Strengthening Reproductive Health Service Project Through Improving Health Facilities and Capacity Building for Medical Service Workers

This project is funded by the Government of Japan and ADRA Japan and implemented by ADRA Nepal in partnership with Safe Motherhood Network Federation (SMNF) Nepal

Strengthening Reproductive Health Service Project through Improving Health Facilities and Capacity Building for Medical Service workers

Annual Report

May 2014 – May 2015

Submitted To: ADRA Japan/Nepal

Submitted By: Safemotherhood Network Federation Nepal

Project activities and its achievement

Strengthening Reproductive Health Service (SRH) Project is funded by ADRA Japan and implemented by ADRA Nepal in partnership with Safe Motherhood Network Federation Nepal (SMNF/N) .The goal of this project is to improve the maternal and Neonatal health in the Jajarkot district. SRH is assisting Government agencies such as District Health Office (DHO) to increase support and access to services for remote communities. SRH Project in Jajarkot has made significant stride of progress towards the achievement of project results particularly in year three with almost all of its targeted activities implemented at its full swing to meet the overall goal of improving maternal and neonatal health and reducing the associated mortality. The SRH project constructed well equipped birthing centers on six VDCs whereas ANMs of 11 health institutions had gained 60 days skilled birth attendant training and six permanent health service providers were trained for implant services.

ADRA SRH Project ppppppp pr

Construction + SBA (6) SBA only (5)

Implant site (6)

Photo: Working VDCs of SRH project at Jajarkot District

A notable progress has been achieved in all planned activities that SRH project intended to implement in Jajarkot in third year. Major highlights that featured third year project included: Construction of well equipped birthing centers assembled with solar power to promote uninterrupted and quality service delivery, installation of solar system at district hospital/delivery ward & cold chain room for 24 hours 2 cold chain maintenance, capacity building of VDC level stakeholders through Result Oriented Leadership Development Training (ROLDP), significant number of ANMs trained on Skilled Birth Attendant (SBA) and Health service providers were trained on Implant service. Considering family planning (FP) as essential component of reproductive health, SRH endorsed new practice. Micro planning on FP, a newly emerging concept to enhance CPR from micro level, SRH had implemented in coordination with Family Health Division, DoHS. Individual micro plan on FP of each health facility was developed with detail implementation plan. FCHVs of all VDCs were oriented on FP micro planned along with their responsibilities and mobilized to bring substantial utilization of quality FP services. The most importantly the project activities reached to beneficiaries, couples, youths, pregnant and mothers through capacity building of service providers and HFOMC members, mobilization of FCHVs, logistics support, various ward level interactions, mother’s group meetings, radio airing, health day celebrations and school health programs.

Key Achievements of Third Year Project v Five well equipped birthing centers back up with solar power system constructed promising safe delivery and sound health of mother and child v District hospital and cold chain room is being provided regular electricity through 3,780 Wp solar power supply v Eleven ANMs from project VDCs trained on SBA v Six service providers trained on Implant service delivery v Two days Result Oriented Leadership and Development Program (ROLPD) training provided to District Reproductive Health Coordination Committee (DRHCC) members. 26 DRHCC members and DHO staffs were benefited from this training v 79 HFOMC members and social workers (key decision makers) of six birthing centers construction sites capacitated through Result oriented leadership development training v 178 institutional deliveries assisted by SBAs in supported sites (until 15th April 2015) v 174 clients benefitted from implant services (until 15th April 2015) v 26 personnel including DHO focal persons, health workers, line agencies staffs and SRH staffs Capacitated through Master ToT on FP micro planning v All of health workers of periphery level including new recruited staffs were oriented on FP micro planning v 248 FCHVs were oriented on FP micro planning and mobilized to their respected wards v Family planning & safe motherhood related message is being broadcasted 480 times through two local FMs v Supported District Health Office on celebration on Family Planning day

Project activities with details:

1.1 Construction of Birthing Centre: Six Birthing Center buildings were constructed by SRH project in six remote VDCs of Jajarkot district namely Archhani, Dhime, Punma, Jhapra, Suwanauli and Salma. The agreement for construction was done on 11th June 2014 with six different contractors. The construction work was started on first week of July 2014 and completed and handover all buildings to HFOMC by 16th May 2015. The inaugural ceremony was organized with huge participation of villagers, HFOMC members, FCHVs, representatives from DAO, DDC, DHO, Journalists, team of ADRA Japan/Nepal, SMNF/N members along with SRH project staffs. The SRH project handed over constructed birthing centers first to District Health Office (DHO) then DHO hand over to respective Health Facility Operation and Management Committee. Birthing Center buildings were designed and constructed as per standard of Government of Nepal. Total plinth area of each birthing centre is 78.8 m2 covering a delivery room, a multipurpose room, sluice, scrub and a toilet. Further, the project approved additional fencing work around the BCs for better security.

