District Fact Sheet, Banke

Health Service Coverage Fact Sheet FY 2071/72 to 2073/074 S.N. Program 2071/72 2072/73 2073/74

District to HMIS section 100 100 100

1:-Reporting Status PHC to District 100 100 100

HP to District 100 100 100

BCG Coverage 106 98 109

DPT3 coverage 97 83 93 2- National Measles 89 77 90 Immunization Program JE 89 71 74

TT2 & 2 + coverage 87 76 95

Growth monitoring coverage as % of <1 yrs children 88 93 60 among new visit

Proportion of Malnourished children ( weight/age) 5.6 5.98 4.2 3- Nutrition Program new visit

% of Iron distribution for new pregnant women 105 97 100

% of postpartum mother received Iron 52 37 34

Reported incidence of ARI/1000<5 Yrs population 820 636 617 4- ARI control Program Proportion of severe pneumonia among new cases 0.30 0.15 0.134

Incidence of diarrheal /1000<5Yrs population 673 573 515 5- Control of Diarrhoeal % of severe dehydration among new cases 0.10 0.05 0.05 Disease Program % of new diarrheal cases treated by ORS and Zinc 88.20 97.25 96

First antenatal visit as a % of expected live birth 75.20 83.2 75

4 ANC visit as % of antenatal visit ( new) 61.20 48.1 65 6- Safe motherhood % of total delivery conducted by SBA % of live birth 125.60 118.1 100 program ANC 1st visit (any time)as % of live birth 145 107 113

Maternal Mortality Ratio per 100000 live Birth 186 114 138

7-Family Planning Contracepective prevalence rate ( CPR) 41.7 Program 43.7 42.08

Malaria parasite incidence /1000 population 0.04 0.04 0.38 8- Malaria Control

Program Slide positivity rate 0.65 0.89 0.84

Case finding rate 87 85 88 9-Tuberculosis Control Sputum conversion Rate 79 83 82 Program Cure rate 77 77 84

Case detection rate /10000 population 22.85 35.08 51.3 10- Leprosy Control Program Prevalence rate/10000 population 1.76 2.76 4.7

11- FCHV Program % of report received from FCHV 90 92 93

Average no of people served by FCHV per month 47 40 38

% of report received from PHC/ORC 90 89 94 12- PHC/ORC Program Average no of people served per clinic per month 32 28 28

Disaster Events 2 5 4 ( fire) 13.Out Break Affected population 51135 8214 600 Management Program Death 15 0 4

14.Curative Services % of OPD new Visit 62.75 53.94 67

Executive Summary

A. INTRODUCTION This is the compile report of annual health activities and its achievements for fiscal year 2073/74 of Banke district. The report focuses on the objectives, targets, strategies adopted by the programs and analyses the achievements of the major activities and attempts to highlight trends in the service coverage of the services over the preceding three fiscal years. This report also identifies issues, problems, constraints and suggests actions to be taken by the related health institutions for further improvements. The executive summary highlights the key issues and observations emerging from the analysis of each programme. Detail programme information is available in specific reports following this summary.

The information and statistics used in this report are based on the data collected by the Health Management Information System (HMIS) from health institutions across the district. A total of 1 Zonal

Hospital, 3 Primary Health Care Centres (PHCCs), 42 Health Posts (HPs) and 2 Sub Health Post (SHPs) reported to HMIS in FY 2073/74. This report also includes service coverage by 148 Primary Health Care/Outreach Clinics (PHC/ORC), 303 Expanded Programme of Immunization (EPI) clinics and 789 Female Community Health Volunteers (FCHVs). A total of five NGO/INGOs and 16 Private Health Institutions (PHI) also reported to HMIS in this year. This implies that 100% of PHCCs, 100% of HPs and SHPs, 94% of PHC/ORCs, 98% of EPI clinics, 94% of FCHVs and 100% of NGO/INGOs reported to HMIS in fiscal year 2073/74.

B. CHILD HEALTH IMMUNIZATION National immunization program is the priority 1 (P1) program. The district coverage of BCG is the highest of all antigens indicates that about 109% children have access in immunization services, while DPT‐HepB‐Hib and OPV‐ 3 coverage are more than 93%. The measles/rubella 1 vaccine coverage is 90 % and Td2+ coverage (Td2 and Td2+) coverage is 95%. The JE coverage is 74%.

NUTRITION In Banke, the coverage of growth monitoring (GM) is 61% in FY 2073/74. The average number for GM visit marginally increased in the fiscal year 2073/74 i.e. 2.7. The proportion of malnutrition children has decreased to 4.2% in FY 2073/74 from 5.9 % of FY 2072/73.

COMMUNITY BASED INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS (CB‐IMCI) AND NEWBORN CARE (CB‐NCP) In FY 2073/74 a total of 580 infant of less than 2 months were treated at health facilities. Treated infection cases (PSBI) have been constant (72) in FY 2073/74 as compared to 2072/73. The incidence of diarrhoea per 1,000 under‐five years' children has decreased slightly to 515/1,000 in FY 2073/74 from 573/1,000 of FY 2072/73. In the case of Severe Dehydration, it has also slightly decreased in FY 2073/74 as compared to FY 2072/73. The incidence of ARI Cases has decreased 617/1000 in FY 2073/74 as compared to (636/1000) FY 2072/73.

C. FAMILY HEALTH FAMILY PLANNING The contraceptive prevalence rate (CPR) for modern family planning method is 41.7% at district level in fiscal year 2073/74. There is wide variation in CPR at the VDC/Municipality level in the reporting year. SAFE MOTHERHOOD In the fiscal year 2073/74 district level ANC first visit as percentage of expected live birth is 75 percent and 4 ANC visit as percentage of expected live birth is 49 percent. Institutional delivery as percentage of expected live birth is 126 %. It is because of reporting from three referral hospitals. FEMALE COMMUNITY HEALTH VOLUNTEERS There are 789 FCHVs (522 FCHVs at rural and 267 at urban/municipality level). FCHVs have contributed in distribution of 57 percent oral pills and 40 percent of condom. FCHVs distributed 359541 condoms out of 8, 83318 in the FY 2073/74. More than one half of the diarrhea and ARI cases were treated by FCHVs. 3

PRIMARY HEALTH CARE OUTREACH CLINICS Total number of clinics expected to run in a year 1776 (148 PHC/ORC Clinics x 12 times) and clinics have been conducted 94 percent in the reporting year. On an average 28 clients were served per clinic during the fiscal year 2073/74.

D. DISEASE CONTROL MALARIA Government of Nepal has set a vision of Malaria free Nepal in 2025. Malaria confirmed cases slightly increased from 24 in fiscal year 2072/73 to 29 in 2073/74.

LYMPHATIC FILARIASIS Lymphatic Filariasis (LF) is a public health problem in Banke and completed the recommended seven rounds of MDA in FY 2073/74 with 73% of coverage adopting local innovative activities. TAS done in previous year shows district has revealed that the prevalence of LF infection has not significantly reduced and contributed in preventing disabilities and sufferings due to LF.

TUBERCULOSIS In the fiscal year 2073/74, there were registered 965 cases; among them positive proportion was 68% (661). The case finding rate of New PBC TB cases was 88%. Case Notification Rate of new and relapse PBC was 103/1, 00, 000 risk population in the fiscal year 2073/74. Similarly the Treatment Success Rate of new smear positive cases registered in fiscal year of 2073/74 was 86%.

LEPROSY During the FY 2073/74 a total number of 288 new leprosy cases were detected including report from mini leprosy elimination campaign and were put under MDT. Total 265 cases were under treatment at the end of the fiscal year 2073/74 which makes the registered prevalence rate of 4.7/10,000 populations at district level. This rate is above the cut‐off point of <1/10,000 population which implies that there still remain a challenge for leprosy elimination in Banke district where as Government of Nepal declared leprosy elimination from Nepal on dated 19 January 2010.

Selected innovative and different ways of program implementation Registration of private HFs: Using national guideline DPHO Banke has registered 123 private health institutions by the end of the fiscal year. Following types of private health facilities were registered and have been providing health services:

SN Type of HFs Number SN Type of HFs Number

1 15 Bed hospital 13 6 Diagonistic centre 10

2 25 Bed hospital 3 Ultra sound 5

3 Pathology 15 7 X-ray 4

4 Polyclinic 8 8 Health clinic 41

5 Dental hospital 6 9 Eye hospital 5

10 Nose Hospital 1

Applied Reaching the Unreached Strategy developed by MoH: MLEC, SMC, MDA additional resource mobilization, from DCC, FID in connection with ODF, I am Healthy and my country is healthy. Attention was paid to provide services to remote areas for example all the positions of human resource was fulfilled and partners' projects activities were implemented in Rapti pari. Control of tobacco, school health program and growth monitoring campaign and my health my country healthy campaign were also implemented in selected areas.

Coordination and support: In support and coordination of DPHO established Haemoglobinopathy/Sickle Cell Disease (SCD) center and One Stop Crisis Management Center (OCMC). Further, DPHO procured equipments for Susil Koirala Prakhar cancer hospital, Khajura. Likewise DPHO team and Nepalgunj sub metropolitan city have been able to start one health promotion center in this year.

E-bidding: DPHO Banke started E-bidding in this year. It has made us efficient and effective to regular supply of medicines, reagents and commodities. This system has also supported to develop local capacity in the area of electronic system (E-Health).

Disaster preparedness and management: DPHO has prepared disaster preparedness plan and responded disaster like fire, flood and also initiated public health action in the area of snake bite.

Different way for effective implementation: From this year all health facilities have been providing health services to clients from 10am to 5 pm. DPHO has focused on completion of planned activities on time making individual plan, partners plan and annual calendar of operation. Further enhanced infection prevention practices, sanitation and communication with stakeholders including media people/journalist. Full Immunization Declaration (FID) has been accelerated and financial support received from DCC for specific activities.

Accepting and adopting change management: As country is moving into federal context, DPHO also exercises to move in line with this change. For example, team engaged in profile preparation, local planning and smooth handover of roles and properties to local government.

Banke District : A Brief Introduction

Banke district belongs to the Mid-Western Development Region, one of the five development region of the country. and in latest contex in province no. 5 The district becomes the main center for this region as well as entry point for Bheri Zone. The district is located in between the latitude 27o 51' to 28o 20' North and longitude 81o 29' to 82o 8' East. The average length and breadth of the district is estimated to be 84 KM and 40 KM respectively.

The Southern part of the district belongs in the Terai plain area where as northern part from east west is covered by Chure Hill. The district is composed in One Sub-metro Politian , One municipality and Six rural municipilities .

The district has borders with Surkhet, Salyan, and Dang to the north, Uttar Pradesh of India to the south, Uttar Pradesh of India, Salyan and parts of Dang to the east and Bardia district to the west.

The total area of the district is 2,337 Sq. Km. The district belongs at the altitude of 127 meter to 1290 meter from the sea level. Jungle and shrubs cover about 50% of the land. About 25 to 30% land of the district is suitable for agriculture activities. The district's big river is Rapti, which separates the district into two parts making difficult accessibilities in those, separated eastern Two Rural municipilities named Narainapur and Raptisonari during rainy season. The temperature of the district varies from minimum 5.4o C. in the winter up to 46o C. in the summer.

According to the National Census report 2068, about 41 % of the total population is residing in the urban areas. About 78.42% of the total populations are Hindu, 18.98% Muslim, 1.316% Chrishchian, 1.14% Buddha and 0.143% are other than these religious groups.

The literacy of the district above 5 years populations have 62.39% whereas male has 69.96% and female has 54.95%.

1. District population:

According to Census 2011

Total Population 491313

Total number of houses: 94,773 (With Institutional)

Population growth rate 2.42

Density of Population 210/sq.km

Literacy Rate 62.39

Literacy Rate Male 69.96

Literacy Female 54.95

Population below poverty line 26.4%

Toilet user households 47.69

ODF declaration 33 VDC and 1 municipality ( at old structure)

Number of Fully immunized VDC's 12

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#=$ 8'8'jf ufpFkflnsf :t/df :jf:Yo If]qdf lqmofzLn lghL tyf u}/;/sf/L ;+3 ;+:yfx?sf] ljj/0f qm= ;+:yfsf] gfd sfo{qmd÷ ;+Vof sfo{qmd /x]sf] j8f g+= ;+=

! u]?jf u|fld0f hfu/0f ;+3 jfn tyf dft[ :jf:Yo, jf; xf]lnof, a]tfxlg, agsl§,

@ Knfg OG6/g]Zgn :af:Yo, afn;+/If0f, jf;, lzIff ;a} j8f

@ ;'cfxf/f kf]if0f tyf ;/;kmfO{ ;a} j8f

# x]Ny km/ nfO{km ;'/lIft dft[Tj ;a} j8f

$ ;d0f{ g]kfn xf]lnof,

% :ofs g]kfn lzIff xf]lnof, agsl§, slDb,

lx/ldlgof

^ kmfltdf kmfpG8]zg Dlxnf xf]lnof, agsl§

& afs]+ o'g]:sf] xf]lnof, agsl§, slDb

* o'jfSna o'jf tyf afnaflnsf a]tfxlg, slDb

( ;]n8{ lap lahg agsl§

!) ls;fg kl/of]hgf lap lahg lx/ldlgof, a]tfxlg,

!! u|fdL0f r]tgf cleofg ;+3 afn clwsf/ a]tfxlg, agsl§

!@ g]kfn d'l:nd ;dfh dlxnf tyf afnaflnsf xf]lnof,

!# OG?8]s ;'zf;g a]tfxlg

!$ :jf:Yo;Fu ;DalGwt z}lIfs 5}g ;+:yfx?

