IM injection) 1 2 3 7. Manual removal of placental (MRP) 1 2 3 Remove retained products if incomplete abortion (e.g. manual vacuum 8. 1 2 3 aspiration (MVA)) 9. Neonatal resuscitation ( e.g. with bag and mask) 1 2 3 10. Caesarean section 1 2 3 11. Blood transfusion service 1 2 3 12. Anesthesia for C/S 1 2 3 13. Laboratory diagnosis service (Culture facility) 1 2 3 14. Hemoglobin testing 1 2 3 15. Antenatal Care 2 3 16. Tetanus toxoid injection 2 3
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17. Post-natal care 2 3 18. Medical Abortion 2 3 19. Surgical abortion in 1st trimester (MVA) 2 3
20. Second trimester abortion 2 3 21. X-ray 1 2 3 22. Ultrasonography (usg.) 1 2 3 23. Service for mental illness 2 3 24. Counseling for gender based violence (GBV) 1 2 3 25. Child immunization (facility or outreach) 2 3 26. Growth monitoring (facility or outreach) 2 3 27. Voluntary Counseling and Testing (VCT) 1 2 3
भाग 2 (Facility Resources) ख赍ड 6: आपू�त셍 तह (सबै संथालाई सो鵍नुपन�) यस संथामा वाथ सामग्री (medical 1 वाथ ;+:yf k|d"v (Health facility Incharge) 2 मे�डकल डा啍टर (Medical Doctor) 028 supplies) माग गन� मु奍य उ配तरदायी 3 फाम셍�सट (Pharmacist) 4 नस셍 (Nurse) 5 अꅍय (खुलाउने) ______핍यि啍त को हो? यस संथामा प�रवार �नयोजनको 1 यस संथाका कम셍चार�ले कु नै सूत्र प्रयोग गर� साधनको आव�यक प�रमाणको माग गछ셍 (Resupplies) 029 साधनको पुनःमाग कसर� 2 यस संथालाई सामग्री आपू�त셍 गन� संथा/भ赍डारले (institution/warehouse) नै आव�यक प�रमाणको �नधा셍रण गछ셍 �नधा셍रण ग�रꅍछ? (एउटामा मात्र �चꅍह लगाउने) 3 अꅍय प्र�क्रया (खुलाउने) ………………………………………………………… 1 के ि ꅍ द्र य औषधी टोर (central medical stores) यस संथालाई उपल녍ध गराउने औष�ध र 2 �ेत्रीय/िज쥍ला औषधी भ赍डार/संथा Regional/District Warehouse or institution 030 अ셁 वा镍य सामग्रीको मु奍य स्रोत के हो? 3 थानीय औषधी भ赍डार (Local medical store on the same site) (एउटामा मात्र �चꅍह लगाउने) 4 गैर-सरकार� संथा (NGO) 5 दाता (Donor) 6 �नजी स्रोत (Private Sources) 7 अꅍय (खुलाउने) ______यस संथास륍म वा镍य सामग्रीह셁 कन ु 1 / 2 / 031 5{{{{{{{ { राि�ट्रय के ि ꅍ द्र य सरकार िज쥍ला थानीय प्रशासन �नकायले ढु वानी ग ? 3संथा आ फै ल े 4 अꅍय (खुलाउने) ______(एउटामा मात्र �चꅍह लगाउने) औसतमा, माग गरेको क�त समय�भत्र 032 1 हꥍता�भत्र 2 b'O{ हꥍतादे�ख १ म�हना�भत्र 3 Ps म�हनादे�ख २ म�हना�भत्र सामग्री आइपु嵍छ? 4 b'O{ म�हनादे�ख ४ म�हना�भत्र 5 rf/ म�हनादे�ख ६ म�हना�भत्र 6 ६ म�हनाभꅍदा बढ� (एउटामा मात्र �चꅍह लगाउने,) औसतमा, क�त चाँडो पुनःआपू�त셍 हुꅍछ? 033 (k"gM eg]sf] lgoldt cfk'lt{ xf]_ 1 २ हꥍतामा एक प쥍ट 2 म�हनामा एक प쥍ट 3 ltg म�हनामा एक प쥍ट
(एउटामा मात्र �चꅍह लगाउने) 4 ^ म�हनामा एक प쥍ट 5 वष셍मा एक प쥍ट Note: @ dlxgfdf eg]df # df lrGx nfupg]
ख赍ड 7: को쥍ड चेनको उपल녍धता(सबै संथालाई सो鵍नुपन)� 034 के संथासँग औषधी/सामग्री भ赍डार गन� आफनै Cold Chain छ? 1 छ 2 छै न
1 �व饍युतीय फ्र�ज (Electric Fridge) 035 य�द प्र.नं. 034 को उ配तर Cold Chain “छ” भने, यो कतो �क�समको Cold 2 (Ice box ) बरफ बाकस (�नय�मत 셁पमा बरफ भनु셍पन� हुꅍछ)
Chain हो? (एउटामा मात्र �चꅍह लगाउने) 3 अꅍय (खुलाउने) ______4 सो鵍न नपन� (प्र.नं. 034 को उ配तर “छै न” भएकोले) 036 य�द प्र.नं. 034 को उ配तर (को쥍ड चेन) “छ” भने, को쥍ड चेनमा भ赍डार ग�रने ...... मात/ृ प्रजनन ्वा镍य स륍बꅍधी औषधी वा सामग्रीको सूची ले奍नुस ्
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1राि�ट्रय �व饍युत प्रसारण (Electricity from national grid) 2 संथाको आ굍नै जेनेरेटर ꥍलाꅍट (Generator plant at the SDP) . . 035 “ ” , 3 (Portable generator) 037 य�द प्र नं को उ配तर फ्र�ज भए सो फ्र�जलाई चा�हने �व饍युतको स्रोत के ब ो के र �हं蕍न �म쥍ने जेनेरेटर हो?(एउटामा मात्र �चꅍह लगाउने) 4 मट्टीतेल/ꥍयारा�फन इꅍधन (Kerosene/paraffin fuel ) 5 अꅍय (खुलाउने) ______6 सो鵍न नपन� (प्र.नं. 035 को उ配तर “छै न” भएकोले)
038 य�द संथासँग Cold Chain छै न भने, Cold Chain मा भ赍डार गन셍पन� औषधी वा ु ...... सामग्री कसर� संर�ण गरेर रा奍छ?