Photo: Constructed Birthing Center building at Punma VDC

1.2 Equipment Support for constructed Birthing Centers: SRH project supported the constructed birthing centre with essential equipments approved by Family Health Division. Forty different types of SBA equipments were supported to six constructed birthing centers. Further, the project supported required equipments for SBA trained ANMs five birthing centers for effective and regular delivery of services. The equipments were supported at Jungathapachaur, Laha, Dalli, Ramidada and Dasera health facilities. Similarly Gooseneck lamp, delivery bed and baby warmer were provided at delivery ward, district hospital.

Photo: Necessary equipments supported at Jhapra & Dhime birthing centers respectively

Photo: Baby warmer, Delivery bed, Gooseneck lamp and step stool supported by SRH project at

District Hospital, Jajarkot

1.3 Equipment support (Solar power) to District Hospital and Birthing Center The project supported two sets of hybrid solar power system (2100+1680 Watts) to District Hospital and Cold Chain room to operate all the equipments and to provide 24 hours services. Similarly, solar power systems (950 watts) were installed in constructed buildings to promote uninterrupted and 24 hours services ensuring smooth operation of all the equipments supported.

Photo: Installation of solar power at District Hospital and cold chain room

Photo: Installation of solar power at Dhime Birthing Center

2.1 Result Oriented Leadership and Management Training to District Reproductive Health Coordination Committees (DRHCC):

Two days Result Oriented Leadership and Management Training was conducted on 14th - 15th September 2014. Twenty two participants (N=22) from different line agencies, local NGOs including DRHCC members, DHO focal persons, project staffs were benefited from this training. The objective of this training was to develop the leadership, management skill and capacity development of DHRCC members. By the end of the training the participants prepared their own CHALLENGE PROJECT.

Photo: DRHCC members on their group work during ROLDP training

During this training, District Health Officer, Dhir Jung shah committed to appoint one additional ANMs in coordination with DDC for approved birthing centers of Punma, Archhani, Jhapra, Salma and Suwanauli and consider for their sustainability of services.

2.2 Mobilization of Management Committees (HFOMC) and Community members: v ROLDP Training Three days Result Oriented Leadership and Management training was conducted at each selected construction sites for Health Facility Operation and Management Committee (HFOMC). Total 79 members were benefited from this training. The objective of the training was to train HFOMC for having their active participation in each meeting, creating accountability to responsibilities, capturing local resource for health services improvement and to prepare the CHALLENGE PROJECT for their management committee. Five members quality care group (construction monitoring committee) was also formed during ROLDP training. This committee conducted regular monitoring of construction works ensuring the quality controls. After receiving the training, the HFOMC actively participated in HFOMC meeting, involve in follow up of construction activities and deploy for completion of challenge

project.

Photo: HFOMC members of Archhani HP actively participated on ROLDP training

v Review and follow up of Result Oriented Leadership and Development Program: In this project period two quarterly review meeting of ROLDP to HFOMC members were completed on all six Birthing center sites constructed by SRH. This meeting was facilitated by Health facility incharge and community Officers. The objective of this review meeting is to review and follow up on challenge projects, strengthening of HFOMCs, creating awareness on institutional delivery, family planning services, review the action plan on quality care group and suggest endorsing appropriate actions.

Photo: HFOMC members actively participated on ROLDP review workshop at Salma & Suwanauli respectively 3.1 Implant training to Health service providers: Eight days implant training was provided to six Health Workers of different health facilities of Jajarkot. The project supported the logistics for service delivery from additional five sites. After training, Implant service sites of district have been increased from nine to fifteen. 179 implants have been inserted to women till April 2015 from six sites. Furthermore, District Health office is mobilizing these trained staffs during the satellite clinics. 8

3.2 Training on Skilled Birth Attendant (SBA): SRH project in coordination with National Health Training Center (NHTC) conducted sixty days SBA training at Seti Zonal Hospital, Dhangadi. Out of eleven ANMs, six were from BC construction sites and five were from other BC sites of Jajarkot. They were trained to conduct normal and complicated deliveries efficiently. Furthermore, they had practice to deliver IUCD insertion and removal service too. This training has increase the confidence of ANMs for handling the delivery cases. The trained ANMs had handled the 241 delivery cases till the reporting period saving lives of mother and newborns.