नेपालयाै नरोगतथाएड्स :af:Yo, ;a} j8f अनुसन्धानकेन्द्र

!% wfdL emfFqmLx?sf] NA ;+Vof

>f]t M lh=h=:jf=sf=, afFs]

#=% g/}gfk"/ ufpFkflnsfdf :jf:Yo ;DjlGw ;]jf lbg] ;+:Yffx?sf] ljj/0f qm=;+ hDdf j8f cg';f/ s}lkmot ;+:yfsf] lsl;d :yfg/j8f = ;+Vof ;+Vof

! k|fylds :jf:Yo s]G› ! j8f g+= @

@ :jf:Yo rf}sL % !,#,$,% / ^

# zx/L :jf:Yo s]Gb| )

qm=;+ hDdf j8f cg';f/ s}lkmot ;+:yfsf] lsl;d :yfg/j8f = ;+Vof ;+Vof

$ cfo\'{j]lbs cf}ifwfno -cfo'{j]b ;+u ) ;dGjo ul/ lng]_

% kl/jf/ lgof]hg ;+3 g]=k=lg=;+3 lSnlgs ;+u ;dGjo ul/ ) lng] - )*!%@)#(*_

ufpF3/ lSnlgs s6\s'O{of @

% nId0fk'/ !

sfnfkmfF6f @ !# g/}gfk'/ #

d6]lxof #

u+ufk'/ @

vf]k lSnlgs s6\s'O{of %

^ nId0fk'/ %

sfnfkmfF6f ^

g/}gfk'/ ^

d6]lxof ^

u+ufk'/ %

& ;fd'bflos :jf:Yo s6\s'O{of ) OsfO{ nId0fk'/ )

sfnfkmfF6f )

qm=;+ hDdf j8f cg';f/ s}lkmot ;+:yfsf] lsl;d :yfg/j8f = ;+Vof ;+Vof

g/}gfk'/ )

d6]lxof )

u+ufk'/ ! ;f]gjiff{

>f]t M lhNnf hg:jf:Yo sfof{no, afFs]

#=^ /fKtL;f]gf/L ufpkflnsfdf :jf:Yo ;DjlGw ;]jf lbg] ;+:Yffx?sf] ljj/0f hDdf j8f cg';f/ s}lkmot qm=;+= ;+:yfsf] lsl;d :yfg/j8f ;+Vof ;+Vof

! k|fylds :jf:Yo s]G› )

@ :jf:Yo rf}sL ^

# zx/L :jf:Yo s]Gb| )

$ cfo\'{j]lbs -cfo'{j]b ;+u ;dGjo cf}ifwfno ) ul/ lng]_

% kl/jf/ lgof]hg ;+3 g]=k=lg=;+3 ;+u lSnlgs NA ;dGjo ul/ lng] - )*!%@)#(*_ ufpF3/ lSnlgs Vff;s'Zdf # srgfk'/ $ % a}hfk'/ $ !# lagf}gf # kmQ]k'/ # dxfb]jk'/L # vf]k lSnlgs Vff;s'Zdf % srgfk'/ &

^ a}hfk'/ % lagf}gf % 21

hDdf j8f cg';f/ s}lkmot qm=;+= ;+:yfsf] lsl;d :yfg/j8f ;+Vof ;+Vof

kmQ]k'/ & dxfb]jk'/L % & ;fd'bflos :jf:Yo Vff;s'Zdf NA OsfO{ srgfk'/ NA a}hfk'/ !

lagf}gf ) kmQ]k'/ ) dxfb]jk'/L NA >f]t M lhNnf hg:jf:Yo sfof{no, afFs]

#=& /fKtL ;f]gf/L ufFpkflnsfdf lqmofzLn lglh tyf u}/;/sf/L ;+3 ;+:yfx?sf] ljj/0f qm= ;+:yfsf] gfd sfo{qmd /x]sf] j8f sfo{qmd ;+= g+=

! cfO{=Pg=Pkm= #,$,%,^ / &g+= dft[ tyf jfn :jf:Yo

% ;d'bfo ljsf;

#,$,%,^ / & g+= k'g{:yfkgf

$ ;'cfxf/f !, @,#,$,%,^,&,* / ( kf]if0f tyf ;/;kmfO{ g+=

% g]kfn kl/jf/ lgof]hg !, @,#,$,%,^,&,* / ( kl/jf/ lgof]hg ;+3/SIFPO2 g+=

#=* hfgsL ufpkflnsfsf] :jf:Yo ;DjlGw ;]jf lbg] ;+:Yffx?sf] ljj/0f M hDdf j8f cg';f/ s}lkmot qm=;+= ;+:yfsf] lsl;d :yfg/j8f ;+Vof ;+Vof

hDdf j8f cg';f/ s}lkmot qm=;+= ;+:yfsf] lsl;d :yfg/j8f ;+Vof ;+Vof

! k|fylds :jf:Yo ^ s]G›÷:jf:Yo rf}sL

@ zx/L :jf:Yo s]Gb| ) - -

# cfo\'{j]lbs cf}ifwfno ) $ kl/jf/ lgof]hg ;+3 ! lSnlgs ;fO{ufp a]nef/ @ % a]nx/L ) O{Gb|k'/ ) vh'/fv'b{ ! ugfk'/ ! ufpF3/ lSnlgs ;fO{ufp $ a]nef/ @ % a]nx/L # !& O{Gb|k'/ # vh'/fv'b{ @ ugfk'/ # vf]k lSnlgs ;fO{ufp % a]nef/ $ ^ @^ a]nx/L % O{Gb|k'/ & vh'/fv'b{{ %

& ;fd'bflos :jf:Yo - -j}hfk'/ / OsfO{ - u+ufk'/ df ! ! j8f dfq_ )

#=( M hfgsL :t/df :jf:Yo If]qdf lqmoflzn lghL tyf u}/ ;/sf/L ;3+;:Yf+fsf] ljj/0fM qm= ;+:yfsf] gfd sfo{qmd /x]sf] sfo{If]q ;+= j8f g+=

! ;]e b lrN8]«g @,# Dfft[, gjhft lzz' tyf afn :jf:Yo

@ kl/jf/ lgof]hg ;3+ l;kmf] @ ! b]lv ^ ;Dd Kfl/jf/ lgof]hg sfo{qmd

# ;'cfxf/f sfo{qmd ! b]lv ^ ;Dd kf]if0f

$ X]Ny km/ nfO{km :jf:Yo k|0ffnL ;[l9lss/0f

% Knfg g]kfn Gjhft lzz' tyf jfn :jf:Yo #=!) vh'/f ufpkflnsf :tl/o :jf:Yo ;DjlGw ;]jf lbg] ;+:Yffx?sf] ljj/0f qm=;+ hDdf j8f cg';f/ s}lkmot ;+:yfsf] lsl;d :yfg/j8f = ;+Vof ;+Vof

! k|fylds :jf:Yo s]G› ! j8f g+= # -$_

@ :jf:Yo rf}sL % !,@,%-^_,&,*

# zx/L :jf:Yo s]Gb| ) )

$ cfo\'{j]lbs cf}ifwfno ) )

% kl/jf/ lgof]hg ;+3 lSnlgs ) )

ufpF3/ lSnlgs jfu]Zj/L # /fwfk'/ # % l;tfk'/ # !# ;f]gk'/ # /lgofk'/ $ p9/fk'/ $ vf]k lSnlgs jfu]Zj/L & 24

qm=;+ hDdf j8f cg';f/ s}lkmot ;+:yfsf] lsl;d :yfg/j8f = ;+Vof ;+Vof

^ /fwfk'/ # l;tfk'/ % ;f]gk'/ % /lgofk'/ % p9/fk'/ ^ & ;fd'bflos :jf:Yo jfu]Zj/L ) OsfO{ /fwfk'/ ) l;tfk'/ )

;f]gk'/ ) /lgofk'/ ) p9/fk'/ )

#=!! vh"/f ufFpkflnsf,:t/df lqmofzLn lglh tyf u}/;/sf/L ;+3 ;+:yfx?sf] ljj/0f

qm= ;+:yfsf] gfd sfo{qmd /x]sf] j8f g+= sfo{qmd ;+=

! x]Ny km/ nfO{km %,^,* :jf:Yo k|0ffnL ;'b[9Ls/0f

# lh=cfO{=h]8= #,$ dft[ tyf gjhft lzz"

$ ;'cfxf/f !,@,#,$,%,^,&,* g+= kf]if0f tyf ;/;kmfO{

% g]kfn kl/jf/ lgof]hg !,@,#,$,%,^,&,* g+= kl/jf/ lgof]hg ;+3/SIFPO2

#=!@ a}hgfy ufFp kflnsfdf :jf:Yo ;DaGwL ;]jf lbg] ;+:Yffx?sf] ljj/0f M hDdf j8f cg';f/ qm=;+= ;+:yfsf] lsl;d :yfg/j8f s}lkmot ;+Vof ;+Vof

@ :jf:Yo rf}sL $

# zx/L :jf:Yo s]Gb| )

hDdf j8f cg';f/ qm=;+= ;+:yfsf] lsl;d :yfg/j8f s}lkmot ;+Vof ;+Vof

kl/jf/ lgof]hg ;+3 & lSnlgs )

* d]/L :6f]K;\ ;]G6/ )

lr;fkfgL # Gf}a:tf $ ufpF3/ lSnlgs !$ ( ags6'jf # l6l6l/of $ lr;fkfgL # Gf}a:tf & vf]k lSnlgs @@ !) ags6'jf & l6l6l/of % >f]t M lhNnf hg:jf:Yo sfof{no, afFs]

#=!# a}hgfy ufFp kflnsf:t/df :jf:Yo If]qdflqmofzLn lghL tyf u}/;/sf/L ;+3 ;+:yfx?sf] ljj/0f qm= ;+:yfsf] gfd sfo{qmd÷ ;+Vof sfo{qmd /x]sf] j8f g+= ;+=

! ;'cfxf/f @ Plss[t kf]if0f ! b]lv * ;Dd

@ ls;fg kl/of]hgf s[lif !b]lv&

# g]kfn kl/jf/ lgof]hg ;+3 kl/jf/ lgof]hg ! b]lv * ;Dd SIFPO2

$ H4L

% GIZ

>f]t M lh=h=:jf=sf=, afFs]

3.14 . Health Institutions:

Zonal Hospital 1

Eye Hospital 3

Police Regional Hospital 1

Army Hospital 1

Primary Health Center: 3

Health Posts 42

Sub health post 2

Urban Health Center 6

community Health unit 2

Aayurbed Hospital/Centers 4

Newly Ragisterd Heatlh Institution at fy 073/74:

SN Type of HFs Number SN Type of HFs Number

1 15 Bed hospital 13 6 Diagonistic centre 10

2 25 Bed hospital 3 Ultra sound 5

3 Pathology 15 7 X-ray 4

4 Polyclinic 8 8 Health clinic 4

5 Dental hospital 6 9 Eye hospital 57

10 Nose Hospital 1

• TB Treatment center/Sub center DOTS Plus center (TB Nepal) 1

DOTS treatment center 59

• Total FCHVs: VDC Level: 522

Municipality/Sub Metropolitan: 267

• Outreach Clinics 148 • EPI Clinic 303 • Cold chain sub center 1 5. National Health Policy, plans and Sustainable Development Goal 5.1.1 National Health Policy 2071 27

Vision All Nepali citizens have the physical, mental, social and spiritual health to lead productive and quality lives.

Mission Ensure citizens fundamental rights to stay healthy by optimally utilizing the available resources optimally and fostering strategic cooperation between health service providers, service users and other stakeholders.

Goal Provide health services through equitable and accountable health system while increasing access to every citizens to quality health services to ensure health as a fundamental human right to every citizens. Objectives 1. Provides free of cost the basic health services that remains as a fundamental rtight of a citizen.

2. Establish effective and accountable health services that are easily accessible and are equipped with essential drugs, diagnostics and skilled human resources. 3. Promote participation of people in health services provision. Promote ownership while increasing involvement/partnership of private sectors and NGOs in health services effectively manage partnership to built ownership within government and private sector.

Policies 1. Provide access quality health services( Universal Health coverage ) to every citizens in an effective way and provide basic health services free of cost. 2. Plan, produce,retain and develop skilled human resources to deliver affordable and effective health services. 3. Develop ayurvedic system of medicine by managing and utilizing the herbs available in the country as well as protect and do systematic development of other complementary medicine systems. 4. Ensuring simple and effective provision/import and utilization of quality medicine and medical products and enhancing in country production capacity gradually head towards self de- pendence. 5. Improve quality of health research inline with international standards and establish effective mechanisms to translate these into policy making, planning and medicine systems. 6. Promote public health by giving priority to health education, information and communication to people protecting people's fundamental right to health information 7. Minimize prevalence of malnutrition through promotion and utilization of healthy food. 8. Ensure provision of quality health services through efficient and accountable

mechanism and process of coordination, monitoring and regulation. 9. Ensure professional standards and quality of health services by making health related professional councils capable, professional and accountable. 10. Gradually mainstream health in all policies by further strengthening collaboration with multi sector stakeholders in health . 11. Ensure citizens right to live in healthy environment through effective control of environmental pollution for health protection and promotion. 12. Improve governance through policies, management and organizational structure to deliver quality health services. 13. Promote public private partnership for systemic and qualitative development of health sector. 14. Gradually increase state's investment in health sector and effectively utilize and manage support from private sector and development partners to ensure affordable and quality health services and ensure financial protection in health expenditures.

5.1.2. Second Long term Health Plan The Ministry of Health and Population has developed a 20-year Second Long-Term Health Plan (SLTHP) for FY 2054-2074 (1997-2017). The aim of the SLTHP is to guide health sector development for the overall improvement of the health of the population; particularly those whose health needs are often not met.

Targets The targets of the SLTHP are as follows: • To reduce the infant mortality rate to 34.4 per thousand live births; • To reduce the under-five mortality rate to 62.5 per thousand live births; • To reduce the total fertility rate to 3.05; • To increase life expectancy to 68.7 years; • To reduce the crude birth rate to 26.6 per thousand population; • To reduce the crude death rate to 6 per thousand population; • To reduce the maternal mortality ratio to 250 per hundred thousand live births; • To increase the contraceptive prevalence rate to 58.2 percent; • To increase the percentage of deliveries attended by trained personnel to 95%; • To increase the percentage of pregnant women attending a minimum of four antenatal visits to 80%; • To reduce the percentage of iron-deficiency anemia among pregnant women to 15%; • To increase the percentage of women of child-bearing age (15-44) who receive tetanus toxoid (TT2) to 90%; • To decrease the percentage of newborns weighing less than 2500 grams to 12%; • To have essential healthcare services (EHCS) available to 90% of the population living within 30 minutes’ travel time to health facility; • To have essential drugs available round the year at 100% of facilities; • To equip 100% of facilities with full staff to deliver essential health care services; • To increase total health expenditures to 10% of total government expenditures.