ख赍ड 8: :jf:Yo ;+:yf ;'zf;fg :jf:Yo ;+:yf ;~rfng tyf Joj:yfkg :jf=;+=Jo= ;ldltdf hDdf slt hgf ;b:o x'g'x'G5 ख赍ड 9: hgzlQm o; v08nfO{ k|zf;g k|d'vsf] ;xof]udf eg'{xf];\ .of] v08df xfdL tkfO{;Fu ut cfly{s jif{df o; ;+:yfdf sfd u/]sf :jf:YosdL{sf] af/]df ;f]Wg rfxG5f}+ 040 utcf=j= df o; :jf:Yo ;+:yfdf ljleGg kbdf slt hgf sd{rf/L x'g'x'GYof]< \ Vof !_ hgzlQm @_ pQ :jf:Yo ;+:yfdf pQ #_ :jf:Yo ;+:yfdf kbk'lt{{ /x]sf] ;ª t.]lsPsf] t.]lsPsf] b/aGbL 1. 8fS6/ / Medical officers 2. cA;6«]l6l;og÷uOgf]sf]nf]lhi6 (Obs/gyne) 3. lkl8of6«Ll;og -afn/f]u_ (Paediatrician) 4. :k];lni6 hg/n \k|flS6:g/(MDGP) 5. Pg]:y]l;of]nf]lhi6 (Anaesthesiologist) 6. l;:6/÷d]6«f]g÷ gl;{ª OG;k]S6/ !_SBAsf] tflnd kfPsf @_Pg]:y]l;of Pl;:6]06 tflnd kfPsf –(Anaesthesist) 7. :6fkm g;{(Staff nurse) !_ SBAsf] tflnd kfPsf 8. c=g=dL(ANM) !_SBAsf] tflnd kfPsf @_ cf]=l6= Joj:yfkg tflnd Page | 127 ख赍ड 10: कम셍चार� ताल�म (प�रवार �नयोजन) (सबै संथालाई सो鵍नुपन�) 041 यस संथामा प�रवार �नयोजन सेवा �दने ताल�मप्राꥍत कम셍चार� छन?् 1 छन ् 2 छै नन ् 042 य�द “छन”् भने, क�त जना छन?् [……………...... ] 043 प�रवार �नयोजनको इ륍ꥍलाꅍट / cfOo';Ll8 (Implant र IUCD) रा奍न र �नका쥍ने ताल�म �लएका 1 छन ् Implant IUCD कु नै �वशेष कम셍चार� छन?् 2 छै नन ् Implant IUCD 044 -sf]7fdf ;+Vof n]Vg] _ य�द “छन”् भने, क�त slt जना छन?् 1 Implant […….] 2 IUCD […….] 045 के ताल�मप्राꥍत कम셍चार�ले प�रवार �नयोजन सेवा अ�हले �दइरहेका छन?् 1 �दंदैछन ् 2 �दंदै छै नन ् 046 Implant ;]jf glbgsf sf/0f < ……...... ][ य�द “�दंदै छै नन ”् भने, यो सेवा न�दनुको कारण ले奍नुस?् IUCD ;]jf glbgsf sf/0f <[……...... ] 047 b'O{ यस संथाका कु नै कम셍चार�ले प�छ쥍लोपटक प�रवार �नयोजन सेवास륍बꅍधी ताल�म क�हले 1 Ps म�हना अगा�ड 2 म�हनादे�ख ६ म�हना अगा�ड 3 Ps 4 Ps �लएको �थयो? (एउटामा मात्र �चꅍह लगाउने) ६ म�हनादे�ख वष셍 अगा�ड वष셍 अगा�ड Note: tflnd lnPsf] dlxgf gk'u] klg ! df lrGx nufpg] . 048 1 �थयो Implant IUCD के 配यो प�छ쥍लो ताल�ममा इ륍ꥍलाꅍट / cfOo';Ll8 (Implant र IUCD) रा奍ने र �नका쥍ने अ땍यास प�न ग�रएको �थयो? 2 �थएन Implant IUCD ख赍ड 11: कम셍चार� सुप�रj]�ण (प्रजनन ्वा镍य सेवा र प�रवार �नयोजन सेवाको ला�ग) (सबै संथालाई सो鵍नुपन�) u¥of] 049 o; :jf:Yo ;+:yfn] utcfly{s jif{ -@)&)÷@)&१_ df;fdflhs k/LIf0f u¥of] sL u/]g< 1 2 u/]g pQm ;fdflhs k/LIf0f -@)&)÷@)& _ :jf:Yotyf hg;ª\VofdGqfnon] hf/L u/]sf] 1lyof] 050 १ lgb]{lzsfcg';f/ ePsf] lyof] lslyPg< 2 lyPg 3 yfxf 5}g j] 1 Ps म�हना अ�घ 051 गत १२ म�हनामा प�छ쥍लो पटक सुप�र �ण अ�धकार�ले क�हले यस संथाको Ps भ्रमण गरेको �थयो? 2 म�हनादे�ख ३ म�हना अ�घ ltg (एउटामा मात्र �चꅍह लगाउने) 3 म�हनादे�ख ६ म�हना अ�घ 4 ६ म�हनादे�ख १ वष셍 अ�घ 5 गत १२ म�हनामा भ्रमण गरेको छै न 1 साꥍता�हक 2 मा�सक 3 ltg म�हनामा 4 052 यस संथाकहाँ सुप�रj]]{�ण अ�धकार�ह셁 क�त-क�त समयमा भ्रमण गन� प्र配येक ४ म�हनामा गछ셍 न?् (एउटामा मात्र �चꅍह लगाउने) 5 प्र配येक ६ म�हनामा 6 वा�ष셍क 7 क�ह쥍यै गद�न 1 उपचार प�दती (Staff clinical practices) 053 2 औषधीको टक र अव�ध-समािꥍत (Drug stock out and expiry) 3 कम셍चार�को उपल녍धता र ताल�म (Staff availability and training) सप�रj]�ण अ�धकार�ह셁 संथाको यी म鵍ये कन प� चा�हं सप�रj]�ण गछ셍 न?् ु ु ु 4 त镍यांकको पूण셍ता, गुणतर, र साम�यक �रपो�ट�ग (Data completeness, (एउटामा मात्र �चꅍह लगाउने) quality, and timely reporting) 5 �नद��शका वा काय셍�ववरणको स�म�ा (प्रजनन ्वा镍य स륍बꅍधी) (Review use of specific guideline or job aid for reproductive health ) 6अꅍय(खुलाउने) ………………………………………………… Page | 128 ख赍ड 12: �नद��शकाको उपल녍धता (जाँच-सूची र काय셍�ववरण) (सबै संथालाई सो鵍नुपन�) संथासँग प�रवार �नयोजन सेवास륍बꅍधी कु नै �नद��शका (Guidelines) छ? 1 छ (प्र�नकता셍ले प्रमाणीकरण गरेको छ) 054 (राि�ट्रय वा �व�व वा镍य संगठनको) 2 छ (तर प्र�नकता셍ले प्रमाणीकरण गरेको छै न) एउटामा मात्र �चꅍह लगाउने) 3 छै न 055 - संथासँग कु नै प�रवार �नयोजन सेवा स륍बꅍधी जाँच सूची वा काय셍�ववरण 1छ (प्र�नकता셍ले प्रमाणीकरण गरेको छ) (Job Aid) ? ) छ एउटामा मात्र �चꅍह लगाउने 2 ( 3 छ तर प्र�नकता셍ले प्रमाणीकरण गरेको छै न) छै न 056 संथासँग गभा셍वथा जाँच सेवास륍बꅍधी कु नै �नद��शका (Guidelines) छ? 1 छ (प्र�नकता셍ले प्रमाणीकरण गरेको छ) (राि�ट्रय वा �व�व वा镍य संगठनको) 2 छ (तर प्र�नकता셍ले प्रमाणीकरण गरेको छै न) (एउटामा मात्र �चꅍह लगाउने) 3 छै न 057 1 छ (प्र�नकता셍ले प्रमाणीकरण गरेको छ) संथासँग गभा셍वथा जाँच सेवा (ANC) स륍बꅍधी कु नै Checklist वा Job-aid छ? (एउटामा 2 छ (तर प्र�नकता셍ले प्रमाणीकरण गरेको छै न) मात्र �चꅍह लगाउने) 3 छै न 058 संथासँग फोहोरमैला 핍यवथापन (Waste disposal) स륍बꅍधी कु नै �नद��शका 1 छ (प्र�नकता셍ले प्रमाणीकरण गरेको छ) (Guidelines) छ? 2 छ (तर प्र�नकता셍ले प्रमाणीकरण गरेको छै न) (एउटामा मात्र �चꅍह लगाउने) 3 छै न ख赍ड 13: सूचना तथा संचार प्र�व�धको उपल녍धता र प्रयोग (सबै संथालाई सो鵍नुपन�) के संथाले कु नै सूचना तथा संचार प्र�व�धको (ICT) प्रयोग गरेको 1 छ (प्र�नकता셍ले उपल녍धताको प्रमाणीकरण गरेको छ) 059 छ? (तल प्र.नं. 062 को सूची हेनु셍स)् 2 छ (तर प्र�नकता셍ले उपल녍धताको प्रमाणीकरण गरेको छै न नोट : छै न भने ख赍ड 14 मा जाने 3 छै न (प्र�व�ध प्रयोग गरेको) 1क륍ꥍयुटर 2 मोबाइल फोन (Mobile Handset) 3 मोबाइल फोन 060 य�द प्रयोग गरेको “छ” भने, यी म鵍ये कु न प्रयोग गरेको छ? (Smart Phone Set) 4 टे �लफोन 5 絍या녍लेट (Tablet) 6 इꅍटरनेट (कु नै वा सबैमा �चꅍह लगाउने) सु�वधा (LAN) 7 इꅍटरनेट सु�वधा (Wi-Fi) 8 Fax 9 अꅍय (खुलाउने) ……………….. 