3.3 Review of SBA and Implant service providers: Two days review workshop for SBA and Implant service providers capacitated under SRH project was organized at District Health office, Jajarkot. The review workshop was conducted on 14th - 15th January 2015. The first day of review workshop was concentrated on SBA service providers whereas second day on Implant service providers. Review workshop was chaired by DHO, Dhir Jung Shah & facilitated by Medical officer, Public Health Nurse, Family planning supervisor and Asst. Statistician Officer . Nine SBA providers and five Implant service providers had attended. All the participants presented the major achievement and challenges of their sites during service delivery. Similarly, gap in scaling up of services from the respective sites were discussed and DHO committed to provide full support on service delivery.

4.1 Master Training of Trainers (MToT) on micro planning on Family Planning (FP) to DHO focal persons, line agencies and project staffs:

MToT on Micro planning on family planning at Jajarkot district was organized on 14th – 16th Oct, 2014 at DDC Hall Jajarkot. Altogether 26 participants were participated including DHO focal persons, peripheral Health workers, project staffs and representatives from line agencies. The three days training was facilitated by interior team of FHD, Teku. Participants were oriented on national FP program with its goal and objectives. The team had generalized on concept of FP micro planning and facilitate to micro plan at each health facility level. Participants were supported to develop detail plan of action to achieve the targets.

Photo: Bhogendra Raj Dotel (Chief, FP section DoHS) facilitating the training

4.2 Two days training of micro planning on family planning to Health Service Providers:

The two days micro planning on family planning training to health workers of Jajarkot was organized on four batches at different venues. The training was facilitated by DHO focal persons, project staffs and line agencies staffs (UNICEF, H4L). 56 health workers were benefited from this training. Similarly, 46 newly recruited health workers were oriented on FP micro planning throughout two batches of training. They had micro planned to bring substantial improvements on CPR from ward level. Detail plan of action, collaborative action had been endorsed to achieve the targets.

Photo: Participants of FP micro planning training at DDC Hall, Khalanga

4.3 Two days workshop on FP micro planning to Female Community Health Volunteers:

The two days workshop on FP Micro Planning to female community health volunteers (FCHVs) harmonizing to address FP needs and to achieve detail plan of action for improvement of CPR at community level. 248 FCHVs of 30 VDCs were benefited from this training. They were oriented on status of FP users at their respective wards, contraception updates, FP micro planned at each ward level and addressed their roles & responsibilities to attain the

targets.

Photo: FCHVs of Sakla HP & Paink SHP participating on two days FP micro planning workshop

4.4 Mass Campaign

v Radio airing Reproductive health, neonatal health and family planning jingles had been broadcasted through local FMs of Jajarkot ( Khalanga and Paila) from ist September 2014 to 30th of April 2015. They had relayed up to 480 times throughout project period. Both of these FM Radios casted the message on importance of institutional deliveries to prevent maternal and neonatal deaths, encouraged for

antenatal check up, postnatal check up and promote for adopting appropriate family planning methods for planned family.

Photo: Local two FMs airing messages on safe motherhood, neonatal health and promotion on utilization of family planning services v Day celebrations ADRA SRH project had supported District Health Office to organize family planning day on September 18. The slogan of the day was,” Bebasthith pariwar: swasthya ra bikas ko aadhar ”. Furthermore SRH and H4L jointly invest to put hoarding boards at Thati bazaar and Buspark area relaying promotion of utilization of family planning services for planned and wealthy family.

Moreover, SRH had organized district level inception meeting at DHO Jajarkot on 26th June 2014, District project advisory committee meeting on 24th December 2014.

Photo: Hoarding board displaying Family Planning related messages placed at Thatibazar, Jajarkot and DHO, Dhir Jung Shah speaking on 1st Family Planning celebration day Expected outcomes of Project:

Expected Result-1: Health Facility’s Basic Infrastructure improved Six birthing centers as per the approved design of Government of Nepal were constructed at Dhime,

Archhani, Salma, Suwanauli, Jhapra and Punma VDCs of Jajarkot.