5.1.3. Millennium Development Goal • In September 2000, representative from 189 countries at the millennium summit in New York to adopt the united state millennium Declaration. It aims to bring peace, security and development to all people. The MDGs drawn from the Millennium declaration are a ground breaking international development agenda for the 21st country to which all nations are committed. The MDGs outline major development priorities to be achieved by 2015. Numer- ical targets are set for each goal and are to be monitored through 48 indicators. • There are 8 goals, 18 targets & 48 indicators. Out of these 3 goals, 8 targets and 18 indicators are directly health related. • The MDGs are: Goal 1: Eradicate extreme poverty and Hunger Goal 2: Achieve universal primary education Goal 3: Promote gender equality and empower women Goal 4: Reduce child mortality Goal 5: Improve maternal health Directly- Health Related Goal 6: Combat HIV/AIDS, malaria and other diseases Goal 7: Ensure environmental sustainability Goal 8: Develop a global partnership for development

5.1.4 Sustainable development Goal: As the world is near to the completion of Millennium development Goal - 2015, United Nation with the presence of head of the state , government and high representatives have declared new Sustainable Development Goal on September 2015. This agenda is the plan of action for people, planet and prosperity. Overall, there are 17 goals and 169 targets. The seventeen targets are given as below: Goal 1. End poverty in all its forms everywhere Goal 2. End hunger, achieve food security and improved nutrition and promote sustainable agriculture . Goal 3. Ensure healthy lives and promote well-being for all at all ages Goal 4. Ensure inclusive and equitable quality education and promote lifelong learning op-portunities for all Goal 5. Achieve gender equality and empower all women and girls Goal 6. Ensure availability and sustainable management of water and sanitation for all Goal 7. Ensure access to affordable, reliable, sustainable and modern energy for all Goal 8. Promote sustained, inclusive and sustainable economic growth, full and productive employment and decent work for all Goal 9. Build resilient infrastructure, promote inclusive and sustainable industrialization and foster innovation Goal 10. Reduce inequality within and among countries 30

Goal 11. Make cities and human settlements inclusive, safe, resilient and sustainable Goal 12. Ensure sustainable consumption and production patterns Goal 13. Take urgent action to combat climate change and its impacts* Goal 14. Conserve and sustainably use the oceans, seas and marine resources for sustainable development Goal 15. Protect, restore and promote sustainable use of terrestrial ecosystems, sustainably manage forests, combat desertification, and halt and reverse land degradation and halt biodiversity loss Goal 16. Promote peaceful and inclusive societies for sustainable development, provide access to justice for all and build effective, accountable and inclusive institutions at all levels Goal 17. Strengthen the means of implementation and revitalize the global partnership for sustainable development. The Goal 3 is directly health related. The targets of the Goal-3 are:

3.1 By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births 3.2 By 2030, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births 3.3 By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases 3.4 By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being 3.5 Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol 3.6 By 2020, halve the number of global deaths and injuries from road traffic accidents 3.7 By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and program. 3.8 Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all 3.9 By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil pollution and contamination 3.a Strengthen the implementation of the World Health Organization Framework Convention on Tobacco Control in all countries, as appropriate 3.b Support the research and development of vaccines and medicines for the communicable and non communicable diseases that primarily affect developing countries, provide access to affordable essential medicines and vaccines, in 31

accordance with the Doha Declaration on the TRIPS Agreement and Public Health, which affirms the right of developing countries to use to the full the provisions in the Agreement on Trade Related Aspects of Intellectual Property Rights regarding flexibilities to protect public health, and, in particular, provide access to medicines for all 3.c Substantially increase health financing and the recruitment, development, training and retention of the health workforce in developing countries, especially in least developed countries and small island developing States 3.d Strengthen the capacity of all countries, in particular developing countries, for early warning, risk reduction and management of national and global health risks

Chapter-1 District Reporting System 32

Reporting of each health facility is to be submitted in DPHO by 7th of the following month. Each report should be complete, timely and consistent. The following Fig. shows the reporting status of different health facilities from FY 2071/72 to 2073/74.

Reporting status of District, PHCC, and HP is 100 % for all F/Y and the status of PHC/ORC and EPI clinic are like same as previous FY. The reporting status of Non Public Health facility is in increasing in trend and there is also problem of having complete report on time in regular basis. it may need to be coordinated from regional and central level for regular reporting in newly revised HMIS formate.

Table No: 1 Average Numbers of People Served by Health Facilities per day.

FY PHCC HP PHC/ORC EPI FCHV

2071/72 45 29 32 29 47

2072/73 36 21 28 32 40

2073/74 37.38 - 26 31 37

Average number of people served by PHCC, HP, PHC/ORC and FCHV are in increasing trend due to proper management of health staffs, 10-5 Office hour, Regular supervision and monitoring .

Chapter-2 National Immunization Programme

1. Background: The National Immunization Programme (NIP) is a high priority programme (P1) of Government of Nepal. Immunization is considered as one of the most cost-effective health interventions. NIP has helped in reducing the burden of vaccine preventable diseases (VPDs) and child mortality and has contributed in achieving the Millennium Development Goal (MDG4) on child mortality reduction.

Eleven antigens are provided through the national programme to eligible infants, children and mothers. Though the initiative of Reaching Every Child and declaring VDCs, municipalities and district as fully covered was initiated in 2012, to date only 12 VDCs have been declared fully immunized. Remaining VDCs and municipalities are preparing and have the plan to complete it by the end of 2017.

2. Guiding documents of National Immunization Programme The National Immunization Programme has two main guiding documents:

• The Nepal Health Sector Programme-2 Implementation Plan (NHSP IP 2) focused on increasing access and utilisation of essential health care services, especially to reduce disparities in access to health care. It gave high priority to the immunization programme. • The Comprehensive Multi-year Plan of Action (2012–2016) is the main guiding document for the national immunization programme. It was aligned with policy documents of the national immunization programme, World Health Assembly (WHAs) resolutions and the Global Vaccine Action Plan. The Comprehensive Multi-Year Plan of Action (cMYPoA for 2012– 16) ended in 2016 and the new Comprehensive Multi-Year Plan (cMYP, 2017-2021) has been prepared. The overall goal of the cMYPoA (2012-2016) was “To reduce child mortality, morbidity and disability associated with vaccine preventable diseases.” Its eight objectives and related strategies are outlined in the table below.

Objectives Related strategies

1. Achieve and maintain at least 90% vaccination coverage for all antigens at national and district level by 2016 • Increase access and utilization to vaccination by implementing reaching every district (RED) strategies in every district. • Enhance human resources capacity for immunization management • Strengthen immunization monitoring system at all levels • Strengthen communication, social mobilization, and advocacy activities • Strengthen immunization services in the municipalities 2. Ensure access to vaccines of assured quality and with appropriate waste management:

• Strengthen the vaccine management system at all levels.

3. Achieve and maintain polio free status: • Achieve and maintain high immunity levels against polio by strengthening routine immunization and conducting high quality national polio immunization campaigns • Respond adequately and timely to outbreak of poliomyelitis with appropriate vaccine • Achieve and maintain certification standard AFP surveillance. 4. Maintain maternal and neonatal tetanus elimination status: • Achieve and maintain at least >80% TT2+ coverage for pregnant women in all districts • Conduct tetanus and diphtheria (Td) follow up campaigns in high risk districts • Expand school based immunization programme • Continue surveillance of neonatal tetanus (NT). 5. Initiate measles elimination: • Achieve and sustain high population immunity to reduce measles incidence to elimination level • Investigate all suspected measles like outbreaks with programme response • Use platform of measles elimination for rubella and CRS control • Continue case-based measles surveillance. 6. Accelerate control of vaccine-preventable diseases by introducing new and underused vaccines: • Introduce new and under-used vaccines (rubella, pneumococcal, typhoid, rota) based on disease burden and financial sustainability 7. Strengthen and expand VPD surveillance: • Expand VPD surveillance to include vaccine preventable diseases of public health concern. • Strengthen and expand laboratory support for surveillance. 8. Continue to expand immunization beyond infancy: • Consider administering booster doses of currently used antigens based on evidence and protection of adults from potential VPDs.

3. Targetpopulation The target population of the National Immunization Programme are:

• under 1 years of age for BCG, DPT-HepB-Hib, OPV, IPV, PCV and measles-rubella vaccine • 12 month old children for Japanese encephalitis • 15 month old children for measles-rubella second dose (MRSD) • pregnant women for tetanus toxoid and lose dose diphtheria toxoid (Td) containing vaccine • 4. National Immunization Schedule Typeofvaccine No. ofdoses Recommendedage

BCG 1 At birth or on first contact with health institution

Oral Polio Vaccine (OPV) 3 6, 10, and 14 weeks of age

DPT-Hep B-Hib 3 6, 10, and 14 weeks of age

IPV 1 14 weeks of age

PCV 3 6 and 10 weeks and 9 months of age

Measles- Rubella 2 MR-1 at 9 months and MR-2 at 15 months of age

Low dose diphtheria toxoid (Td) 2 Pregnant women

Japanese Encephalitis 1 12 months of age

5. Logical tools for measuring major indicators of EPI program

1. Coverage percentage of antigen (BCG, DPT3, Measles and JE) =

2. Dropout rate of DPT1 Vs. DPT3=

3. Dropout rate of BCG Vs. Measles =

4. Coverage percentage of TT2 &TT2+ =

5. Vaccine wastage rate =

6. Analysis of Service Statistics: Table 6.1 Palika wise Coverage of EPI Program FY 2071/72 to 2073/74

PANTA 3/ S.N palika BCG POLIO 3 PCV 3 MR 1 JE 1

1 Narainapur 110 98 95.8 95.7 83

2 Raptisonari 90 91 87 87 65

3 Nepalgunj 141 87.4 85 84 70

4 Duduwa 93 89.6 88.6 88,6 75

5 Baijanath 88 90 93 93 74

6 Kohalpur 117 103 96.9 96.9 76.8

7 Khajura 92.7 101 97.5 97.4 82

8 janaki 76 77.8 78.8 78.8 64.4

9 Banke total 109 93 89 89.8 75

Table 6.1 shows coverage of BCG/PANTA3/PCV2/MR1 and JE. majority of palika's have BCG coverage more than 90 % except baijanath .especially in urban sector BCG coverage higher And other vaccine coverage declining trend. Data shows lowest performance in JE, that’s indicates parents does not give priority their child to immunized when they grew up.

7. Analysis of Service Statistics: Fig 6.1 : District Coverage of EPI Program FY 2071/72 to 2073/74

The above figure shows that all antigen coverage are increased as compare to previous FY due to regular antigen suply,proper supervision and monitoring of EPI clinic operation and campain for full immunization decleration.

Table No. 6.2: Coverage of BCG, DPT III/Hep B III/Hib and Measles as HF wise:

BCG DPT 3 Measles 1

SN Health Facility

72 73 74 71 72 73 74 71 72 73 74

------

2071 2072 2073 2070 2071 2072 2073 2070 2071 2072 2073

1 Bageswari 96 83 64 102 125 116 92.6 85 116 100 80

2 Belahari 144 132 94 108 151 127 101 107 151 133 101

3 Indarpur 96 67 94 79 104 67 90.6 75 77 68 94

4 Khajurakhurda 100 96 91 98 111 94 89.2 99 105 91 95

5 Radhapur 60 64 87 81 84 76 105 77 65 77 98

6 Banakatawa 81 77 98 81 91 77 104 81 89 70 94

7 Chisapani 67 61 86 83 74 70 82.1 76 74 76 78

8 Naubasta 95 68 77 83 101 74 82.6 87 96 70 89

9 Rajhena 169 182 166 50 130 116 125 47 139 113 127

10 Titihiriya 79 60 92 61 89 72 81.8 54 80 77 83

11 Kathkuiya 136 145 125 103 117 110 101 98 116 113 112

12 Laxmanpur 113 144 125 90 55 117 121 77 45 85 113

13 Gangapur 103 106 108 102 97 97 101 88 98 93 96

14 Matahiya 109 91 108 84 91 78 93 73 83 68 84

15 Belbhar 74 69 84 79 76 77 87.4 85 67 51 101

16 Hirminiya 83 87 89 103 94 80 83.5 99 92 89 77

17 Jaispur 79 83 128 94 77 65 85.2 99 85 46 94

18 Paraspur 100 66 88 77 92 69 88.1 61 89 63 75

19 Piparhawa 85 82 106 85 76 59 89.3 85 79 61 91

20 Saigaun 99 99 92 113 103 99 91.3 109 105 85 95

21 Kachanapur 84 66 96 53 77 57 105 51 83 65 92

22 Khaskusma 74 72 82 91 86 79 94.9 80 82 61 75

23 Mahadevpuri 78 78 93 82 89 92 104 79 98 89 89

24 Kalaphata 102 80 115 74 72 65 102 56 55 38 87

25 Narainapur 146 148 84 123 174 139 75.3 120 143 142 80

26 Basudevapur 88 75 92 83 81 78 104 70 85 80 101

27 Kamdi 101 69 84 82 97 80 87 79 95 77 89

28 Khaskarkado 90 75 92 56 93 86 91.2 54 92 65 75

29 Nepalgung 188 190 175 16 118 90 74.1 14 85 80 72

30 Puraini 60 74 104 69 60 51 106 65 53 42 88

31 Bejapur 92 67 88 60 85 69 92.5 60 80 75 92

32 Binauna 87 78 82 64 91 82 78.3 63 80 80 97

33 Phattepur 86 84 94 69 88 71 79.9 62 76 63 80

34 Ganapur 125 120 85 101 114 98 90.7 111 78 106 88

35 Kohalpur 80 62 82 53 70 64 89.5 50 68 58 71

36 Manikapur 87 66 79 63 81 74 100 57 68 74 96

37 Shamsergunj 92 74 94 93 110 74 97.7 88 107 73 86

38 Raniyapur 98 88 100 73 100 87 98.4 89 100 87 111

39 Sitapur 91 67 86 87 106 85 96.6 88 94 89 99

40 Sonpur 101 86 120 113 92 87 132 121 75 99 107

41 Udharapur 91 79 103 64 93 69 90.2 53 75 57 98

42 Banakatti 81 79 105 87 75 62 101 77 63 61 108

43 Betahani 107 113 105 84 110 122 97.2 48 97 76 87

44 Bhawaniyapur 88 88 123 92 102 70 112 96 89 77 109

45 Holiya 72 89 85 103 77 86 83.8 83 94 79 85

46 Puraina 123 97 137 118 150 96 155 109 143 81 146

47 Udayapur 114 122 108 94 123 108 113 94 118 115 112

48 District Total 106 98 109 79 97 83 93.5 73 89 77 89

Table No.6.3: Coverage of JE, TT2 /TT2+ and dropout rate of DPT1 vs DPT3:

SN Health Facility JE TT2 & TT2+ DPT1 Vs DPT3

72 73 74 72 73 74 72 73 74

------

2071 2072 2073 2071 2072 2073 2071 2072 2073 1 Bageswari 126 86 72 80 44 63 -19 -3 -11.5