1 कम셍चार�को 핍यि啍तगत उपकरण (Staff members personal item) 2 सरकारले �दएको (Provided by government ) 061 संथाले यी सूचना र संचार प्र�व�ध (ICT) कहाँबाट प्राꥍत गय�? 3 संथा संचालकले �दएको (Provided by proprietor of SDP ) (कु नै वा सबैमा �चꅍह लगाउने) 4 दानव셁प पाएको (Received as Donation) 5 अꅍय(खुलाउने)…… …………………… 1 �बरामी दता셍 गन셍 (Patient registration) 2 संथाको रेकड셍 रा奍न (Facility record keeping ) 3 �बरामीको �ववरण/�व饍यतीय मे�डकल रेकड셍 रा奍न (Individual patient records/Electronic Medical Record ) संथाले यी प्र�व�ध मु奍यतया ु 4 (Health Insurance Claims and Reimbursement System) के क ो ला�ग प्रयोग गछ셍 ? वा镍य बीमा दाबी र बीमा भु啍तानी �दन 5 रकम थानाꅍतरण र भ啍तानी गन셍 (Mobile money cash transfers and payments ) (कु नै वा सबैमा �चꅍह लगाउने) ु 062 6 (Routine communication) �नय�मत संचार गन셍 7 ( ) (Clinical consultation (long distance communication with experts) वा镍य परामश셍 टाढाको �वशेष�सँग स 륍 प क셍 को ला�ग 8 चेतनामूलक र सेवाको माग बढाउने गन셍 (Awareness and demand creation activities ) 9 आपू�त셍 핍यवथापन/टक �नयꅍत्रण ला�ग (Supply chain management/stock control ) 10 वा镍य कम셍चार� ताल�मको ला�ग (Health worker training ) 11अꅍय (खुलाउने)…...... ……………….. 1 k7fpF5 063 संथाले LMIS (Logestic Management and Information system) cGtu{t l/kf]6{ u5{< 2 k7fpb}g k7fpF5 eg] jif{df slt k6s k7fp5? ======k6s Page | 129 ख赍ड 14: फोहोरमैला 핍यवथापन (सबै संथालाई सो鵍नुपन�) 1 संथाको आ굍नै हातामा जलाएर k|fo M h;f] of ] संथाले फोहोरमैला 2 संथाको आफनै हातामा �वशेष खा쥍डोमा पुरेर 064 कसर� 핍यवथापन गछ셍 ? 3 इिꅍसनेटर (Incinetor) प्रयोग गरेर (एउटामा मात्र �चꅍह लगाउने) 4 के ि ꅍ द्र य तरमै कु नै �वशेष �नकायले संकलन गरेर टाढा लगेर 핍यवथापन गन � 5 अ셁 फोहोरमैला संगै फा쥍ने ख赍ड 15: सेवाग्राह� सेवा शु쥍क(सबै संथालाई सो鵍नुपन�) ? 065 संथाले �बरामीसँग सेवा शु쥍क �लꅍछ 1 �लꅍछ 2 �ल ंदैन य�द शु쥍क �लꅍछ भने, यी सु�वधाको ला�ग कु नै छु ट/�मनाहा �दꅍछ? 1प�रवार �नयोजन सेवा (कु नै वा सबैमा �चꅍह लगाउने) 2 गभा셍वथा जाँच (ANC) सेवा 3 प्रसू�त सेवा 066 4 स ु 配 के र � प � छ क ो (PNC) सेवा 5 नवजात �शश ु सेवा 6 पाँचवष셍 मु�नका ब楍चाको उपचार 7 HIV उपचार (जतै, HIV care (e.g. HTC and ART) 8 अꅍय (खुलाउने)………………….. 067 संथाले �बरामीसँग bIf :jf:Yo sdL{n] lbPsf] सु�वधाको ला�ग शु쥍क 1 �लꅍछ 2 �ल ंदैन �लꅍछ? य�द शु쥍क �लꅍछ भने, यी सु�वधाको ला�ग कु नै छु ट/�मनाहा �दꅍछ? 1 प�रवार �नयोजनका साधन 068 (कु नै वा सबैमा �चꅍह लगाउने) 2 मात ृ वा镍यका औषधी 3 बाल वा镍यका औषधी 4 अꅍय (खुलाउने)………………….. नोट: यो चरणमा, 1) उ配तरदातालाई वहाँको समयको ला�ग र वहाँले �दनभएकोु सूचनाको ला�ग धꅍयवाद �दनसु ् 2) अब नयाँ भागको सव��णको ला�ग (तपाइले प�ह쥍यै जानकार� गराउन ु भए अनसारु ) उहाँलाई प�रवार �नयोजन सेवा �लन आउने सेवाग्राह�लाई अꅍतवा셍ता셍 �लन लागेको अवगत गराउनसु ् 3) उ配तरदातालाई यो आ�वत पानु셍स ् �क यी सूचनाह셁 कु नै सेवाग्राह� वा संथा �व셁द्ध प्रयोग ग�रने छै न, मात्र सेवाग्राह�को �वचार बु畍न र अझ राम्रो सेवा कसर� �दन स�कꅍछ भꅍनेमा प्रयोग ग�रनेछ 4) �वशेष गर�, सेवाग्राह�लाई एि啍जट अꅍतवा셍ता셍 �लनको संथाको िज륍मेवार अ�धकार�सँग अनम�तु मा嵍नसु ् Page | 130 भाग 3 – एि啍जट अꅍतवा셍ता셍 प्रजनन ्वा镍य सेवा स륍बꅍधी सेवाग्राह�को अनभु �तू र म쥍यांकनू नोट: उ�रदातालाई �न륍न कु राको जानकार� गराउनसु :् • म आफू यो संथाको सदय होइन, तपाइँले भख셍र पाएको सेवाको बारे �वचार जा� खोजेको मा� हो । • संथालाई तपाईसंगको अꅍतवा셍ता셍बारे जानकार� गराइसके को र वीकृ �त प�न �दइसके को छ । • उ�रदाताल े बताउने कु नै कु राको जानकार� संथालाई �दइने छैन भ�ेमा आ�त पान셍सु ् । • ��ह셁 핍यि�गत हनु े छैन र उ�रदाता सेवा�ाह�को नाम र �ववरण रेकड셍 ग�रने छैन । • सेवा�ाह�को जानकार� कसै�व셁� �योग ग�रने छै न । • तपाइँ कु नै ��को उ�र �दन अवीकार गन셍 स啍नहु ꅍछु , र कु नै प�न बेला अꅍतवा셍ता셍 समा� गन셍 स啍नहु ꅍछु . तर हामी आशा गछ� तपाइँले सबै ��को उ�र �दनहु नु ेछ, जसले गदा셍 वा镍य सेवालाई रा�ो पन셍 म饍饍饍त प嵍नु ेछ । • अ�हले, तपाइँलाई यो सव�क्षणस륍बꅍधीु नै क �� छ भने सो鵍न स啍नहु ꅍछु । अꅍतवा셍ता셍 स셁ु गन셍 अनम�तु �लनसु .् अनम�तु पाएप�छ अꅍतवा셍ता셍 श셁ु गन셍 स啍नहु ꅍछु । Page | 131 ख赍ड 15: सेवास륍बꅍधी सेवाग्राह�को अनुभू�त (संथाबाट प�रवार �नयोजन वा镍य सेवा �लने सेवाग्राह�सँग सो�धनुपन� (प्र.नं.008 को उ配तर “हो" भएको अवथामा) 15.1 सेवाग्राह� उ配तरदाताको प�ठभृ ू�म (Respondent’s Background) 069 उमेर पूरा भएको वष셍 ______ 070 �ल ंग 1 पु셁ष 2 म�हला 3 तेस्रो �लंग 071 वैवा�हक िथ�त 1 अ�ववा�हत 2 �ववा�हत 3 स륍बꅍध�ब楍छेद/छु �टएको/�वधवा/�वधुर 1 �नर�र 2 सा�र 3 �न륍न मा鵍य�मक 4 प्राथ�मक 5 मा鵍य�मक र 072 �श�ाको तह सोभꅍदा मा�थ 1 pk :jf:Yorf}sL 2 :jf:Yorf}sL 3 kf|ylds :jfYo ;]jf s]Gb| 4 lhNnf tkfO{n] k|of]u ug]{ kl/jf/ lgof]hgsf (Family planning) c:ktfn 5 c+rn c:ktfn 6 pk If]lqo c:ktfn 7 If]lqo c:ktfn 8 073 cfw'lgs ;fwg÷ljlwx? k|fKt ug]{ d'Vo ;|f]t s] xf]< s]lb|o c:ktfn 9 cGo c:ktfn 10 ;+lugL outlets 11 d]l8sn ;]G6/ 12 kf]nL SnLlgs 13 FPAN 14 Marie Stopes 15 PSSN (Pariwar Swastha Sewa Network) 16 अꅍय (खुलाउने) ...... - 1 2 b'O{ 3 ltg 074 प�रवार �नयोजन सेवाको ला�ग क�त क�त समयमा यो संथामा म�हनाको एक प쥍ट म�हनामा एक प쥍ट म�हनामा एक प쥍ट आउनुहुꅍछ ? 4 अꅍय (खुलाउने) …………………. 