100% of the constructed birthing centers (N=6) received major fifty essential equipments for safe delivery which included Delivery set, Episiotomy set, cervical inspection set, Delivery bed, examination table, fetoscope, vacuum extractor, baby warmer, autoclave, ambu bag and mask etc.

Based on the needs assessed in five other birthing centers of Jajarkot viz. at Jungathapachaur, Laha, Khagenkot, Ramidada and Dasera, twenty different safe delivery equipments were provided such as delivery bed with footsteps, surgical drums, autoclave, delivery packs, ambu bags, stretchers etc.

The SBA trained ANMs are providing delivery services regularly on the constructed sites. They are giving more priority on infection prevention too. Thus, constructed infrastructure and equipments have supported for quality service delivery. The installed solar power had supported on handle the cases even at the night time. So, 24 hour interrupted services are being provided at the sites.

Expected Result 2: Capacity of Health institutions will be strengthened After receiving the Result Oriented Leadership and Management Training, HFOMC members have started attending meeting regularly. A tangible improvements and successions have seen. Some of the successions are as follows: v 100% of the HFOMCs (N=6) received grant from VDCs in this fiscal year and also declared for next FY through VDC’s Commission. The allocated budget is being used on salary of VDC hired ANMs, support staff of birthing centers, maintenance of infrastructure and other purposes. It filled the gap of service for 24 hours. v In Punma VDC, building under construction is given priority for its final completion and will use for residence purpose for staffs. VDC has allocated NRs.90,000 for this. The sanctioned posts are fulfilled. v The HFOMC of Dhime HP has allocated NRs 45,000 for encouragement of FCHVs performances. The HFOMC decided to use single room of VDC Office for EPI purpose. Latrine is being constructed and declared for maintenance of roof of HP building. v The ROLDP training at Salma HP has allocated NRs.20,000 for declaration of fully immunized VDC. NRs.35,000 has been allocated for WASH activities. v At Jhapra HP, NRs.73,500 has been allocated for remuneration of VDC hired ANM and NRs.32,400 for miscellaneous activities. v NRs.1,39,000 has been allocated by Suwanauli VDC for remuneration of VDC hired ANM and maintenance of roof of HP building from gratification of ROLDP training. 13

These above examples revealed that the capacity of HFOMC have been improved after ROLDP training.

Expected Result 3: Reduced Unplanned Pregnancy in the district MToT on FP micro plan was organized to capacitate district level supervisors. Similarly health facility level FP micro plan training was organized to develop individual plan of health facility to bring improvements on family planning services from periphery levels. Six service providers (N=6) of project VDCs received eight days implant training. After the training the Health Facilities are providing implant services regularly. As of April 2015 within the duration of 9 months, 174 new clients have inserted implant rods through those implant service sites. After completion of these training, Implant service centers of district has been increased from 9 to 15. Thus, the coverage of implant service has been increased. The figure thus shows the increasing interest of women using implant services. Jul/ Aug/ Sep/ Oct/ Nov/ Dec Jan/ Feb/ Mar/ SN VDC Aug Sep Oct Nov Dec /Jan Feb Mar Apr Total 1 Paink 0 0 0 0 0 0 0 0 0 0 Nayakw 2 ada 0 4 6 0 9 9 7 0 0 35 3 Jhapra 0 0 0 0 0 0 0 0 0 0 4 Limsa 10 13 0 0 26 2 6 1 0 58 5 Sima 0 0 5 1 0 1 21 3 0 31 6 Salma 0 0 0 0 0 15 7 24 4 50 Total 10 17 11 1 35 27 41 28 4 174

Table 1: Number of Implant service received

Ten service providers (ANM) (N=11) received Skilled Birth Attendant (SBA) Training. As of April 2015, 178 mothers received delivery service from skilled ANMs after completion of SBA training on October 2015. Sep/ Oct/ Nov/ Dec Jan/ Feb/ Mar/ SN VDC Total Oct Nov Dec /Jan Feb Mar Apr 1 Dhime 2 3 2 2 0 1 0 10 2 Jhapra 2 0 2 5 2 0 0 11 3 Archhani 0 0 0 0 0 0 0 0 4 Punma 0 0 0 1 2 0 2 5 5 Suwanauli 1 2 4 4 2 3 1 17 6 Salma 0 1 9 1 5 0 3 19 7 Dasera 3 7 4 4 11 7 9 45 8 Laha 11 8 4 3 6 0 4 36 14

9 Khagenkot 3 5 4 2 2 6 5 27 10 Ramidada 0 0 0 0 0 3 5 8 Jungathap 11 achaur 0 0 0 0 0 0 0 0 Total 22 26 29 22 30 20 29 178