2 Belahari 152 158 85 164 115 82 -1 1 -0.59

3 Indarpur 88 71 78 77 79 91 -5 11 5.2

4 Khajurakhurda 111 89 86 89 88 82 -9 6 4.5

5 Radhapur 77 61 89 69 72 74 -26 2 -18.2

6 Banakatawa 99 66 79 66 63 66 -9 8 -7.9

7 Chisapani 96 50 70 76 68 83 1 6 7.6

8 Naubasta 106 75 70 94 54 62 -4 3 3.9

9 Rajhena 125 113 100 126 61 240 3 7 12.3

10 Titihiriya 75 75 81 72 64 103 -2 1 -2.1

11 Kathkuiya 76 61 68 122 138 109 11 20 20.4

12 Laxmanpur 32 114 106 110 234 106 45 7 4.5

13 Gangapur 92 93 85 84 160 87 2 3 -1.6

14 Matahiya 83 53 84 98 113 95 9 18 27.2

15 Belbhar 52 32 60 67 80 106 7 -2 0

16 Hirminiya 90 79 64 98 152 128 -6 5 9.2

17 Jaispur 78 28 54 130 137 173 5 19 30.6

18 Paraspur 72 44 64 81 75 71 9 8 -3.5

19 Piparhawa 85 38 53 63 96 89 9 23 14.8

20 Saigaun 102 77 81 76 114 87 3 -1 1

21 Kachanapur 71 72 66 37 51 81 -7 10 10

22 Khaskusma 77 61 58 80 96 90 0 8 -5.7

23 Mahadevpuri 103 71 79 95 63 95 1 -8 -12.4

24 Kalaphata 78 57 84 94 107 110 30 16 13.3

25 Narainapur 194 141 75 143 139 95 -10 7 11.4

26 Basudevapur 86 72 105 73 76 103 0 11 -4.6

27 Kamdi 93 74 70 74 85 92 5 3 4.9

28 Khaskarkado 64 75 63 92 65 87 6 0 7.9

29 Nepalgung 93 72 63 90 45 75 5 17 17.8

30 Puraini 57 35 68 59 113 127 8 30 4.2

31 Bejapur 86 71 72 79 55 82 0 3 -3.8

32 Binauna 79 77 83 69 57 79 -3 -9 9.2

33 Phattepur 69 45 49 68 62 80 2 11 16.5

34 Ganapur 116 87 74 112 123 84 -1 14 -6.4

35 Kohalpur 69 56 61 68 60 93 10 -5 -9.2

36 Manikapur 66 69 75 69 86 116 14 -3 -5.1

37 Shamsergunj 100 74 73 95 84 94 -7 8 -8.2

38 Raniyapur 100 93 83 107 136 122 -2 4 5.1

39 Sitapur 98 100 83 83 68 93 -3 -7 5.7

40 Sonpur 84 70 106 101 122 133 5 14 -6.8

41 Udharapur 55 48 71 68 84 103 1 10 20.8

42 Banakatti 60 39 76 79 115 132 12 26 9.7

43 Betahani 82 54 88 121 103 118 2 -3 8.2

44 Bhawaniyapur 95 72 101 73 101 152 -3 10 4.4

45 Holiya 106 69 83 81 109 95 -1 -1 7.7

46 Puraina 139 92 116 127 137 158 -14 12 -10.1

47 Udayapur 95 111 115 201 145 116 1 6 7.8

48 District Total 89 71 75 87 76 94 2 8 5.8

Table 6.4 : VDCs Categorized based on the coverage of DPT-HepB-Hib3 and drop out 2073/74

Category 1 Category 2 Category 3 Category 4

(less Problem) (Problem) (Problem) (Problem)

Low Drop-Out High Drop-out Low Drop-out High Drop-out (<10%) High (≥10%) High (<10%) Low (≥10%) Low Coverage (≥90%) Coverage (≥90%) Bankatwa, Bankati,Basudevpur , Jaispur, kalaphata Bagesori,Coverage baijapur (<90%) Narainapur,Coverage (< 90%) Belhari, Khachanapur, Balbhar,Binauna,chisap Nepalgunj katkuiya , ani.ganapur Betahani, Bhabaniyapur, Gangapur, Matehiya, Khaskusum kohalpur, Hiriminiya , Holiya, Indrapur, kamdi phattepur,piprahawa Naubasta , paraspur, Khajurakhurd, khaskarkado, , ,Radhapur, titiriya laxmanpur, Mahadevpuri, Manikapur, Rajhena ,udharapur Puraina,puraini

Raniyapur, Saigau,shamsergunj, sitapur,sonpur, udaypur

From above table, each health facility has been categorized according to EPI categorization i.e. coverageof DPT3 greater than 90% and dropout of DPT1 Vs DPT3 less than 10% are categorized in Category1, coverage of DPT3 greater than 90% and dropout of DPT1 Vs DPT3 greater than 10%, are categorized in Category 2, low coverage of DPT3 less than 90% and dropoutof DPT1 Vs DPT3 is also less than 10%, Category 3 and low coverage of DPT3 less than 90% and dropout of DPT1 Vs DPT3 greater than 10 is categorized in Category 4

Fig: 6.2 District Dropout Rate: DPT1 Vs. Measles and DPT1 Vs. DPT3

Drop-out rate of both DPT1 Vs Measles and DPT1 vs DPT3 is in decreasing trend in this FY 73/74. Overall achievement of Banke district in EPI program is well satisfactory however in achievement in VDCs are still remaining challenge for full immunization declaration.

k')f{ vf]k # f]if) ffs f ] c j :yf t yf of]hgf BANKE N

Salyan Particulars Total FID % Chisapani VDCs 33 12 36 Bardiya Municipalitie 2 0 0 Naubasta

Rajhena DPHO Kohalpur Banakatawa Titihiriya Mahadevpuri Raniyapur Samserganj Sonapur Bageswari Kanchanapur Udarapur Ganapur KhajuraKhurda Belahari Manikapur Sitapur KhajuraKhur a Kamdi Indrapur ha karka od Dang asudevapur Radhapur Belbha NepalgunjN.P.Pnurai i Par spur Binauna Saigaun Puraina Banakatti J r wa dpauyrapur Phatepur Piparhaw Hirminiya Betahani Khaskusma Bejapur

Holiya sign India Gangapur FULL IMMUNIZATION VDC/ward Matahiya Narainapur Laxmanpur

PROCESSING 2074/075 Mangir Kalaphanta Kathkuiya

k'0f { vf]k ; 'lgZrLt elj Zo

7. Problems/Constraints :

Problems/Constraints Action to be taken Responsibility

• Low coverage and low • Defaulter tracing through FCHV in the • HF Incharge of dropout in 12VDCs and low related wards. related VDC and caverage and high dropout in • Supervision and monitoring should be Vaccinator. 2 VDC strengthening on these VDCs. • DPHO and EPI • Manage proper and regular antigen and Supervisors. other logistic supply. • CHD, LMD • Data based supervision and • Database Integrated supportive DPHO monitoring is weak at all supervision and monitoring should be levels implemented.

• Problem of vaccine storage • Provision of ice lined refrigerator , DCC , local body in Phatepur Sub centre maintenance physical infrastructure at sub centre • Knowledge and skill gap, • Provision of training Dpho. DCC. Local poor Recording by some • Motivation body vaccinator due to old age • Regular fallow up • Staying short time period during vaccination and lack of fallow up system about their target. Discontinuity in the supply of PCV • Essure supply chain /system CHD vaccine at month asar

Low budget allocation for full • Ensure properly budgeting CHD immunized ward/VDC/Palika

Chapter-3 NUTRITION

1. Background

Improvement in nutrition status has been seen as some of the most powerful and cost effective investment for the overall socio economic development by enhancing the optimal physical growth and cognitive development especially of women and children. Nutrition is crucial for accelerated attainment 44

of Millennium Development Goals as its impact is felt in developing human capital thereby influencing the economic development. Convention on Rights of the Child has andatorily ensured child protection from all forms of neglect, violence/abuse and exploitation including the right to food and nutrition. Having endorsed several international endorsements and declarations, Government of Nepal is committed to its citizens for adequate food, health and nutrition.The Interim Constitution has also ensured the right to food, health and nutrition to all citizens in Nepal. Failing to ensure protection of the population from the hunger and under nutrition often results in the vicious cycle of malnutrition, poor health and cognitive and intellectual underdevelopment which, in turn, lead to less productivity leading to compromised socio economic development. When combined with household food insecurity, frequent illness and infections, inadequate dietary intake, poor hygiene, care and practices, the cycle of intergenerational malnutrition comes into existence and continues.

1.1 Current changes and focus in nutrition

Globally, there has been a significant progress made in reducing the hunger and poverty in the last ecade. More focus was made in concerted way in improving the nutritional status, especially of women and children. In 2009, G8 leaders pledged to increase funding and coordination for investment inagriculture and food security. In subsequent year 2010, more than a dozen countries initiated a country led global effort “Scaling Up Nutrition Movement” to advance health and development through improved evidence based cost effective nutrition interventions. It is the start of a larger movement to focus global attention, align and increase resources, and build partnerships to alleviate the suffering caused by under nutrition among millions of people around the world. SUN calls for greater ‘multi sectoral’ action on nutrition during the first critical 1000 days of a child’s life, starting at pregnancy to children under 2 years of age.

Being part of global SUN movement, Nutrition is high on the Government of Nepal’s priority as demonstrated with the adoption of the Multi Sector Nutrition Plan (MSNP). Additionally, external development partners are alsochanneling significant resources towards improving the nutritional status of the Nepali people. Yet another paradigm shift is the realization of issues affecting the nutritional status are multidimensional and that a multi sectoral approach is required to address the multifaceted challenges. Understanding the fact that under nutrition is a complex, multi faceted problem, and responses need to include many diverse actors, the high level political will, involvement of sectoral ministries, and support from the EDPs have placed Nepal in a unique position. In recent years, improving the nutritional status of women and children is one of the top priorities for the Government of Nepal.

1.2 Summary of policy initiatives

National health policy 2014 has nutrition direction towards use and promotion of quality and nutritious foods generated from community level to fight against malnutrition. The relation between food security and nutrition needs to be addressed with increased food production, promote community health program to ensure intake of nutritious foods. With outline of multi sectoral determinants for nutrition and subsequently calling for multi sectoral approach to address the problem of malnutrition; as suggested by the Nutrition Assessment and Gap Analysis (NAGA) in 2009, National Planning Commission with the support of EDPs and multilateral agencies developed a comprehensive Multi Sector Nutrition Plan (MSNP) involving the six key line ministries. The longer term vision of the multi sector nutrition plan, over the next ten years, is to embark the country towards significantly reducing chronic malnutrition (stunting) to ensure that it no longer 45

becomes an impending factor to enhance human capital and for overall socio economic development. The goal over the next five years is to improve maternal and child nutrition, which will result in the reduction of MIYC under nutrition, in terms of maternal Body Mass Index (BMI) and child stunting, by one third. With the approval and endorsement by the government in 2012, the MSNP program has been implemented in six different districts in the country.

Despite the realization of the fact that malnutrition is a multi sectoral issue, it is health sector who has been leading in terms of addressing the problem of under nutrition in the country. The National Nutrition Policy and Strategy was developed and approved in 2004 realizing a need for a comprehensive document on nutrition for generating support and effective implementation of the program. It is the main policy document which has been guiding the nutrition interventions in the health sector till now. Later in 2006, MoHP has also put in place School Health and Nutrition Strategy. Aligning with the MSNP and current global initiatives, Department of Health Services, Child Health Division has developed different strategies and plan of actions for maternal infant and young child with technical support of Nutrition Technical Committee (NuTEC).

During the development of MSNP, a health sector review commissioned by the World Bank in 2011 for nutrition has recommended three pronged approaches for the nutrition interventions. It also laid the emphasis to intensify the priority interventions as recommended by the Lancet Series in 2008. As a result, Nepal Health Sector Programme II 2010 2015 (NHSP II) has also given a special priority for nutrition and emphasized the need for a multi sectoral approach. Considering the need of architecture for nutrition in the country, as recommended by the NAGA report in 2009, MoHP approved a decision to carry out organization and management survey for the establishment of National Nutrition Centre under the MoHP and it is currently being carried out.

2 Problem of Malnutrition in Nepal

In last 15 years, Nepal has shown notable decrease in less than 5 mortality rate, infant mortality rate and maternal mortality ratio. These steep declines in mortality rates have been attributed to strong public health interventions including the control of the micro nutrient deficiencies during the same period. However, the neonatal mortality rate has remained stagnant over the same time period and accounts for more than two third of infant deaths.

The prevailing high rate of child under nutrition in the country is one of the major contributing factors of under five mortality. Despite a steady, but slow, decline in reduction of maternal and child under nutrition, Nepal still faces high chronic as well as acute under nutrition in children. The NDHS 2011 has shown 41 percent of children less than 5 years of age suffering from chronic under nutrition (stunting) while more than 10 percent are acutely under nourished. Additionally, it estimates low birth weight (i.e. “very small” or “smaller than average”) at 12 percent. Furthermore, national nutrition status estimates mask wide inequities. Children from the lowest quintile or whose mother has no education are more than twice likely to be stunted than those from richest quintile or whose mother has secondary level or more education. The mountain zone has the highest stunting rate of 56 percent, while the Terai has the lowest rate (37.4%).

The same DHS study in 2011 showed 18.2 percent of non pregnant women are undernourished or chronically energy deficient (BMI<18.5kg/m2) and 14 percent are overweight or obese which is in increasing trend (NDHS 2011).The prevalence of both underweight and overweight among women is indicative of a potential double burden of malnutrition in the country. At particular risk for 46

chronically energy deficiency are girls 15 19 years of age, women living in the Terai, Western Mountains, Far Western Development Region and women with no formal schooling and from the lowest wealth quintiles.Women in Nepal are generally of short stature. 12 percent of women in Nepal are less than 145 cm. Risk factors for short height include living in a rural area, having limited schooling and coming from the lowest wealth quintiles. In terms of etiology, short stature is likely consequence of the high prevalence of stunting in childhood. Babies who grow poorly and become stunted are likely to continue being stunted thus perpetuating the intergenerational cycle of malnutrition in the population. Adolescent girls in Nepal fair worse as 25.8 percent of them have a low body mass index less than 18.5 kg/m2.

Compared to improvement in macronutrient deficiency status, Nepal is globally recognized in reducing the high rate of micronutrient deficiencies (IDA, IDD and VAD) through its successful community based supplementation programs. Nepal has reduced the prevalence of anaemia among women of reproductive age by almost half from the 1998 level. From 68 percent in 1998 to 35 percent in 2011, Nepal has made a remarkable progress in the reduction of anaemia, however, this reduction has ceased in the last five years. In the same duration, the prevalence of anaemia in the pregnant women has increased by 6 percent. Anaemia rates were higher among pregnant women (48%) and breastfeeding women (38%) compared to women who were neither pregnant nor breastfeeding (33%). The prevalence of anaemia among adolescent girls has remained stagnant at around 39 percent over the last five years. Similarly, 46 percent of children under five years of age still remain anaemic, with younger children under 2 years of age having the highest burden (69%), which is a very serious concern.