15.2 प्रा�व�धक प�मा संथाको लगाव (Provider adherence to technical aspects) 075 यस संथाबाट तपाइले आ굍नो चाहना अनुसारको प�रवार �नयोजनको साधन/�व�ध पाउनुभयो? पाएँ 1 पाइनँ 2 15 tkfO{n] o; ;+:yfaf6 kl/jf/ lgof]hgsf cfw'lgs ;fwg÷ljlwx? pknAw geP/ kmls{g' ePsf] 5< 5 eg] slt k6s kmls{g' ePsf] 5< 076 ======k6s 2 5}g 077 tkfO{nfO{ tL ljwL÷;fwgsf a]kmfObf (side effects) x? af/] atfOof]< 1atfOof] 2 atfOPg 1 xf] d}n] cfkm}n] lg0f{o u/]sf] xf] 078 kl/jf/ lgof]hgsf] ;fwg÷ljlw 5fGg] lg0f{o tkfO{ cfkm}n] ug'{ eof] < 2 xf]Og, c?n] ul/lbPsf] xf] 15 tkfO{n] o; ;+:yfaf6 dft[ :jf:Yo÷k|hgg :jf:Yo ;daGwL cf}ifwL pknAw geP/ kmls{g' ePsf] 5< 5 eg] slt k6s kmls{g' ePsf] 5< 079 ======k6s 2 5}g तपाइँले पाउनुभएको प�रवार �नयोजनको �व�धको बारेमा �नण셍य गदा셍 संथाले तपाईको चाहनालाई प�न समेटे को 080 1 �थयो 2 �थएन �थयो? 081 वा镍यकम�ले तपाईलाई प�रवार �नयोजनको �व�ध/साधन प्रयोग गन셍 �सकाए? 1 �सकाए 2 �सकाएनन ् प�रवार �नयोजनको �व�ध/साधनले पान셍स啍ने प्र�तकु ल असर (side effects) बारे वा镍यकम�ले तपाईलाई 082 1 �दए 2 �दएनन ् जानकार� �दए? प�रवार �नयोजनको �व�ध/साधनले प्र�तकु ल असर (side effects) पारेमा के गन� भꅍने बारेमा वा镍यकम�ले 083 1 �दए 2 �दएनन ् तपाईलाई जानकार� �दए? प�रवार �नयोजनको �व�ध/साधनको प्रयोगले हुनस啍ने ग륍भीर ज�टलता (serious complications) को बारेमा र 084 1 �दए 2 �दएनन ् यतो ज�टलता भएमा तु셁ꅍत यह� संथामा फक� र आउने बारेमा वा镍यकम�ले तपाईलाई के � ह जानकार� �दए? 085 वा镍यकम�ले वा镍य जाँच वा औषधी/साधनको ला�ग फे � र कु न �दन आउने भनी स쥍लाह �दए? 1 �दए 2 �दएनन ् 15.3 संगठ�नक प� (Organizational aspect) 086 तपाइले यस संथाबाट प�रवार �नयोजन सेवा �लनको ला�ग धेरै समय पख셍नु पय�? 1 पय� 2 परेन 087 यो संथाको सरसफाई अवथाबाट तपाई सꅍतु�ट हुनुहुꅍछ? 1 छु 2 छै न Page | 132 088 जाँच कोठामा हुने गोप�नयता (privacy) बारे तपाई सꅍतु�ट हुनुहुꅍछ? 1 छु 2 छै न 089 वा镍यकम�ले तपाईलाई �दनुभएको समयबाट तपाई सꅍतु�ट हुनुहुꅍछ? 1 छु 2 छै न 15.4 (Interpersonal aspect) अꅍतरवैयि啍तक प� 090 यस संथाका कम셍चार�ले तपाईलाई आदरपूण셍 र �श�ट 핍यवहार गरे? 1 गरे 2 गरेनन ् 091 वा镍यकम�ले तपाइले अ�हले पाउनुभएको प�रवार �नयोजनको साधन/�व�ध वीकार गन셍 कु नै दबाब वा जोड �दए? 1 �दए 2 �दएनन ् 092 वा镍यकम�ले तपाईलाई गरेको 핍यवहारबाट तपाइँ सꅍतु�ट हुनुहुꅍछ? 1 छु 2 छै न 15.5 न�तजा प� (Outcome aspect) 093 तपाइले पाउनुभएको सेवाबाट तपाइँ सꅍतु�ट हुनुहुꅍछ? 1 छु 2 छै न 094 के तपाइँ फे � र यो संथामा सेवा �लन आउनुहुꅍछ? 1 आउँ छु 2 आउँ �दन 095 यो संथामा वा镍य सेवा �लन जान तपाइले आ굍ना नातेदार वा साथीलाई स쥍लाह �दनुहुꅍछ? 1 �दꅍछु 2 �दꅍन 1 w]/} ;Gt'i6 ;du|df o; ;+:yfaf6 kfPsf] ;]jfaf6 tkfO{ slQsf] ;Gt'i6 x'g'x'G5 < 2 ;Gt'i6 096 3 ;Gt'i6÷c;Gt'i6 s]xL 5}g 4 c;Gt'i6 5 w]/} c;Gt'i6 ख赍ड 16: एि啍जट अꅍतवा셍ता셍 – प�रवार �नयोजन सेवा शु쥍क बारे सेवाग्राह�को मू쥍यांकन (संथाबाट प�रवार �नयोजन वा镍य सेवा �लने सेवाग्राह�सँग सो�धनुपन � (प्र.नं.008 को उ配तर “हो" भएको अवथामा) 16.1 प�रवार �नयोजन सेवा शु쥍क तपाइ{ले आज पाउनुभएको सेवाको ला�ग शु쥍क �तनु셍भयो? 097 1 �तर� 2 �त�रन (य�द �तरेको भए, प्र.नं. 098 मा जाने) �तनु셍भएको भए, तलका सेवाको ला�ग क�त-क�त �तनु셍भयो? (लागू हुने सबैमा �चꅍह लगाउनुस)् 1 /______/ 3 /______/ 098 काड셍 संथाबाट �लएको प�रवार �नयोजनको साधन 2 प्रयोगशाला जाँच/ए啍स-रे /______/ 4 फाम셍सीमा �कनेको प�रवार �नयोजनको साधन /______/ 5 k/fdz{ शु쥍क /______/ अꅍय (खुलाउने) 6 ……….……………. /______/ 16.2 प�रवार �नयोजन सेवाको ला�ग रकम प्रबꅍध तपाइँले आज पाउनुभएको प�रवार �नयोजन सेवाको खच셍 कसले/कु न स्रोतले बेहोछ셍? (लागू हुने सबै �वक쥍पमा �चꅍह लगाउनुस)् 099 प्र.नं. 98 मा उ쥍ले�खत खच셍 (सेवा शु쥍क) मात्र संल嵍न गन)� आ फै 1 2 प�त/प配नी 3 प�त/प配नीबाहेक प�रवारका अꅍय सदय 4 अꅍय (खुलाउने) …………………….….. प्र.नं. 099 मा उ쥍लेख गनु셍भएको प्र配येक स्रोतले आज तपाइँलाई लागेको खच셍 क�त-क�त बेहोछ셍 होला? (लागू हुने सबै �वक쥍पमा �चꅍह लगाउनुस ् (प्र.नं. 098 मा उ쥍ले�खत खच셍 (सेवा शु쥍क) मात्र संल嵍न गन)� 0100 1 आ फै /______/ 2 प�त/प配नी 3 प�त/प配नीबाहेक प�रवारका अꅍय सदय 4 अꅍय (खुलाउने) ………………… (셁पैया) /______/(셁पैया) /______/(셁पैया) /______/(셁पैया 16.3 सवार� खच셍 तपाइँ आफू बसेको ठ ाउँ दे �ख यो संथास륍म कसर� आउनुभयो? (एउटामा मात्र �चꅍह लगाउने) 0101 2 साइकल 1 पैदल (“पैदल” भए, प्र.नं. 105 मा जानुस)् । 3 मोटरसाइकल Page | 133 4 बस/絍या啍सी 5 �नजी सवार� साधन 6 अꅍय खुलाउने) ……….………… 1 /______/ 2 /______/ 0102 तपाइँ आफू बसेको ठ ाउँ दे �ख यो संथा क�त दर�माू छ? �कलोमीटर कोस (एउटामा मात्र �चꅍह लगाउने) 0103 तपाइँ आफू बसेको ठ ाउँ दे �ख यो संथास륍म आउँ द ा सवार�मा क�त खच셍 भयो? /______/ (셁पैया) 0104 अब तपाइँ यो संथादे�ख आ굍नो बसेको ठ ाउँ स륍 म जान सवार�मा क�त खच셍 ला嵍छ? /______/(셁पैया) 16.4 प�रवार �नयोजन सेवाको ला�ग खच�को समय र रकम 0105 आज आ굍नो बसेको ठ ाउँ दे �ख यो संथास륍म आउँ द ा क�त समय ला嵍यो? /______/ घ赍टा /______/ �मनेट 0106 तपाइँलाई यहाँ आइपुगेप�छ सेवा �लन क�त समय कु न ु셍 पय�? /______/ घ赍टा /______/ �मनेट 0107 तपाइँलाई अब आफू बसेको ठ ाउँ स륍 म पु嵍न क�त समय ला嵍छ ? /______/ घ赍टा /______/ �मनेट तपाइँ यहाँ आएर सेवाको ला�ग कु रेको समयमा य�द घरमा हुनुभएको भए मु奍य गरेर तपाई के काम गद� हुनुहुꅍ镍यो होला? (एउटामा मात्र �चꅍह लगाउने) 0108 1 घरायसी काम 2 घरको खेतमा काम 3 बजारमा बे楍दै/핍यापार गद� /Trading 4 अद� 煍यालादार� काम 5 द� 煍यालादार� काम 6 का�रꅍदा वा 핍यावसा�यक काम 7 अꅍय (खुलाउने) ……….…………. तपाइँले प्र.नं. 108 मा “गद� हुꅍथ�” भनेको काम अ�हले कसले गद�छ त?(एउटामा मात्र �चꅍह लगाउने) 0109 1 घरका सदय 2 सहकम� 3 कसैले प�न होइन 4 अꅍय (खुलाउने) ……….…………. 0110 तपाइँको अनुपिथ�तमा तपाइँको काम गन� 핍यि啍तलाई तपाइँले 煍याला �तनु 셍 पछ셍 ? 