Table 2: Number of institutional deliveries attended by SBA at project sites

Expected Result 4: Improved health seeking behavior Micro plan of each health facility on family planning was made for encourage and promotion of utilization of services. Detail plan of action was developed to reach at micro level and bring sustainable improvements on CPR. HFOMCs were capacitated to relay positive messages, to promote utilization of antenatal, intranatal and postnatal services. Female Community Health Volunteers (FCHVs), as such the frontline health volunteers at the community level were capacitated through micro planning training. These FCHVs have been fully mobilized up to the ward level and have reached the targeted beneficiaries through various topics of discussions on health issues such as safe motherhood, family planning and child health in the monthly mother’s group meeting. These monthly meetings facilitated by FCHVs and therefore provided grounds for discussion on different health related issues and also have influenced their health seeking behavior to some extent. Different radio jingles related to safe motherhood, child health and Family planning were broadcasted through 2 different local FMs which indeed played a role for demand generation in the project sites. The two local FMs have coverage on maximum VDCs of Jajarkot.

Sustainability(with relevant plan after after the project to assure the Sustainability)

The construction of birthing centre is complemented by equipment supply and skilled birth attendant (SBA). The well equipped building is very likely to increase motivation of service providers, while the same with the trained staffs have increased client satisfaction leading to better service utilization. Commitment letters have been received from ANMs and HFOMC for the retention of skilled birth attendant in the VDC. The HFOMCs have committed to provide conducive environment for the SBA to provide quality service. After receiving SBA training, ANMs have increased their skills on safer delivery and handling of supplied equipments. Furthermore, Female Community Health Workers

(FCHVs) are actively conducting the mother groups meeting in their respective wards. They are encouraging the pregnant women for ANC check up and promoting the institutional delivery at BC with SBA trained ANMs. The number of institutional delivery within eight months shows the good trend of demand creation.

Furthermore, all the equipments and solar power supported at birthing centers are distributed according to the government’s logistic requirement. All the equipments are verified by representative of DHO, which is then registered at DHO. Logistic unit of DHO prepared dispatch letter and equipments to all respective sites. Thus, quality control was done by both project and DHO representative during distribution process.

Similarly, after providing Result Oriented Leadership Development Program (ROLDP) training, presence of HFOMC members in the HFOMC monthly meeting is increasing. The HFOMCs of six sites have struggled to achieve their action plans prepared during the training.

Similarly, at the district level, the birthing centers building were handed over to DHO, after which DHO handed over it to the HFOMC. Hence, it is the property of HFOMC and DHO. Both have expressed their sincere concerns to take the responsibilities for the sustainability of the birthing centers, its equipments and solar sets. In ROLDP review meeting, the HFOMC have committed to retain the SBA trained ANMs, for their residence and provision of security for birthing centers.

The solar set suppliers Sunshine Energy Pvt. Ltd. and Luniva Energy Private Limited have oriented the health workers and HFOMC on its operation and procedures. The operation manual with detailed numbers is attached at delivery room of each Birthing center.

Project management structure and others

Special issues (any information about the security and difficulties with local stakeholders etc.)

v Frequent transfers of trained government staffs have affected the regular service delivery at selected sites v Climatic condition, topography and road access of the project areas has made delay on completion of project on time v Lethargic nature of contractors and unavailability of skilled labors at local market delay the construction work v Initiation should be taken for timely payment of installment of contractors and vendors v Late implementation of the project activities due to monsoon, busy schedule of FHD team and hampered to conduct ROLDP trainings and delayed in FP micro planning trainings

v Epidemic of Swine flu in Jajarkot and devastating earthquake in Nepal had delayed in handover of birthing centers v Resignation of project staffs hampered smooth implementation of project activities

Attachment Photos which shows project activities and project result (in word format)

Photo: Birthing center at Dhime HP (Before & After)

Photo: Birthing center at Archhani HP (Before & After)

Photo: Birthing center at Salma S HP (Before & After)

Photo: Handover ceremony organized at Jhapra HP Jajarkot, chaired by Chief District Officer (6th April 2015)

Photo: Handover of Birthing center of Punma by ADRA/SMNF to District Health Office Jajarkot (15th March 2015)