2.3 Efforts to Address Under nutrition in Nepal

Ministry of Health and Population has been implementing nutritional programs for last two decades. Since the treatment of goiter through iodine injection, vitamin A supplementation, IFA supplementation and promotion of IYCF practices, the problem of malnutrition has significantly reduced over the years. In Nepal, micronutrients programs adopting community based approach has contributed considerably in reducing micronutrient deficiencies. The goal of reducing micronutrient deficiencies set out in the World Fit for Children Summit 1990 is on track.

Bi annual supplementation of vitamin A to the children aged 6 59 months of age is implemented through our strong network of female community health volunteers. The success of the Vitamin A Deficiency Prevention and Control program has become an example as a global success story as how with strong community mobilization, partnership across sectors, regular monitoring and commitment from concerned stakeholders involved could result in the achievement of common goals. With sustained coverage of more than 90 percent over the years, this program has saved valuable lives of thousands of children each year. Likewise, supplementation of iron and folic acid tablets to the pregnant and lactating women has helped to reduce the prevalence of anemia among women from 67 percent in 1998 to 35 percent in 2011. During this period, anaemia prevalence among children under five years of age has also decreased by more than one third (from 78 to 46 percent). After the elimination of goiter with intensive program on iodine supplementation, government has been promoting to use the adequately iodized salt by the family. Ministry of Health and Population has been advocating for access of iodized salt and promote for its increased use through awareness campaign. Likewise, micronutrient powder is being provided to the children aged 6 23 months to address the high rate of anemia in that age group.

Despite the above success, chronic malnutrition continues to be a long standing challenge. Progress in reducing general malnutrition among children and women has been relatively slow. The acute and chronic

malnutrition in children remains at critical levels. According to latest data, stunting (a form of chronic malnutrition) has come down to 41 percent in 2011 from 49 percent in 2006. While wasting continues to linger at 11 percent, and 29 percent of the children are still underweight. Malnutrition and under nutrition diminishes cognitive and economic growth of the affected population which in turn reduces GDP by at least 3 percent. The issue of food insecurity and its contributing factors such as climate change related outcomes (droughts, floods) including chronic poverty, illiteracy, socio economic disparity, internal displacements, rising gasoline price, rugged geo topography are also conducive factors for under nutrition. Despite of all these complex and multi facet problems contributing to deterioration of nutritional status, Nepal has been implementing the proven and highly cost effective interventions like infant and young child feeding, integrated management of acute malnutrition (phase wise nation wide expansion) to address the malnutrition / under nutrition problems with continued progress.

4. National Nutrition Program

Goal

The overall goal of national nutrition program is to achieve nutritional well being of all people to maintain a healthy life to contribute in the socio economic development of the country, through improved nutrition program implementation in collaboration with relevant sectors.

General Objective

The general objective of the National Nutrition Program is to enhance nutritional well being, reduce child and maternal mortality and to contribute for equitable human development.

Specific Objectives:

• To reduce protein energy malnutrition in children under 5 years of age and women of reproductive age

• To reduce the prevalence of anemia among adolescent girls, women and children

• To virtually eliminate iodine deficiency disorders and vitamin A deficiency and sustain the elimination

• To reduce the infestation of intestinal worms among children and pregnant women

• To reduce the prevalence of low birth weight

• To improve household food security to ensure that all people can have adequate access, availability and utilization of food needed for healthy life

• To promote the practice of good dietary habits to improve the nutritional status of all people

• To prevent and control infectious diseases to improve nutritional status and reduce child mortality

• To control the incidence of life style related diseases (coronary artery disease, hypertension, tobacco and smoke related diseases, cancer, diabetes, dyslipidemia, etc.)

• To improve health and nutritional status of school children

• To reduce the critical risk of malnutrition and life during exceptionally difficult circumstances

• To strengthen the system for analyzing, monitoring and evaluating the nutrition situation

• To align the health sector programs on nutrition with Multi sectoral Nutrition Initiative

• To improve the maternal nutrition

5. Target

Indicators NDHS 2001 NDHS 2006 NDHS 2011 MDG 2015 Stunting among children 57 49 41 28 Wasting among children 11 13 11 5 Underweight among children 43 39 29 27 Anemia among children under 5 48 46 <40 Anemia among2 children under 6‐23 26 2478 1869 BMI (<18.5kg/m ) among women monthsAnemia among pregnant women 42 48 <40

6. Program Strategies

Control of Protein Energy Malnutrition (PEM)

• Ensure early initiation of breast feeding within one hour of birth, avoidance of pre lacteal feedand promotion of exclusive breastfeeding forthe first 6 months.

• Ensure continuation of breast feeding for at least 2 years and introduction of appropriate (quantity and quality) complementary feeding after 6 months.

• Strengthen the capacity of health workers/medical professionals for nutrition/breast feeding management

• Protect from commercial promotional practices which undermine optimal breast feeding practices

• Empower all mothers, families and care givers to make and carry out fully informed decisions about feeding

• Support community based programs 49

• Promote mother and child friendly working environment

• Promote the use of appropriate and adequate locally available complementary foods like Jaulo and Sarbottam Pitho

• Strengthen the system of growth monitoring and its supervision/monitoring

• Improve skills and knowledge regarding growth monitoring and nutrition counseling among health workers

• Provide PHC/HP/HP with necessary equipment and material for growth monitoring

• Create awareness regarding the importance of appropriate and adequate nutrition for children, pregnant and lactating mothers

• Change culturally acceptable nutrition behavior to improve intake of nutritious foods and diversification of diet

• Facilitate the function of nutrition rehabilitationhomes

• Strengthen the ability of health personnel in dietary and clinical management of severely malnourished children

• Distribute fortified foods to pregnant, lactating women and children aged 6 to 36 in food deficient areas

• Improve maternal and adolescent nutrition and low birth weight through improved maternal nutrition practices.

• Create awareness of the importance of additional dietary intake during pregnancy and lactation

• Strengthen the activities of nutrition education and Counseling

• Promote social (community and family) support for maintaining good health care and dietary habit

• Reduce heavy work load of pregnant and lactating women

• Prevent early pregnancy and ensure adequate birth spacing

• Improve iron status of pregnant and lactating women

Control of Iron Deficiency Anaemia (IDA)

• Create awareness of anemia and importance of iron and folic acid supplementation

• Ensure availability of iron/folate supplements at all health facilities and ORC 50

• Increase accessibility of iron/folate at the family and community level

• Increase coverage and compliance of iron/folic supplementation for pregnant and breast feeding women

• Strengthen parasitic infestation control programs (intestinal helminthes, malaria and kalazar)

• Create awareness about improving living conditions including sanitation and Hygiene

• Increase awareness about iron rich foods, both animal and vegetables sources

• Promote dietary practices that improve the content and bioavailability of iron in diet

• Identify and implement food fortification to increase the dietary iron intake focusing on commercial as well as small scale community based fortification initiatives

• Promote dietary diversification to improve the quality of food consumed with an emphasis on bio available iron

• Promote maternal care practices and services to improve health and nutritional status of mother and babies

• Weekly supplementation of iron and folic acid tablet to the adolescent girls (in and out of school) along with deworming tablet

• Advocate for equity among genders in access and control over household foods

• Home fortification of complementary food with micronutrient powder for children 6 23 months of age for prevention and control of anemia

• Create awareness of the importance of increased food intake and reduced work load during Pregnancy

• Promote advocacy campaigns against teen age pregnancy, early marriage and short birth Spacing

• Develop a scheme for screening and diagnosing high risk women for severe Anemia

• Conduct operational research regarding anemia

• Review the possibility of extending iron/folate supplementation to other groups at risk as well as to find out alternative approaches to supplementation

De worming

• De worming of pregnant women with a single dose tablet (Albendazole 400 mg) starting from 2nd trimester (4 months) of the pregnancy

• Distribute bi annual de worming tablet to school children (grade 1 10) in 75 districts for all public and private schools

• Create awareness about improving living conditions including sanitation and hygiene

• Bi annual deworming tablet to children 12 59 months of age during vitamin A supplementation

Control of Iodine Deficiency Disorders

• Strengthen the implementation of Iodized Salt Act, 2055 for regulation and monitoring of iodized salt trade to ensure that all edible salt is iodized

• Encourage better storage practices to prevent iodine loss

• Ensure systematic monitoring of iodized salt

• Increase the accessibility and market share of iodized packet salt with ‘two child’ logo

• Create awareness about the importance of use of iodized salt for the control of IDD through social marketing campaign

• Develop IDD monitoring system and implement the monitoring survey at national level

Control of Vitamin A Deficiency (VAD)

• Ensure availability of VA capsules at health facilities

• Increase awareness of importance of VA capsules supplementation

• Bi annual distribution of vitamin A capsule to children between 6 to 59 months through FCHVs

• Advocate for increased home production, consumption and preservation of Vitamin A rich foods at the community level

• Strengthen the usage of Vitamin A Treatment protocol

• Promote the consumption of VA rich foods and balanced diet through nutrition education

• Supplementation of Vitamin A capsule (200,000 IU) to postpartum mothers through health care facilities and community volunteers

Low Birth Weight

• Reduce maternal PEM

• Reduce maternal IDD

• Reduce maternal VAD

• Reduce maternal anemia

• Reduce workload of pregnant women

• Increase awareness of risks of smoking and alcohol to LBW

• Increase awareness of risks of teen age pregnancy to infant and maternal health

• Strengthen activities for nutrition monitoring /counseling at antenatal clinics

Household Food Security

• Promote kitchen gardening

• Improve agricultural skills

• Promote raising of poultry, fish and livestock for household consumption

• Advocate among community people as to how to store and preserve their foods at home

• Improve technical knowledge of food processing

• Advocate among community people as to how to manage their food allocation

• Promote activities of women’s groups which are interested in income generation

Improved dietary practices

• Conduct a study to clarify the problems of culturally related dietary habits

• Promote nutrition education activities and advocate for good diets and dietary habits

• Develop and strengthen programs that focus on behavior change as the means of improving dietary habits

• Strengthen the activities of nutrition education/advocacy which seek to eliminate the food taboos affecting nutritional status

• Promote the program of household food security

• Promote empowerment of women/gender equity

Infectious Disease Prevention and Control

• Promote knowledge, attitudes and practices which will prevent infectious diseases

• Ensure access to appropriate health services

• Improve nutritional status to raise resistance against infectious disease

• Improve safe water supply, sanitation and housing

• Improve food hygiene

School Health and Nutrition Program

• Build capacity of the policy and working level Stakeholders

• Biannual distribution of de worming tablets to school children from grade 1 to 10

• Celebration of SHN week in the month of June to raise awareness on malnutrition focusing at the community level through the medium of school children and health workers

• Distribution of First Aid kit box to the public schools

• Enhance knowledge, skills, and learning ability

• Introduce child to child and child to parent approach

Integrated Management of Acute Malnutrition

• Capacity building of all levels of health workers for the management of acute malnutrition through regular health services and of other community workers for the screening and referral of the cases for their management

• Effective establishment and implementation of 4 key structures of IMAM programme: Community mobilization, Inpatient therapeutic care, Outpatient therapeutic care and management of MAM therapy

• Effective implementation of IMAM programme based on 4 principles: Maximum coverage & access, Timeliness of service, Appropriate care, and Care as long as it is needed

• Integration of the management of acute malnutrition across the sectors to ensure that the treatment is linked to support for continued rehabilitation of cases and to wider malnutrition prevention programme and services

• Support and promote IYCF, WASH, ECD, social protection and child health & care along with the management of acute malnutrition

• Advocate IMAM programme as the bridge between emergency and development programme: Disaster Risk Reduction

• Supportive supervision and monitoring of IMAM programme activities for better result

• Harmonize both community as well facility based management of acute malnutrition

• Strengthen coordination and functional capacity of Nutrition Rehabilitation Homes

Nutrition in Emergencies

• Develop adequate capacity and predictable leadership in the nutrition sector for managing humanitarian response

• Formulate an emergency nutrition in emergency preparedness, nutrition in emergency response, including contingency plans and DRR, for the nutrition sector

• Identify gaps and priorities in the emergency nutrition sector, and generate resources for improving humanitarian nutrition services

• Establish and strengthen stronger partnerships and coordination mechanisms between government, UN and non UN agencies (I/NGOs, donors and non state sector)

• Response during emergencies through the activated nutrition cluster

Life Style Related Diseases

• Create awareness among adults about the importance of maintaining good food habits for life

• Develop capacity for counseling at health facilities

• Create awareness about the importance for adolescents and adults to control smoking and body weight

• Create awareness to increase physical activity and improve stress management techniques

7. Logical tools for measuring major indicators of Nutrition program:

1. Percentage of new growth monitoring under 1/2 years children =

2. Average number of growth monitoring =

3. Proportion of malnourishedchildren (weight for age)=

4. Iron distribution coverage for pregnant women =

5. Albendazole tab. distribution coverage for pregnant women =

6. Iron distribution coverage for postpartum mother =

7. Vitamin A coverage for post partum mother =

8. Major Achievements : Nuitrition status < 1 years in district:

Above figure shows that percentage of new growth monitoring under 1 years children are decreasing. Especially to emphasize counseling we stopped GM at immunization session and improvement in recording and reporting system brought GM coverage at 60 % in Banke and average number of visit are slightly in increasing trend. There is still problem of conducting quality growth monitoring, regular supply of weight machine , Infrastructure at PHC-ORC clinic and other nutrition activities by the health staffs.

Above figure shows that the distribution of Albendazole to pregnant women are almost same as previous FY but iron distribution to the post partum mother are in decreasing trend due to irregular suplly of iron tablet to the health facility.