1 पछ셍 2 पद�न 0111 य�द �तनु셍पछ셍 भने, अꅍदाजी क�त रकम �तन ु셍 पछ셍 ? /______/ (셁पैया) अꅍतमा, 1) उ配तरदातालाई अꅍतवा셍ता셍 स�कएको जानकार� �दनसु ् 2) उ配तरदातालाई वहाँले �दनुभएको समय र जानकार�को ला�ग धꅍयवाद �दनसु ् धꅍयवाद !!! Page | 134 Annex 8: Persons responsible for ordering medical supplies by region, residence and management Percentage Total Health number Development Region Medical Pharmacis Nurse/AHW Storekeeper Facility In Others of SDPs Doctor t / ANM (N) Charge Eastern Development 89.3% 0.0% 5.1% 1.0% 1.0% 3.6% 196 Region Central Development 88.3% 1.5% 5.1% 2.0% 1.5% 1.5% 197 Region Western Development 83.0% .7% 9.6% 2.2% 3.0% 1.5% 135 Region Mid-Western 74.5% 1.8% .9% 12.7% 1.8% 8.2% 110 Development Region Far-Western 89.6% 0.0% 3.2% 4.0% 2.4% .8% 125 Development Region Residence Urban 68.1% .8% 15.1% 1.7% 4.2% 10.1% 119 Rural 89.1% .8% 3.1% 4.0% 1.4% 1.6% 644 Management of facility Government 90.4% .7% 2.0% 3.8% 2.0% 1.0% 686 Private 43.9% 1.5% 33.3% 3.0% 0.0% 18.2% 66 NGO 54.5% 0.0% 18.2% 0.0% 0.0% 27.3% 11 Total 85.8% .8% 5.0% 3.7% 1.8% 2.9% 763 *Others include: Proprietor, Health assistant, public health inspector, CMA, etc Annex 9: Quantification of resupply by Development region, residence and management Percentage Pull System Push system Staff member(s) of this facility Quantity is Development Region As per Total makes request Demand Any other determined by the stock based on form filled method institution/warehouse demand is calculation of as per need used responsible for made quantity needed supplying this SDP using a formula Eastern Development 56.5% 6.6% 8.7% .5% 31.6% 196 Central Development 66.5% 4.1% 5.1% 4.1% 20.3% 197 Western Development 52.6% 39.3% 3.0% .7% 4.4% 135 Mid-Western 53.6% 7.3% 26.4% 6.4% 6.4% 110 Far-Western 70.4% 10.4% 6.4% 1.6% 11.2% 125 Residence Urban 47.9% 12.6% 22.7% 6.7% 10.1% 119 Rural 61.3% 12.4% 6.4% 1.7% 18.2% 644 Management of SDP Government 61.2% 13.6% 4.7% 1.9% 18.6% 686 Private 39.4% 3.0% 50.0% 7.6% 0.0% 66 NGO 54.5% 0.0% 27.3% 0.0% 18.2% 11 Total 59.3% 12.5% 8.9% 2.5% 16.9% 763 *Others include: CRS distributor, Adhoc demand by the facility Page | 135 Annex 10: Main source of supplies by development region, residence and management Regional/ Local Central district medical Private Other local Development Region medical NGO Total warehouse store on the sources sources* stores or institution same site Eastern Development 2.6% 78.1% 2.6% .5% 5.1% 11.3% 196 Region Central Development 4.6% 79.7% 5.6% .5% 5.1% 4.5% 197 Region Western Development 4.4% 86.7% .7% 2.2% 5.9% 0.0% 135 Region Mid-Western 6.4% 80.0% 2.7% 1.8% 8.2% 0.9% 110 Development Region Far-Western 5.6% 84.8% 2.4% .8% 6.4% 0.0% 125 Development Region Area Urban 10.1% 54.6% 9.2% 2.5% 19.3% 5.2% 119 Rural 3.4% 86.3% 1.9% .8% 3.4% 4.2% 644 Management of SDP Government 4.1% 90.1% 1.3% 0.0% 0.0% 4.5% 686 Private 3.0% 4.5% 18.2% 6.1% 66.7% 1.5% 66 NGO 36.4% 0.0% 18.2% 36.4% 9.1% 0.0% 11 Total 4.5% 81.4% 3.0% 1.0% 5.9% 4.2% 763 Others: Supplied from illaka (mainly during vaccine route)/nearby health facilities Annex 11: Frequency of supplies by development region, residence and management Percentage Administrative Unit (Region) Total number Once every 1 Once every three Once every six of SDPs (N) month or less months months Eastern Development Region 26.5% 55.6% 17.9% 196 Central Development Region 24.4% 71.6% 4.1% 197 Western Development Region 32.6% 61.5% 5.9% 135 Mid-Western Development Region 57.3% 26.4% 16.4% 110 Far-Western Development Region 28.8% 69.6% 1.6% 125 Residence Urban 52.1% 44.5% 3.4% 119 Rural 28.1% 61.5% 10.4% 644 Management of facility Government 25.5% 64.4% 10.1% 686 Private 90.9% 7.6% 1.5% 66 NGO 72.7% 18.2% 9.1% 11 Total 31.8% 58.8% 9.3% 763 Page | 136 Annex 12: Responsibility for transportation of supplies by development region, residence and management Percentage Development Region Central/Regional District Facility Total others warehouse warehouse itself Eastern Development Region 23.5% 50.5% 25.5% .5% 196 Central Development Region 10.2% 54.3% 34.5% 1.0% 197 Western Development Region 5.9% 75.6% 16.3% 2.2% 135 Mid-Western Development Region 13.6% 50.0% 30.0% 6.4% 110 Far-Western Development Region 4.0% 60.8% 29.6% 5.6% 125 Area of Service Delivery Point Urban 14.3% 35.3% 39.5% 10.9% 119 Rural 12.0% 61.6% 25.3% 1.1% 644 Management of the facility Government 13.3% 63.5% 22.0% 1.0% 686 Private 3.0% 3.0% 80.3% 13.6% 66 NGO 9.1% 0.0% 54.5% 36.4% 11 Total 12.3% 57.5% 27.5% 2.6% 763 Annex 13: Availability of fridges by Administrative Unit region, residence and management Percentage Type of cold chain available Total number Administrative Unit (Region) No cold chain Ice box Electric of SDPs (N) available (SDP have to regularly Fridge replenish ice supply) Eastern Development Region 79.1% 16.8% 4.1% 196 Central Development Region 66.5% 31.5% 2.0% 197 Western Development Region 63.7% 29.6% 6.7% 135 Mid-Western Development Region 72.7% 26.4% .9% 110 Far-Western Development Region 47.2% 40.8% 12.0% 125 Residence Urban Urban 42.0% 54.6% 3.4% 119 Rural 71.6% 23.3% 5.1% 644 Management of facility Government 70.7% 24.2% 5.1% 686 Private 34.8% 63.6% 1.5% 66 NGO 27.3% 63.6% 9.1% 11 Total 67.0% 28.2% 4.8% 763 Page | 137 Annex 14: Source of power for Fridges used for cold chain by administrative unit region, residence and management Percentage Total facility Administrative Unit (Region) Electricity from national Solar power Others* using fridge (N) grid Eastern Development Region 84.8% 0.0% 15.2% 33 Central Development Region 95.2% 4.8% 0.0% 62 Western Development Region 100.0% 0.0% 0.0% 40 Mid-Western Development Region 72.4% 17.2% 10.3% 29 Far-Western Development Region 86.3% 7.8% 5.9% 51 Residence Urban 96.9% 1.5% 1.5% 65 Rural 86.0% 7.3% 6.7% 150 Management of facility Government 88.0% 6.1% 5.4% 166 Private 92.9% 2.4% 4.8% 42 NGO 100.0% 0.0% 0.0% 7 Total 89.3% 5.6% 5.1% 215 *Others :Electricity from local grid, Kerosene/Paraffin(negligible) Annex 15: Staffs trained for the insertion and removal of Implants and IUCD by type of government SDPs region, residence and management Total SDP with Staff trained Staff trained in Staff trained in IUCD staff trained in Characteristics in Implants IUCD and Implant both Implants and IUCD Region Eastern Development Region 88.9% 77.8% 66.7% 27 Central Development Region 74.5% 78.2% 52.7% 55 Western Development Region 69.8% 83.7% 53.5% 43 Mid-Western Development Region 94.2% 76.9% 71.2% 52 Far-Western Development Region 67.3% 79.6% 46.9% 49 Residence Urban 78.7% 85.1% 63.8% 47 Rural 78.2% 77.7% 55.9% 179 Management of SDP Government 77.8% 77.8% 55.6% 207 Private 70.7% 100.0% 70.0% 10 NGO 100.0% 88.9% 88.9% 9 Total 78.3% 79.2% 57.5% 226 Page | 138 Annex 16: Frequency of supervisory visits by region, residence and management Frequency of supervisory visits (%) Not Total Administrative Unit Every three Every four Every six supervised sample (Region) Annually monthly monthly monthly (%) size (N) Eastern Development Region 44.9% 4.1% 14.3% 24.5% 12.2% 196 Central Development 25.4% 8.6% 24.4% 28.9% 12.7% 197 Region Western Development 50.4% 11.9% 19.3% 16.3% 2.2% 135 Region Mid-Western Development 42.7% 9.1% 20.9% 15.5% 11.8% 110 Region Far-Western Development 29.6% 9.6% 17.6% 32.8% 10.4% 125 Region Residence Urban 46.2% 8.4% 21.0% 13.4% 10.9% 119 Rural 36.5% 8.2% 18.9% 26.2% 10.1% 644 Management Government 38.2% 8.6% 19.2% 25.1% 8.9% 686 Private 34.8% 4.5% 18.2% 16.7% 25.8% 66 NGO 45.5% 9.1% 27.3% 18.2% 0.0% 11 Total 38.0% 8.3% 19.3% 24.2% 10.2% 763 Annex 17: Percentage of SDPs with issues included in supervisory visits by Administrative Unit region, residence and management Issues included in Supervisory visits Review use of Data Drug specific Staff Staff completeness, stock out guideline or Administrative Unit clinical availability quality, and Others Total and job aid for (Region) practices and training timely expiry reproductive reporting health Eastern Development 10.5% 18.6% 8.7% 45.3% 5.2% 11.6% 172 Region Central Development 15.1% 14.0% 9.9% 48.8% 2.9% 9.3% 172 Region Western Development 6.8% 44.7% 8.3% 29.5% 2.3% 8.3% 132 Region Mid-Western 10.3% 17.5% 9.3% 37.1% 17.5% 8.2% 97 Development Region Far-Western 5.4% 22.3% 8.0% 26.8% 8.9% 28.6% 112 Development Region Residence Urban 11.3% 32.1% 5.7% 31.1% 5.7% 14.2% 106 Rural 9.8% 21.2% 9.5% 40.4% 6.6% 12.4% 579 Management Government 9.6% 19.8% 9.6% 41.0% 6.6% 13.4% 625 Private 12.2% 65.3% 0.0% 14.3% 6.1% 2.0% 49 NGO 27.3% 9.1% 9.1% 36.4% 0.0% 18.2% 11 Total 10.1% 22.9% 8.9% 39.0% 6.4% 12.7% 685 Page | 139 Annex 18: Availability of family planning guidelines, ANC/PNC job aids and Waste disposal guidelines by type regions, residence and management Percentage Total Family planning Sample guidelines (national- ANC job-aids Waste disposal guidelines Size NMS Vol-1) (N) Region Yes, Yes, Yes, Yes, Yes, Yes, Availability Availability Availability Availability Availability Availability verified not verified verified not verified verified not verified EasternDevelopment 55.6% 8.7% 53.1% 7.7% 10.2% 4.1% 196 Region CentralDevelopment 38.1% 27.9% 35.0% 29.9% 10.2% 13.2% 197 Region WesternDevelopment 55.6% 15.6% 36.3% 26.7% 16.3% 13.3% 135 Region Mid-Western Development 55.5% 20.0% 46.4% 16.4% 20.0% 10.9% 110 Region Far-Western Development 33.6% 24.0% 31.5% 20.2% 14.4% 8.8% 125 Region Residence Urban 40.3% 20.2% 26.9% 18.5% 18.5% 11.8% 119 Rural 48.8% 18.8% 43.5% 20.4% 12.4% 9.5% 644 Management Government 49.6% 19.7% 44.1% 21.6% 13.3% 10.3% 686 Private 24.2% 10.6% 44.1% 21.6% 10.6% 4.5% 68 NGO 54.5% 27.3% 36.4% 18.2% 36.4% 9.1% 11 Total 47.4% 19.0% 40.9% 20.1% 13.4% 9.8% 763 Annex 19: Percentage of SDPs with types of Information Communication Technology available in region, residence and management Percentage Total Mobile Landline Internet Sample Characteristics Computer Others* phones telephone facilities Size (N) Region Eastern Development Region 9.8% 93.3% 12.3% 4.9% 1.8% 163 Central Development Region 15.0% 93.0% 21.4% 9.1% 3.7% 187 Western Development Region 14.9% 98.5% 9.7% 9.0% 5.2% 134 Mid-Western Development Region 15.6% 91.1% 16.7% 10.0% 12.2% 90 Far-Western Development Region 26.8% 87.8% 17.1% 13.0% 8.1% 123 Residence