Photo: Birthing center building at Suwanauli VDC, Jajarkot

Photo: Visibility board placed at Punma birthing center Jajarkot, Jajarkot

Photo: CDO, Planning Officer, ADRA Japan/Nepal members, SMNF/N members monitoring Jhapra BC, Jajarkot (6th April 2015)

Photo: Locals performing Khado Naach on handover ceremony Dhime BC, Jajarkot (16th May 2015)

Photo: Project Manager Mai Ogawa been greeted by HFOMC members of Dhime BC, Jajarkot (16th May 2015)

Success Stories

SRH Project helps me to stand on my own feet

My name is Chakra Bahadur B.K. I’m residence of Salma-3, Jajarkot. I had got opportunity to accomplish furnishing tasks of building supported by ADRA project at Salma VDC. During this, I get a chance to learn other skills like plumbing, plastering, tiling etc. I didn’t see this kind of well equipped building yet. Many of villagers got opportunity to income. Now we don’t have to walk long distance for services. Our sisters and mothers get chance to receive safe services nearby.

After this, I had brought 100m water pipe and recently, I have constructed a water tap on my yard. We are heartily thankful to this project.

Project implies the best outcomes in Jhapra

I am Jyoti Acharya. I lives in Jhapra-3, Jajarkot. I am a shopkeeper. About 1.5 years ago, some persons had came from Khalanga and consults with HFOMC about need of own land for construction of birthing center. Then I heard that ADRA SRH project had funded for construction of birthing center in our VDC. After few months HFOMC manage a land nearby constructing HP building.

I get opportunity to glance this project activity closely. Snacks and stationeries during trainings were borrowed from my shop. HFOMC were oriented on their roles and responsibilities & made challenge project from three days ROLDP training. After this training, HFOMC meetings were held regularly and necessary decisions were made & practice. They took ownership for supervision of construction sites, financial management, staff recruiting and others.

After two days FP micro planning training, FCHVs were actively involved on mother groups meeting, discussed on family planning and safe delivery practices, disseminating health messages and so on.

We are thankful to donor organization. Our brides, sisters and mothers are able to receive services from here instead of Surkhet and Nepalgunj.

Case Study Request for regular supply of commodities

My name is Shanti Sunar. I live in Nayakwada-8. It takes three hours to reach my home. My child

suffers from fever. My husband has gone India for seeking job. We have three daughters and one elderly son. Our son is 1.5 years old. I was using depo injection for last two years. I think this depo injection doesn’t favor me. It bleeds more and caused drowsiness. So we decide to consume other methods. One day, I met Ganesh sir (AHW, Nayakwada SHP) on outreach clinic and share my problems. He suggests me to use implant services. I was unknown about this. He said to come HP tomorrow. Next day we (me & husband) went to HP and met Lila sister(ANM). She said she had taken eight days training for Implant services from ADRA SRH project. After that she had provided implant services for 11 clients. She explained me about its physiology and functioning. Then I was ready to use this service. She inserted two rods on my left hand. She said it works for 5 years. I don’t feel any kind of complexities and dizziness. I am pleased to her.

Now I used to suggest my peers to follow this service. Some of them were passionate and gone to HP but return without service. They said, implant rods weren’t supplied for few months. I was so sorry to hear this. Now, more than ten neighbors want to receive implant services but ANM replied it shortages. Therefore, it seen necessity of regular supply of logistics for better mother’s health. I request to support commodities for this project. Annex I: List of SBA Participants

SN Name & Designation Name of Health Facility 1 Sunita Sahu, ANM Laha SHP 2 Sumitra Oli, ANM Dalli PHC 3 Hasina Shah, ANM Punma SHP 4 Sarada Basnet, ANM Jhapra HP 5 Abisara Sahi, ANM Dasera HP 6 Saraswoti Sahi, ANM Suwanauli SHP 7 Khima Oli, ANM Archhane Hp 8 Nirmala Thapa, ANM Dhime HP 9 Malati Bohora, ANM Salma SHP 10 Dikshya Budathoki, ANM Jungathapachaur SHP 11 Bishnu Kumari Thapa, ANM Ramidada SHP

Annex II: List of Implant Participants

SN Name & Designation Name of Health Facility 1 Ram Narayan Chaudhary, AHW Sima HP 2 Lila kumara Shah, ANM Nayakwada SHP 3 Bishnu Giri, Sr.AHW Jhapra HP

4 Om Bdr. Rana, AHW Salma SHP

5 Bishnu Kathayat, ANM Limsa PHC

6 Yagna Nath Gautam, AHW Paink SHP