Table No.7.1 Health Facility wise Achievements on Child Growth Monitoring

SN Name of Health New Growth Monitoring Average No. of % of Malnourished Facility (%) under 1 year Growth Monitoring Children among new

visit

72 73 74 72 73 74 72 73 74

------

2071 2072 2073 2071 2072 2073 2071 2072 2073 1 Bageswari 98.0 106.4 59.0 1.1 1.2 1 2.1 4.03 0.5

2 Belahari 102.7 182.9 85.0 2.4 2.7 2.9 1.6 0.44 0.0

3 Indarpur 75.7 86.9 104.0 1.1 1.4 5.9 5.8 7.80 9.4

4 Khajurakhurda 90.8 125.3 57.0 2.0 2.2 2.5 4.3 10.61 5.3

5 Radhapur 143.1 140.4 96.0 2.2 4.0 5.4 0.5 0.00 0.0

6 Banakatawa 60.6 77.9 6.0 1.5 1.4 1.6 17.9 12.91 10.3

7 Chisapani 78.3 87.4 75.0 5.8 7.3 4.2 0.6 2.78 0.8

8 Naubasta 149.1 65.9 50.0 1.3 1.0 1 0.4 0.00 4.9

9 Rajhena 92.0 92.8 48.0 1.5 1.9 1.3 2.9 9.09 1.4

10 Titihiriya 91.6 121.8 70.0 3.3 3.2 5.1 9.3 4.12 7.0

11 Kathkuiya 44.3 58.8 57.0 1.8 2.2 1.8 5.9 0.00 13.6

12 Laxmanpur 54.6 66.9 32.0 1.0 1.5 1.6 2.6 3.54 0.0

13 Gangapur 65.2 186.8 85.0 1.4 1.5 1.4 16.6 15.76 8.2

14 Matahiya 174.3 109.1 110.0 2.2 4.5 4.2 28.7 33.86 4.7

15 Belbhar 77.6 135.8 81.0 2.2 1.1 1 12.1 0.00 2.9

16 Hirminiya 99.2 84.1 68.0 1.3 1.9 1.7 2.7 7.56 7.9

17 Jaispur 17.0 98.3 53.0 1.0 1.4 1.1 13.0 11.50 6.3

18 Paraspur 47.1 62.7 57.0 2.4 2.2 2.2 0.0 0.00 0.0

19 Piparhawa 56.1 53.8 172.0 2.0 1.6 2 16.6 22.58 25.2

20 Saigaun 149.7 72.9 50.0 4.2 4.9 4.8 7.6 3.45 1.0

21 Kachanapur 32.9 87.4 67.0 1.4 1.2 2.3 4.0 13.93 3.4

22 Khaskusma 86.4 177.4 35.0 1.2 1.6 2.8 0.7 3.27 0.0

23 Mahadevpuri 139.0 87.9 80.0 2.6 5.0 6.4 1.0 1.90 1.6

24 Kalaphata 90.6 270.7 159.0 1.1 1.0 1 6.5 7.50 3.4

25 Narainapur 171.7 265.9 70.0 1.3 1.1 1.3 2.2 1.53 0.8

26 Basudevapur 134.2 146.4 109.0 2.3 4.1 5.4 8.3 8.09 3.6

27 Kamdi 179.7 118.8 49.0 2.4 4.0 5.5 6.0 4.44 0.7

28 Khaskarkado 89.4 99.5 32.0 3.0 2.2 1.8 3.7 1.51 6.1

29 Nepalgung 52.5 34.7 27.0 1.7 1.1 1.5 2.0 7.71 2.4

30 Puraini 131.4 97.8 95.0 2.5 1.4 3.7 5.2 6.11 1.9

31 Bejapur 131.9 38.7 79.0 2.5 6.3 3 1.4 0.00 0.5

32 Binauna 79.3 48.2 65.0 3.7 6.6 3.7 5.8 1.08 17.0

33 Phattepur 94.1 94.1 123.0 1.0 1.0 1.3 6.4 9.58 7.3

34 Ganapur 139.9 125.1 46.0 1.2 1.3 4.7 14.9 18.69 12.9

35 Kohalpur 64.4 90.0 42.0 1.4 1.3 1.2 0.9 0.12 0.0

36 Manikapur 66.2 94.9 29.0 1.0 1.0 1 2.9 3.67 1.2

37 Shamsergunj 66.7 150.8 47.0 1.0 1.0 1.1 0.0 0.00 0.0

38 Raniyapur 43.0 105.9 60.0 1.5 1.0 1 2.5 3.83 0.9

39 Sitapur 72.8 66.4 39.0 4.1 1.6 1 1.1 8.78 3.8

40 Sonpur 67.1 103.5 79.0 1.1 1.4 2.9 9.0 0.00 1.1

41 Udharapur 81.7 115.5 26.0 1.3 1.3 2 1.5 3.90 2.5

42 Banakatti 70.4 82.0 79.0 3.8 3.2 4.5 24.2 7.49 0.7

43 Betahani 93.3 70.6 61.0 3.8 2.6 1.9 2.2 4.93 7.5

44 Bhawaniyapur 87.7 109.9 133.0 4.1 2.3 1.6 0.0 0.00 0.0

45 Holiya 43.5 61.2 71.0 1.8 1.3 1.5 2.2 3.82 0.8

46 Puraina 171.3 100.0 134.0 11.9 20.4 10.3 0.0 0.00 0.0

47 Udayapur 161.1 162.0 169.0 3.5 3.3 2.8 19.8 3.43 4.3

District Total 88.2 93.2 60.0 2.1 2.3 2.7 5.6 5.98 4.3

Table No.7.2: Health Facility wise Achievements on Pregnant Women and Postpartum Mother Iron and Albendazole tablet distribution:

Iron Supplimentation Albendazole distributed SN Post Natal Women to pregnant Women pregnant Women Name of receiving 45 iron VDC/Health

Facility

72 73 72 73 74 72 73 74

------

2071 2072 2073/74 2071 2072 2073 2071 2072 2073 1 Bageswari 145.7 107 108.4 145.7 107.4 108.4 24.4 26.4 17.3 2 Belahari 129.7 172 89.0 129.7 171.7 89.0 10.8 26.4 4.0 3 Indarpur 97.8 89 115.3 95.6 81.9 115.3 23.2 13.6 26.8 4 Khajurakhurda 93.1 104 80.1 93.1 102.8 80.1 76.6 3.5 0.0 5 Radhapur 66.7 96 78.7 74.3 88.9 78.7 30.5 30.6 31.5 6 Banakatawa 101.4 93 97.3 101.8 95.0 97.3 26.3 27.0 20.0 7 Chisapani 87.3 62 88.0 87.3 68.7 88.0 20.1 2.2 0.6 8 Naubasta 79.8 66 64.9 79.8 65.9 64.9 24.7 10.7 9.9 9 Rajhena 79.4 76 74.6 71.8 91.1 74.6 206.6 0.3 0.0 10 Titihiriya 88.9 78 96.8 89.4 78.1 96.8 53.5 42.1 41.9 11 Kathkuiya 141.7 248 151.1 112.1 200.8 151.1 90.9 95.8 101.1 12 Laxmanpur 123.0 110 109.8 119.1 109.9 109.8 63.8 105.8 104.9 13 Gangapur 128.5 172 116.7 128.5 171.8 116.7 61.5 91.6 67.7

14 Matahiya 122.1 168 208.6 171.6 204.2 208.6 87.0 98.2 64.1 15 Belbhar 37.2 19 94.7 43.9 23.9 94.7 40.5 37.2 42.7 16 Hirminiya 115.6 154 117.2 112.1 102.4 117.2 79.0 70.2 79.4 17 Jaispur 150.7 237 179.7 150.7 217.6 179.7 77.8 245.0 117.6 18 Paraspur 97.1 100 111.5 97.1 100.0 111.5 3.6 0.8 0.0 19 Piparhawa 78.5 158 112.7 68.4 157.8 112.7 51.3 56.9 34.1 20 Saigaun 94.4 154 93.9 94.4 141.1 93.9 62.2 78.3 42.3 21 Kachanapur 61.3 88 105.1 62.7 83.0 105.1 27.4 31.3 39.0 22 Khaskusma 31.7 98 69.5 31.7 97.7 69.5 21.1 45.9 25.5 23 Mahadevpuri 95.9 87 93.1 90.0 87.3 93.1 47.5 41.3 53.2 24 Kalaphata 105.0 192 221.2 106.7 189.6 221.2 108.3 71.9 74.3 25 Narainapur 166.1 183 109.9 175.7 182.7 109.9 229.6 235.5 114.1 26 Basudevapur 65.4 90 87.3 69.6 98.2 87.3 1.0 3.6 0.6 27 Kamdi 97.8 120 101.4 97.1 100.8 101.4 40.1 40.1 42.4 28 Khaskarkado 101.1 93 99.1 101.1 82.1 99.1 8.8 0.0 0.0 29 Nepalgung 91.7 62 63.6 116.2 49.6 63.6 2.1 2.5 2.7 30 Puraini 88.4 122 114.4 88.4 124.1 114.4 31.2 50.0 33.3 31 Bejapur 118.1 64 94.7 156.2 69.7 94.7 73.0 50.8 58.9 32 Binauna 88.5 75 94.9 88.5 61.5 94.9 71.3 51.8 66.9 33 Phattepur 107.1 94 98.2 107.1 95.9 98.2 90.5 91.6 85.1 34 Ganapur 145.5 160 89.4 145.5 160.2 89.4 48.7 112.2 71.3 35 Kohalpur 84.9 88 81.4 84.9 87.7 81.4 21.1 7.2 4.7 36 Manikapur 76.0 85 93.3 77.0 85.5 93.3 32.5 24.2 49.8 37 Shamsergunj 122.9 123 100.0 122.9 122.7 100.0 35.5 43.3 15.7 38 Raniyapur 90.5 138 111.9 106.5 138.3 111.9 107.0 79.2 59.6 39 Sitapur 96.1 80 108.1 96.1 78.7 108.1 36.3 20.9 28.6 40 Sonpur 179.0 188 146.9 260.5 202.7 146.9 74.7 89.9 63.7 41 Udharapur 86.0 129 106.6 86.0 132.3 106.6 34.2 53.8 31.3 42 Banakatti 91.3 165 133.0 93.2 164.8 133.0 15.0 1.6 20.9 43 Betahani 148.3 156 133.9 138.3 131.4 133.9 87.2 114.2 107.6 44 Bhawaniyapur 97.9 130 131.3 97.9 123.1 131.3 82.9 86.8 84.8 45 Holiya 106.2 142 84.7 106.2 142.4 84.7 15.9 0.0 19.5

46 Puraina 128.0 149 189.7 128.0 127.6 189.7 84.8 90.3 12.4 47 Udayapur 157.9 200 157.6 182.1 200.0 157.6 131.6 253.5 184.7 District Total 100.1 100 99.3 105.7 96.9 99.3 51.5 37.0 34.6

Table no. 7.3: Vitamin A Campaign FY 2073/74:

S.N. Date of campaign Target 6-59 Number of children Percentage Remarks month children with Vitamin A of children distribution coverage

1. 2073 Kartik month 52150 51386 98.5

2. 2074 baishakh month 52150 47142 90

9. Problem and Constraints:

Problems/Constraints Action to be taken Responsibility

• Lack of quality of growth monitoring and• Work division to health staffs for CHD, DPHO proper counseling to mothers conducting nutrition program. • Irregular and insufficient distribution of• Maintain adequate and timely supply of LMD and CHD Iron Tablet. commodities. • Poor recording and Reporting • Strictly fulfill the norms of nutrition Focal person . Register, update GM service from PHC- HFs incharge ORC at nutrition Register

Chapter-4

COMMUNITY BASED INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESSES (CB IMCI) AND NEWBORN CARE PROGRAM (CB NCP)

1. Background:

Community Based Integrated Management of Childhood Illness (CB IMCI) Program is an integrated package of child-survival interventions and addresses major childhood killer diseases like Pneumonia, Diarrhoea, Malaria, Measles and Malnutrition in 2 months to 5 years children in a holistic way. CB-IMCI also includes management of infection, Jaundice, Hypothermia and counseling on breastfeeding for young infants less than 2 months of age. With the implementation of this package children are diagnosed early and treated appropriately for major childhood illnesses at the health facility and community level. At the community level, Health Workers are the main vehicle of service delivery and FCHV play a key supporting role to increase access to services through counseling and community mobilization.

In 1997, the IMCI program was initiated in Mahottari district as a pilot program. Based on the recommendations from the pilot, it was decided to include a community component, enabling mobilization of community health workers (VHWs and MCHWs) and FCHV to provide CDD, ARI, Nutrition and Immunization services to the community. Eventually, the Community based ARI and CDD (CBAC) program was merged into IMCI in 1999 and was named the Community Based Integrated Management of Childhood Illness (CB IMCI). CB IMCI Program has covered 75 districts by the end of fiscal year 2066/67 (2009/2010). Newborn component was added to CB IMCI in 2004. An integrated package of CBIMCI and CBNCP is being planned and will be implemented as IMNCIfrom 2071/72. The integration process is also being carried out through active support of many external development partners.

2. Vision

• Contribute to survival, healthy growth and development of underfive years children of Nepal.

• Sustain the achievement of MDG 4 beyond 2015.

3. Goal

• To reduce morbidity and mortality among children under five due to pneumonia, diarrhoea, malnutrition, measles and malaria.

4. Targets

• To reduce under five mortality from the current rate of 54/1,000 live births to 38/1,000 live births and infant mortality from the current rate of 46/1,000 live births to 32/1,000 live births by 2015.

• To reduce neonatal mortality from the current rate of 33/1,000 live births to 16/1,000 live births by 2015.

• To reduce morbidity among infants less than 2 months of age.

5. Objectives

• Reduce frequency and severity of illness and death related to ARI, Diarrhoea, Malnutrition, Measles and Malaria.

• Contribute to improved growth and development.

6. Strategy

The following strategies have been adopted by CB IMCI program

1. Improving knowledge and case management skills of health service providers

CB IMCI aims to improve the knowledge and skills of health service providers through:

• Training on integrated management of childhood illnesses including follow up and onsite coaching for improved performance;

• Regular integrated review and refresher trainings to health service providers emphasizing on recent updates in CBIMCI protocols;

• Technical support visit from higher levels to respective institutions; central to regional to district to HFs to FCHVs

• Capacity building training to the CB IMCI focal persons of the districts

• Inclusion of CB IMCI component in the curriculum of pre service medical and paramedical schools

2. Improving overall health systems

• Carry out CB IMCI program maintenance activities as per the recommendations made by IMCI technical working group

• Improve logistic supply of key commodities.

• Ensure transferred and new health workers are skilled in CBIMCI program

• Regularize community based activities of FCHV and outreach clinics including reactivating health mother’s group meeting.

• Strengthen supervision and monitoring of the program within regular integrated supervision

• Strengthen recording and reporting system of the CBIMCI program at all levels.

3. Improving family and community practices

• Disseminate key behavioral message through FCHVs, outreach clinics and health facilities to individuals, families and communities using localized IEC materials.

• Reach the disadvantaged and hard to reach communities through reactivated and socially inclusive health mothers’ group and planned outreach clinics.