Urban 42.5% 87.6% 44.2% 28.3% 16.8% 113 Rural 10.8% 94.0% 10.1% 5.1% 3.3% 584 Management Government 11.6% 93.4% 10.3% 6.1% 3.5% 620 Private 43.9% 92.4% 56.1% 28.8% 21.2% 66 NGO 90.9% 72.7% 72.7% 45.5% 18.2% 11 Total 15.9% 93.0% 15.6% 8.9% 5.5% 697 * Others include: Fax, tablets, TV, FM/Radio Page | 140 Annex 20: Percentage of SDPs by How ICT was acquired by region, residence and management Percentage Provided by Total Sample Staff Provided by HDP/HFOMC/ Received as Size Characteristics members government Proprietor of the Donation (N) personal item company Region Eastern Development Region 96.9% 6.7% 2.5% 1.2% 163 Central Development Region 91.4% 11.2% 4.3% 3.7% 187 Western Development Region 96.3% 6.7% 6.0% 134 Mid-Western Development 88.9% 10.0% 5.6% 2.2% 90 Region Far-Western Development 91.1% 13.8% 7.3% 2.4% 123 Region Residence Urban 85.8% 19.5% 16.8% 1.8% 113 Rural 94.7% 7.7% 2.6% 2.1% 584 Management Government 94.7% 10.2% 1.6% 2.3% 620 Private 87.9% 4.5% 24.2% 0.0% 66 NGO 45.5% 9.1% 72.7% 0.0% 11 Total 93.3% 9.6% 4.9% 2.0% 697 Page | 141 Annex 21: Main Purpose for which ICTs is used by region, residence and management Percentage Characteristics creation creation distance distance Total Sample size Patient Patient registration record Facility keeping money Mobile transfers cash payments and Routine communication Clinical consultation (long communication experts) with Awareness and demand activities Supply chain management/stock control worker Health training Others Region Eastern Development Region 7.4% 11.0% 1.2% 82.2% 39.9% 9.8% 30.7% 23.3% 4.3% 163 Central Development Region 10.7% 12.3% 3.7% 95.2% 34.8% 15.5% 35.8% 19.3% 12.3% 187 Western Development Region 7.5% 15.7% 2.2% 94.0% 46.3% 24.6% 54.5% 35.1% 5.3% 134 Mid-Western Development 10.0% 8.9% 3.3% 71.1% 41.1% 30.0% 35.6% 20.0% 15.6% 90 Region Far-Western Development 8.1% 17.1% 4.9% 77.2% 30.9% 14.6% 20.3% 23.6% 18.0% 123 Region Residence Urban 27.4% 34.5% 9.7% 79.6% 38.9% 17.7% 47.8% 20.4% 18.8% 113 Rural 5.1% 8.9% 1.7% 86.8% 38.2% 17.6% 33.0% 24.8% 8.9% 584 Management Government 5.5% 8.9% 1.8% 86.8% 37.9% 17.3% 33.7% 25.2% 9.2% 620 Private 30.3% 39.4% 12.1% 80.3% 39.4% 18.2% 50.0% 9.1% 13.6% 66 NGO 63.6% 90.9% 18.2% 54.5% 54.5% 36.4% 45.5% 54.5% 63.6% 11 Total 8.8% 13.1% 3.0% 85.7% 38.3% 17.6% 35.4% 24.1% 10.5% 697 *Others include : Individual patient records/Electronic Medical Record, Health Insurance Claims and Reimbursement System, etc. Page | 142 Annex 22: Methods of waste disposal by region, residence and management Percentage Centrally collected Disposed Total Bury in Use of by specific agency with Sample Burning special Incinerators Characteristics for disposal away regular size dump pits from the SDP garbage Region Eastern Development Region 60.7% 29.6% 5.6% 3.6% .5% 196 Central Development Region 72.6% 18.3% 7.1% 2.0% 197 Western Development Region 82.2% 5.9% 5.9% 5.2% .7% 135 Mid-Western Development Region 58.2% 27.3% 10.9% 3.6% 110 Far-Western Development Region 49.6% 32.0% 16.8% 1.6% 125 Residence Urban 48.7% 17.6% 18.5% 13.4% 1.7% 119 Rural 68.5% 23.4% 6.8% .6% .6% 644 Management Government 67.8% 23.3% 8.2% .4% .3% 686 Private 48.5% 16.7% 3.0% 25.8% 6.1% 66 NGO 18.2% 9.1% 72.7% 0.0% 0.0% 11 Total 65.4% 22.5% 8.7% 2.6% .8% 763 Annex 23: Issues for which user fee charged and Exemptions for user fees – services provided by region, residence and management Percentage HIV Care of Total Facility Post care Family Antenatal Newborn sick sample charging Delivery natal (e.g. Characteristics planning care care children size patients services care HTC services services services under 5 (N) services and years ART) Region Eastern 54.3% 60.0% 60.0% 45.7% 17.1% 2.9% 35 17.9% 196 Central 50.0% 54.2% 54.2% 41.7% 29.2% 29.2% 12.5% 24 12.2% 197 Western 50.0% 30.0% 30.0% 30.0% 20.0% 10.0% 10.0% 20 14.8% 135 Mid-Western 65.2% 47.8% 43.5% 34.8% 39.1% 34.8% 26.1% 23 20.9% 110 Far-Western 70.5% 72.7% 70.5% 56.8% 40.9% 25.0% 20.5% 44 35.2% 125 Residence Urban 42.3% 28.8% 26.9% 19.2% 15.4% 15.4% 7.7% 52 43.7% 119 Rural 69.1% 72.3% 71.3% 58.5% 38.3% 22.3% 17.0% 94 14.6% 644 Management Government 91.1% 97.5% 97.5% 79.7% 53.2% 29.1% 24.1% 79 11.5% 686 Private 18.6% 5.1% 6.8% 3.4% 3.4% 10.2% 1.7% 59 89.4% 66 NGO 50.0% 37.5% 0.0% 0.0% 0.0% 0.0% 0.0% 8 72.7% 11 Total 59.6% 56.8% 55.5% 44.5% 30.1% 19.9% 13.7% 146 19.1% 763 Note: *The charge incurred by the patients in government facility is mostly for registration, few for abortion services and after hour charges Page | 143 Annex 24: Issues for which user fee is charged for services provided by a qualified health care provider by region, residence & management Percentage Total sample Facility charging Family Maternal Child health size patients Characteristics planning health medicines (N) (N) methods medicines Region Eastern Development Region 57.1% 50.0% 21.4% 28 14.3% 196 Central Development Region 38.9% 27.8% 55.6% 18 9.1% 197 Western Development Region 25.0% 25.0% 16.7% 12 8.9% 