• Create an enabling environment for practicing key individual and family behaviors through continuous advocacy and social mobilization for child health promotion at national, district and community level

7. Major components of CB IMCI

1. Management of sick children below 2 months of age

Health service providers assess each case and classify into following categories (one or more) according to IMCI protocol.

• Possible Severe Bacterial Infection (PSBI)

• Local Bacterial Infection (LBI)

• Jaundice

• Hypothermia

• Low weight or feeding problem

Based on the classification they manage the cases following the IMCI protocol. They also mention whether the case was treated by Cotrimoxazole and/or Gentamycin (for infection) and refer to the appropriate facility if needed.

2. Management of sick children 2 months to 5 years of age a) Management of Acute Respiratory Infection (ARI): The Ministry of Health and Population (MoHP) recognizes Acute Respiratory Infection (ARI) as one of the major public health problems in Nepal among children less than 5 years of age. CB IMCI Program follows WHO guidelines (IMCI Protocol) on standard ARI case management. Accordingly, all cases of ARI assessed by health workers should be classified into one of the following categories:

 • Severe pneumonia or Very severe disease

 • Pneumonia

 • No pneumonia (cough and cold)

The program recognizes the important role of mothers and other caretakers in identifying the difference between the need for home care and for referral to health facilities. Therefore all healthworkers should be able to communicate the necessary information effectively to mothers and caretakers. b) Management of Diarrhoeal Diseases: Diarrhoea is still a leading killer disease in Nepal. CB-IMCI program intensely focuses on management of diarrhoeal diseases among the under-five year’s children. Standard diarrhoea case management with Oral Rehydration Therapy (ORT), continued feeding and Zinc tablet have been providing in the health institutions. All health facilities and community health volunteers have been serving as the primary health service providers in the treatment of diarrhoea with low osmolar oral Rehydration Solutions (ORS) and Zinc supplementation.

The targets of important components of the CB-IMCI program were achieved by 100 percent in three consecutive fiscal years. c) Zinc Supplementation: Zinc tablet in the treatment of diarrhea was introduced in FY 2062/63 as a pilot program in two districts of Nepal (Rautahat and Parbat). The scaling up of the program was completed in 2066/67.

8. Logical tools for measuring major indicators of CDD and ARI program:

1. Annual Incidence of Diarrheaper 1000 =

2. Percentage of some dehydration =

3. Percentage of severe dehydration =

4. Annual Incidence of ARIper 1000 =

5. Percentage of pneumonia among new cases=

6. Percentage of severe pneumonia among new cases=

1. Analysis of CB-NCP Service:

Table no.9: Management of below 2 Months Cases The status of the under two month’s cases registered at health facilities as shown below:

Indicators and Classification 2070/71 2071/72 2072/73 2073/74

Percentage of under 2 months case registered 1.8 out of total case 2.3 2.8 2.5

Percentage of possible sever bacterial 12.4 infection(PSBI) 17.6 14.6 9.7

Percentage of local bacterial infection(LBI) 44 44 49 49

Percentage of Jaundice 1.5 2.2 3.5 2.4

Percentage of treatment by Cotrimoxazole 48.4 47.1 45.5 43.7

Percentage of treatment by Gentamycin 20.4 11.2 9.2 10.8

Above table shows that, the percentage of total under 2 month case registered in health facility is in decreasing trend and the percentage of PSBI cases is increasing trend.

Fig. 8.1 : Indicators of CDD program:

The above diagram shows that the incidence of diarrheal diseases and percentage of severe dehydration remains slighlty in decreasing trend as compared to previous F/Y. Even though incidence of diarrheal disease is still more, it may be due to poor personal hygiene and environmental sanitations. People are ignoring about the sanitation importance, but want to visit health facilities if they suffer.Percentage of children treated by ORS and Zinc is still less than 100% in this FY. This is due to irregular suplly of zinc tab. Table No 8.1: Health Facility wise CDD Indicators for F/Y 2070/71 to 073/074

CDD SN Health Facility Incidence of Diarrhoea /1000

2070-71 2071-72 2072-73 2073-74

1 Bageswari 577 569 596 369.6

2 Belahari 805 1550 2218 1144.4

3 Indarpur 488 487 534 669

4 Khajurakhurda 234 610 430 314

5 Radhapur 2270 1066 930 651.7

6 Banakatawa 655 610 486 441.4

7 Chisapani 267 294 253 351.1

8 Naubasta 451 405 256 271.9

9 Rajhena 235 336 313 225

10 Titihiriya 617 748 890 739.8

11 Kathkuiya 264 290 226 128.2

12 Laxmanpur 1096 808 560 522

13 Gangapur 1070 994 992 1230.1

14 Matahiya 1002 780 546 734.8

15 Belbhar 1170 1065 950 983.8

16 Hirminiya 742 593 616 447.7

17 Jaispur 861 930 844 1099.7

18 Paraspur 887 1500 982 934.6

19 Piparhawa 876 810 687 792.9

20 Saigaun 989 886 583 495.5

21 Kachanapur 505 892 927 1001.2

22 Khaskusma 1464 1254 1234 777.8

23 Mahadevpuri 1090 903 644 488.5

24 Kalaphata 1134 1115 714 657.3

25 Narainapur 1972 1270 1071 517.7

26 Basudevapur 589 548 545 594.1

27 Kamdi 662 504 396 341.5

28 Khaskarkado 625 888 637 688.1

29 Nepalgung 3 234 168 122

30 Puraini 1264 1386 1049 1053.5

31 Bejapur 1564 1638 1527 1408.8

32 Binauna 708 505 414 470.2

33 Phattepur 516 514 500 539.7

34 Ganapur 1249 700 801 583.8

35 Kohalpur 456 394 309 300

36 Manikapur 357 470 312 283.5

37 Shamsergunj 755 586 511 417.3

38 Raniyapur 1268 1016 734 685.7

39 Sitapur 1176 889 810 762.6

40 Sonpur 917 776 706 665.2

41 Udharapur 561 362 420 499

42 Banakatti 678 681 554 633.9

43 Betahani 405 411 167 249.5

44 Bhawaniyapur 1270 919 791 1040.5

45 Holiya 1318 1031 632 916.5

46 Puraina 1625 2118 1778 2252.6

47 Udayapur 1442 933 622 440.3

District Total 667 673 573 515

. Fig. 8.2: Indicators of ARI program:

The above table shows that there is decreasing trend of new ARI cases and almost same in percentage of pneumonia and severity of Pneumonia among new cases which shows that delay referral/arrival of ARI cases from community.

Table No 8.2: Health Facility wise ARI Indicators for F/Y 2070/71 to 073/74 ARI Programme

ARI SN Health Facility Incidence of ARI /1000

2070-71 2071-72 2072-73 2073-74

1 Bageswari 949 879 616 388

2 Belahari 554 842 1699 1222

3 Indarpur 755 521 574 676

4 Khajurakhurda 1297 1609 1223 1145

5 Radhapur 1483 1126 1013 581

6 Banakatawa 693 800 591 546

7 Chisapani 916 529 707 707

8 Naubasta 643 502 406 408

9 Rajhena 384 389 369 303

10 Titihiriya 967 1208 918 1098

11 Kathkuiya 430 225 166 104

12 Laxmanpur 1044 1049 538 446

13 Gangapur 904 931 1055 1139

14 Matahiya 1006 698 512 587

15 Belbhar 1024 1063 925 1058

16 Hirminiya 958 802 691 639

17 Jaispur 1227 1234 853 1330

18 Paraspur 1885 1913 1331 1503

19 Piparhawa 949 885 570 857

20 Saigaun 1031 879 448 421

21 Kachanapur 829 1190 1089 845

22 Khaskusma 2666 1329 1084 1104

23 Mahadevpuri 1408 1168 745 567

24 Kalaphata 1097 1402 762 678

25 Narainapur 2278 1563 969 483

26 Basudevapur 454 524 459 769

27 Kamdi 714 605 550 463

28 Khaskarkado 1385 1351 1073 1104

29 Nepalgung 8 165 144

30 Puraini 2356 2068 1495 1801

31 Bejapur 1054 764 700 769

32 Binauna 714 727 444 667

33 Phattepur 635 563 466 653

34 Ganapur 1111 741 503 1139

35 Kohalpur 435 526 453 334

36 Manikapur 558 842 270 432

37 Shamsergunj 1314 1122 905 837

38 Raniyapur 1751 1729 690 634

39 Sitapur 1325 1234 1391 1323

40 Sonpur 1228 936 784 650

41 Udharapur 539 404 379 475

42 Banakatti 668 883 739 897

43 Betahani 860 623 214 365

44 Bhawaniyapur 993 1039 838 1392

45 Holiya 3182 1790 1288 1470

46 Puraina 2186 2433 2100 3002

47 Udayapur 1839 1726 795 537

District Total 855 820 636 719

8.3Problem and Constraints:

Problems/Constraints Action to be taken Responsibility

• All diahoreal cases not get treated by• Follow Treatment Protocol. • In-charge and Health ORS and Zinc. • Insure regular and timely supply of zinc and workers. ORS • DPHO • Severity of pneumonia among ARI is• Training for untrained HWs and refresher for• CHD, DPHO and HF In- less than 1 % in district but in some trained staff. charge. HF has higher than 1%. • Inadequate supportive • Improve integrated supportive supervision• DPHO Supervision and monitoring in all levels and improve supportive feedback system by systematic planning.

Chapter-5 Safe Motherhood and Newborn Health

Table no. 9.1 : palika wise performance :

s.n

palika

protocal

remarks

per per protocal

SBA delivery SBA

preganat woman who who woman preganat

Instituational delivery Instituational

had four ANC check as as check ANC four had

% of % of who woman % preganat of who woman % preganat of

had at least one ANC check ANC one least at had had first ANC check as per per as check first ANC had 1 baijanath 85 64 51 18 19

2 kohalpur 123 72 35 56 235 KMC

3 raptisonari 99 77 47 60 62

4 Narainapur 133 96 51 77 80

5 Duduwa 102 78 57.7 53 52

6 Nepalgunj 128 68 47 250 253 bheri & NMC

7 janiki 101 78 51 26 26

8 khajura 109 83 62 36 35

Table no. 9.1 shows safe motherhood program's overall performance. Institutional delivery of kohalpur municipality and Nepalgunj sub-metropolitan seems extremely higher due to locating referral hospital kohalpur nursing Home at kohalpur and Nepalgunj Medical collage and Bheri Zonal Hospital at nepalgunj sub-metropolitan Overall all palika's ANC 1 (any time) is above 100% except baijanath. that’s indicates HFS weighted but their result is far away having lowest achievement in Instituational delivery. that’s indicates us to improvement on service delivery ,

Table 9.2 : HFs wise achievement of ANC 1 (any time) :

Source: HMIS Banke

Table 9.3: HFS WISE PERFORMANCE OF ANC1 (as per protocol ) and Institutional delivery:

S.N HFs ANC 1 as protocal Institualtion delivery

1 57 BANKE 75.3 126.7

2 BAGESWARI 78.3 17.3

3 BANAKATAWA 71.5 25.3

4 BANAKATTI 62.1 21.4

5 BASUDEVAPUR 82.3 0.0

6 BEJAPUR 78.9 58.9

7 BELAHARI 83.8 0.0

8 BELBHAR 85.5 47.3

9 BETAHANI 90.6 107.6

10 BHAWANIYAPUR 117.2 19.2

11 BINAUNA 70.7 66.9

12 CHISAPANI-BANKE 59.3 0.0

13 GANAPUR 76.6 67.0

14 GANGAPUR 82.8 67.7

15 HIRMINIYA 79.8 73.8

16 HOLIYA 72.6 0.0

17 INDARPUR 79.9 0.0

18 JAISPUR 143.1 133.3

19 KALAPHANTA 146.0 74.3

20 KAMDI 83.8 42.4

21 KANCHANAPUR 73.4 40.1

22 KATHKUIYA 99.5 97.8

23 KHAJURAKHURDA 59.6 0.0

24 KHASKARKADO 60.7 0.0

25 KHASKUSMA 78.7 37.6

26 KOHALPUR 84.3 4.0

27 LAXMANPUR 121.3 104.9

28 MAHADEVPURI 82.3 54.5

29 MANIKAPUR 67.2 46.8

30 MATAHIYA 83.2 41.4

31 NARAINAPUR 71.4 105.2

32 NAUBASTA 53.2 9.9

33 NEPALGUNJ MUNICIPALITY 45.4 444.3

34 PARASPUR 67.6 0.0

35 PHATEPUR 77.2 86.7

36 PIPARHAWA 88.9 0.0

37 PURAINA 160.0 0.0

38 PURAINI 64.9 31.5

39 RADHAPUR 74.2 31.5

40 RAJHENA 48.8 626.9

41 RANIYAPUR 92.2 64.8

42 SAIGAUN 83.1 45.5

43 SAMSERGANJ 94.2 22.0

44 SITAPUR-BANKE 91.0 25.7

45 SONAPUR-BANKE 80.8 54.7

46 TITIHIRIYA 78.5 41.9

47 UDARAPUR 83.6 28.9

48 UDAYAPUR-BANKE 151.8 182.4

1. Background The goal of the National Safe Motherhood Program is to improve the maternal and neonatal health through preventive and promotive activities as well as by addressing avoidable factors that causes complications of 76

pregnancy and childbirth. Evidences suggested that three delays are of critical importance to the outcomes of an obstetric emergency in Nepal’s context: (i) delay in seeking care, (ii) delay in reaching care, and (iii) delay in receiving care. To reduce the risks associated with pregnancy and childbirth and address factors associated with mortality and morbidity three major strategies have been adopted in Nepal: • Promoting birth preparedness and complication readiness including awareness raising and improving the availability of funds, transport and blood supplies. • Encouraging for institutional delivery. • Expansion of 24‐hour emergency obstetric care services (basic and comprehensive) at selected public health facilities in every district. Since its initiation in 1997, the Safe Motherhood Program has made significant progress. Service coverage has grown along with the development of policies and protocols. For example, role of service providers such as skilled birth attendants (SBA) has expanded. The policy on skilled birth attendants endorsed in 2006 by MoHP specifically identifies the importance of skilled birth attendance at every birth and embodies the Government’s commitment to training and deploying doctors and nurses/ANMs with the required skills across the country. Similarly, endorsement of revised National Blood Transfusion Policy 2006 is also a significant step towards ensuring the availability of safe blood supplies in the event of an emergency. Nepal almost achieved MDG 5 of improving maternal health as the maternal mortality ratio (MMR) dropped from 850/100,000 live births in 1990 to 258 in 2015. Significant progress has been made on reducing mortality and improving health.The total fertility rate of women aged 15-49 dropped from 4.1 children in 2000 to 2.3 in 2016. The proportion of pregnant women having antenatal check-ups by a skilled provider increased from 28 percent in 2000 to 84 percent in 2016. The proportion of births in health facilities increased from 9 percent in 2000 to 57 percent in 2016 while the proportion of births attended by a skilled provider increased from 11 percent in 2000 to 58 percent in 2016. This all led to the large drop in the MMR from 850/100,000 live births in 1990 to 258 in 2015. In order to ensure focused and coordinated efforts among the various stakeholders involved in safe motherhood and neonatal health programming, government and non government, national and international, the National Safe Motherhood Plan (2002 2017) has been revised, with wide participation of partners. The revised Safe Motherhood and Neonatal Health Long Term Plan (SMNHLTP 2006 2017) includes recent developments not adequately covered in the original plan. These include: recognition of the importance of addressing neonatal health as an integral part of safe motherhood programming; the policy for skilled birth attendants; health sector reform initiatives; legalization of abortion and the integration of safe abortion services under the safe motherhood umbrella; addressing the increasing problem of mother to child transmission of HIV/AIDS; and recognition of the importance of equity and access efforts to ensure that most needy women can access the services they need. The SMNHLTP identifies the following goal, purposes and outputs.