135 Mid-Western Development Region 33.3% 6.7% 13.3% 15 13.6% 110 Far-Western Development Region 11 8.8% 125 Residence Urban 34.9% 20.9% 20.9% 43 36.1% 119 Rural 39.0% 34.1% 26.8% 41 6.4% 644 Management Government 85.7% 85.7% 38.1% 21 3.1% 686 Private 17.9% 7.1% 19.6% 56 84.8% 66 NGO 42.9% 14.3% 14.3% 7 63.6% 11 Total 36.9% 27.4% 23.8% 84 11.0% 763 Annex 25: Clients perspective of FP service provider’s adherence to technical aspects by clients according to region, residence & management Percentage what can Characteristics Total method sample to SDP for check for to SDP what to do in to do what wishes into size their choice their (N) Provided with method method with Provided of clients took Provider preference and consideration to how taught Client use the the about told Client common the of effects side method informed Provider about client be regarding done the of effects side the method clien informed Provider about serious any case complications occur to date given Client return /or and up supplies additional Region Eastern Development Region 99.3% 98.4% 81.3% 92.0% 91.9% 91.7% 96.8% 974 Central Development Region 99.3% 99.2% 87.2% 94.2% 89.7% 87.0% 96.5% 983 Western Development Region 99.6% 98.5% 46.6% 92.6% 93.5% 89.3% 93.9% 676 Mid-Western Development Region 96.1% 99.6% 81.3% 89.5% 87.7% 86.1% 97.2% 562 Far-Western Development Region 99.7% 99.2% 67.0% 89.0% 89.5% 92.4% 94.6% 628 Residence Urban 99.7% 98.7% 65.3% 87.1% 86.0% 84.6% 90.8% 629 Rural 98.8% 99.0% 76.1% 92.7% 91.5% 90.3% 96.9% 3194 Management Government 98.8% 99.0% 76.1% 93.2% 91.9% 90.6% 97.6% 3447 Private 100.0% 98.4% 57.0% 77.5% 76.3% 76.3% 79.1% 316 NGOs 100.0% 98.3% 63.3% 90.0% 91.7% 88.3% 88.3% 60 Total 98.9 98.9 74.3 91.8 90.6 89.4 95.9 3823 Page | 144 Annex 26: Clients perspective of FP service provider’s adherence to technical aspects by clients according to region, residence & management Percentage Returned from Made decision Returned from SDP due to Total Characteristics SDP due to lack to use FP lack of Maternal / RH sample of FP services services Medicines when needed size (N) Region Eastern Development Region 4.5% 97.9% 6.4% 974 Central Development Region 2.6% 99.7% 1.1% 983 Western Development Region 9.5% 99.5% 7.4% 676 Mid-Western Development Region 4.9% 98.5% 6.9% 562 Far-Western Development Region 3.2% 99.5% 1.6% 628 Residence Urban 4.7% 98.6% 3.5% 629 Rural 4.8% 99.1% 4.8% 3194 Management Government 5.0% 98.9% 4.7% 3447 Private 3.2% 95.3% 3.2% 316 NGOs 1.7% 98.3% 1.7% 60 Total 4.8% 99.0% 4.6% 3823 Annex 27: Perspective of FP service provider’s adherence to organizational aspects according to region, residence and management Percentage Client satisfied with Client perceived Client satisfied with Client satisfied Total the time that was Characteristics waiting time as the cleanliness of the with the privacy sample allotted to his/her too long health facility at the exam room size (N) case Region Eastern Development 10.3% 97.5% 89.2% 98.9% 974 Region Central Development 8.9% 95.9% 90.8% 98.9% 983 Region Western Development 10.5% 98.5% 98.5% 99.3% 676 Region Mid-Western 10.0% 91.4% 96.4% 99.8% 562 Development Region Far-Western 5.9% 97.3% 97.5% 99.7% 628 Development Region Residence Urban 11.8% 96.8% 96.5% 99.2% 629 Rural 8.7% 96.3% 93.1% 99.2% 3194 Management Government 8.8% 96.1% 93.4% 99.3% 3447 Private 11.7% 98.4% 96.5% 98.4% 316 NGOs 16.7% 98.3% 93.3% 100.0% 60 Total 9.2 96.4 93.7 99.2 3823 Page | 145 Annex 28: Clients perspective of FP service provider’s adherence to inter-personal aspects according to region, residence and management Percentage Client indicated he/she was treated Client satisfied with the attitude of the Total sample Characteristics with courtesy and respect by staff at health provider towards him/her size (N) the SDP generally Region Eastern Development 95.5% 99.5% 974 Region Central Development 98.6% 98.9% 983 Region Western 99.3% 99.3% 676 Development Region Mid-Western 99.8% 99.8% 562 Development Region Far-Western 98.1% 99.4% 628 Development Region Residence Urban 98.7% 99.5% 629 Rural 97.9% 99.3% 3194 Management Government 97.9% 99.3% 3447 Private 98.4% 99.1% 316 NGOs 100.0% 98.3% 60 Total 98.0 99.3 3823 Annex 29: Clients perspective of FP service provider’s adherence to outcome aspects according to region, residence and management Percentage Client will continue Total sample Client satisfied with Client would recommend this Characteristics visiting this SDP in size (N) the service received SDP to relatives or friends future Region Eastern Development 98.9% 99.6% 98.4% 974 Central Development 98.6% 99.9% 96.8% 983 Western Development 99.4% 98.5% 96.6% 676 Mid-Western 98.8% 96.3% 93.0% 562 Development Region Far-Western 100.0% 99.2% 95.7% 628 Development Region Residence Urban 100.0% 99.0% 96.8% 629 Rural 98.9% 98.9% 96.4% 3194 Management Government 99.0% 99.0% 96.9% 3447 Private 99.7% 97.8% 93.7% 316 NGOs 100.0% 100.0% 86.7% 60 Total 99.1 98.9 96.4 3823 Page | 146