2. Strategies Following strategies have been taken to achieve the goals of safe motherhood program:

1. Promoting inter sectoral collaboration by ensuring advocacy for and commitments to reproductive health, including safe motherhood, at the central, regional, district and community levels focusing on poor and excluded groups;

▪ Ensuring the commitment to SMNH initiative at all levels by promoting collaboration between sectors like health, education, and social welfare, legal and local development. (Strengthening RHSC, RHCC, District RHCC and SMNSC)

▪ Mobilizing national authorities, District Health Management Committee (DHMC), community leaders and community members to play active roles in creating suitable environment for promoting safe motherhood.

2. Strengthening and expanding delivery by skilled birth attendant, basic and comprehensive obstetric care services (including family planning) at all levels. Interventions include the following:

• Developing the infrastructure for delivery and emergency obstetric care.

• Standardizing basic maternity care and emergency obstetric care at appropriate levels of the healthcare system;

• Strengthening human resource management;

• Establishing functional referral system and advocating for emergency transport systems and funds from communities to district hospitals for obstetric emergencies and high risk pregnancies;

• Strengthening community based awareness on birth preparedness and complication readiness through FCHVs, increasing access of all relevant maternal health information and service.

3. Supporting activities that raise the status of women in society;

4. Promoting research on safe motherhood to contribute to improved planning, higher quality services, and more cost effective interventions.

3. Major Activities

The major activities of safe motherhood program are as follows-

• Birth Preparedness Package and MNH Activities at Community Level

• Rural Ultra Sound Program

• Uterine Prolapse

• Human Resource

• Emergency Referral Fund

• Safe Abortion Services

• Aama Program

4. Targets:

• To reduce MMR from 281/100000 in NDHS report 2006 to 134/100000 by 2nd long term health plan 2017.Reduce, by 2030, the global maternal mortality ratio to less than 70 per 100,000 live births. (SDGs)

• To reduce NMR from 33 /1000 to 15 by 2nd long term health plan 2017.Reduce preventable deaths of newborn and children to less than 1 percent (SDGs).

• To increase delivery by health workers from 18% to 60% by 2017.Raises the proportion of births attended by SBAs to 90 percent (SDGs).

• Increase institutional deliveries to 90 percent and provide post-natal care for 90 percent of mothers(SDGs).

Table no.9.4: Major Service outlets of Safe Motherhood Program in Banke district in FY 2073/74

S.N. Service type Number of Service sites

1. CEOC sites 3

2. BEOC sites 3

3. Birthing sites 31

5. Safe abortion sites (only medical abortion) 10

6. Safe abortion sites( both medical and surgical) 11

7. Adolescents friendly health facilities 13

Table no. 9.5: Details of these service outlets:

S.N. Birthing Center BEOC Sites CEOC sites Safe Abortion Safe Adolescents Remarks Sites( only Abortion friendly medical Sites ( both health abortion) medical & facilities surgical abortion)

Banakatawa Bheri Zonal Kachanapur Bheri Zonal Bejapur HP 1 Phattepur HP PHC Hospital HP Hospital

2 Bejapur HP Laxmanpur Bageshori Westren Shamsergunj Bankatawa 79

PHC Hospital HP PHC PHC

Nepalgunj Phattepur HP Medical Laxmanpur Collage, Bageshori 3 Betahani HP PHC Nepalgunj Phattepur HP PHC

Laxmanpur Bankatawa 4 Saigaun HP Sonpur HP PHC PHC

Marie Stops Titihiriya HP 5 Hirminiya HP Gangapur HP Kohalpur

Kachanapur 6 Sonpur HP Udayepur HP HP

Nepalgunj Shamsergunj Medical HP Collage, 7 Narainapur HP hirminiya HP Kohalpur

Kohalpur Sonpur HP Mahadevpuri Health Care 8 HP titiriya HP Pvt. Kohalpur

Mid- Sitapur HP Westren Policlinic, 9 Binauna HP naubasta HP Nepalgunj

Health Care Bageshori Research PHC Center, 10 Gangapur HP raniyapur HP Nepalgunj

Nepal Family Kamdi HP Planning Association, 11 Kamdi HP Banke

Basudevpur 12 Kalaphata HP HP

Institutional Clinic 13 Kathkuiya HP Nepalgunj

14 Kachanapur HP

15 Titihiriya HP

16 Udharapur HP

17 Jaispur HP

18 Khaskusma HP

19 Shamsergunj HP

20 Udayapur HP

21 Naubasta HP

22 Radhapur HP

23 Sitapur HP

24 Matahiya HP

25 Raniyapur HP

26 Belbhar HP

27 Ganapur HP

28 PurainiHP

29 Manikapur HP

30 Kohalpur HP

31 Bankatti HP

• Logical tools for measuring major indicators Safe mother hood program:

1. ANC 1st visit as % of expected live birth=

2. ANC 4th visit as % of expected live birth =

3. ANC 4th visit as % of ANC 1st visit =

4. Delivery conducted by SBA as % of expected live birth =

5. PNC 1st visit as % of live birth=

• Analysis of Safe Motherhood Program:

Fig-9.1: Achievement on safe motherhood program by District level:

Above figure shows that ANC 1st visit as percentage of expected live births is increased in this FY as compared to previous FY but ANC 1st visit as protocol has been decreased in this FY which shows that awareness has been increased among pregnant women for ANC visit but quality service and counseling should be improved for increasing 1st and 4th ANC visits as protocol. As well as delivery conducted BY SBA has decreased from last year which is due to irregularity of health staffs in birthing centers and low human resources but the number of delivery sites and focused community awareness programs has been increasing.

Table no. 9.6: Health facility wise achievement on Safe Motherhood Services:

SN Health Facility INDICATORS

Delivery Conducted by SBA ANC 4 visit as % of Expt. Live (HFs+Home) as % of Exp. Live Birth

Birth

71 72 74 71 72 74

------

2072/73 2072/73

2070 2071 2073 2070 2071 2073

1 Bageswari 72.1 73.3 55.9 56.9 29.2 26.7 26.4 17.3 2 Belahari 48.1 40.5 95.3 43.4 0.0 0.0 0.0 0 3 Indarpur 44.0 33.8 25.6 43.5 0.0 0.0 0.0 0 4 Khajurakhurda 47.0 53.8 66.2 57.3 0.0 0.0 0.0 0 5 Radhapur 55.2 54.3 58.3 59.6 29.5 30.5 22.2 31.5 6 Banakatawa 37.4 35.7 43.3 54.9 30.4 23.0 27.4 24.1 7 Chisapani 32.6 32.8 41.9 36.5 0.0 0.0 0.0 0 8 Naubasta 31.7 44.8 43.4 48.8 7.7 9.4 12.2 9.9 9 Rajhena 22.9 27.2 32.1 20.4 0.0 689.2 477.6 126.6 10 Titihiriya 38.4 56.2 53.3 59.1 37.0 52.5 47.9 43 11 Kathkuiya 83.9 53.0 90.0 80.4 60.1 97.0 120.8 84.2 12 Laxmanpur 0.0 89.5 46.3 68.9 33.1 75.7 109.1 104.9 13 Gangapur 82.8 35.2 87.8 55.2 47.3 65.9 109.9 67.7 14 Matahiya 59.1 46.2 56.5 27.3 38.4 38.0 57.7 41.4 15 Belbhar 55.2 39.9 44.2 56.5 27.6 30.4 61.1 47.3 16 Hirminiya 43.4 56.0 57.1 43.4 79.5 92.6 125.6 79.4 17 Jaispur 80.3 46.9 107.6 72.5 46.0 77.8 245.0 133.3 18 Paraspur 58.4 50.7 60.5 41.7 0.0 0.0 0.0 0 19 Piparhawa 42.1 17.7 104.3 92.9 0.0 0.0 0.0 0 20 Saigaun 68.5 75.6 86.0 53.1 61.4 74.4 83.7 45.5 21 Kachanapur 27.1 25.5 46.9 57.6 25.9 36.3 36.6 40.1 22 Khaskusma 52.2 43.7 53.4 48.2 39.6 43.7 43.6 39.7 23 Mahadevpuri 69.6 82.6 71.8 79.7 47.3 53.4 50.8 54.5 24 Kalaphata 51.4 14.2 44.8 46 100.7 104.2 63.5 69 25 Narainapur 114.4 78.3 124.5 38 131.4 229.6 267.3 105.2 26 Basudevapur 42.0 38.2 41.6 38 0.0 0.0 0.0 0 27 Kamdi 60.0 55.2 70.0 74.5 35.7 42.6 47.3 41.7 28 Khaskarkado 20.3 44.8 29.4 37.9 0.0 0.0 0.0 0 29 Nepalgung 3.1 34.8 18.3 36.8 0.0 567.3 331.8 439 30 Puraini 34.5 23.7 44.4 39.6 12.2 28.3 51.9 31.5

31 Bejapur 43.2 68.7 51.7 49.2 54.1 83.6 55.2 58.9 32 Binauna 51.8 29.9 26.2 31.8 50.0 71.3 52.3 46.5 33 Phattepur 51.2 27.1 36.1 28.7 78.2 90.7 100.0 86.7 34 Ganapur 26.7 72.1 112.2 58 10.8 43.5 117.1 67 35 Kohalpur 24.4 35.8 26.9 41 0.0 0.0 2.0 4 36 Manikapur 60.8 57.6 38.4 47.2 0.0 0.7 26.1 46.8 37 Shamsergunj 53.5 65.4 61.6 55.6 11.5 37.4 47.8 22 38 Raniyapur 39.3 25.9 72.1 62.7 21.9 52.7 79.2 64.8 39 Sitapur 50.0 65.2 49.8 58.6 24.6 36.3 18.9 25.7 40 Sonpur 40.5 72.1 116.5 69 64.8 67.8 88.3 62 41 Udharapur 54.2 45.7 67.3 65.8 36.9 33.9 40.6 28.9 42 Banakatti 14.1 5.8 71.2 32.4 0.0 0.0 1.6 21.4 43 Betahani 56.3 73.9 107.1 72.8 80.2 82.2 146.2 107.6 44 Bhawaniyapur 83.6 56.4 41.8 53.5 0.7 0.0 0.0 24.2 45 Holiya 64.8 53.3 31.2 60 0.0 0.0 0.0 0 46 Puraina 115.9 100.0 100.0 106.2 3.6 0.0 0.7 0 47 Udayapur 88.4 74.7 160.6 109.4 85.7 137.9 243.7 182.4 District Total 48.1 46.0 48.1 49.5 100.8 125.6 118.0 100.1

Table no.9.6 shows the 4 ANC Check up coverage AND delivery conducted by SBA . Twenty two HFS have less than 50 % 4 ANC check up coverage and Four HFS have more than 80 % coverage

Table no. 9.7: Achievement of Safe Motherhood services Activities: Neonatal Maternal Mortality Safe Abortion Care in Post Abortion Care Mortality Ratio Fiscal Year Ratio per 100000 live number in number per 1000 live birth birth 2070/71 3094 754 23 146 (22) 2071/72 1280 325 22 186 (22) 2072/73 1669 394 26 114 (14) 2073/74 2203 208 4 121( 15)* (*source= MPDSR , Banke only) Table no.9.8: Number atnd type of Cases treated and refer on uterine prolapsed/obstetric Fistula Screening Camp conduction in FY 2073/74:

A. List of screening cases:

S.N. Screening Site Total

Client

degree

PID/STI PID/STI

surgery st

Refer toRefer

Remarks

3 treatment

ringpessary

Women with Women

No. women of withobs.fistula 1 Baijapur 129 2 4 6 94 0 11 5 2 Betahani 39 3 2 4 30 0 9 4 3 Belvar 30 3 2 6 19 8 6 4 Udharapur 27 3 2 3 19 0 2 3 5 Kalaphata 31 5 2 4 20 0 11 2 6 Raniyapur 46 2 1 3 40 6 3 totals 302 18 13 26 222 0 47 23

Problem and Constraints: Problem and Action to be Taken Responsible Constraints

• 4 ANC visit low • Actively mobilize FCHVs • HFs In-charges among the 1st ANC • Timely follow-up ANC cases through • Service providers visit FCHVs • Service providers • Detect high risk cases and timely refer in appropriate HFs. • Improve quality of counselling • Knowledge and Skill • Onsite coaching and timely feedback by In- • HFs In-charges is lacking in some charges. • DPHO, FHD, Local Service Providers • Shared updated matters and issues which NGO/INGO discussed in HFs level monthly meeting. • District Supervisors • Strengthen knowledge and skill by clinical • HFOMC/Region and update and manage quarterly base RH review Center level • Need base supportive supervision • Quality of 24 hour • Motivate HWs always ready to provide • HFs Birthing center need service( Medicine, sterilize equipments, other incharges/HFOMC/VDC to be improved management) • VDC/DDC/DPHO/FHD • Manage sufficient Nursing staffs and • VDC/DDC/DPHO/FHD/ supportive staff to run 24 hrs. Delivery Management Division services (Minimum 2 Nsg. Staff with • VDC/DDC/FHD Supportive staffs in every shift.) • Regularly manage necessary equipments, medicine and recording and reporting tools. • Infrastructure need to be improved with staff quarter.

Early marriage and Community awareness • VDC/DDC/FHD frequent marriage especially in madhesi and muslim society