HEALTH FOR LIFE PROJECT ANNUAL REPORT
JULY 1, 2016 TO JUNE 30, 2017
JULY 31, 2017 (revised September 18, 2017) This publication was produced for review by the United States Agency for International Development. It was prepared by RTI International. HEALTH FOR LIFE PROJECT ANNUAL REPORT
July 31, 2017
Contract AID-367-C-13-00001
Prepared for , COR Office of Health USAID/Nepal P.O. Box No. 295 U.S. Embassy, Maharajgunj Kathmandu, Nepal
Prepared by RTI International 3040 Cornwallis Road Post Office Box 12194 Research Triangle Park, NC 27709-2194
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The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government. CONTENTS List Of Figures ...... iv List of Tables ...... iv Abbreviations ...... v Background ...... 4 A. Accomplishments And Intended Outcomes For The Period ...... 5 Objective 1: Improve health systems governance of district offices and sub-district-level facilities ...... 5 Objective 2: Develop and implement national evidence-based policy ...... 12 Objective 3: Strengthen national-level stewardship of the health sector ...... 16 Objective 4: Institutionalize nationwide system for quality improvement ...... 18 Objective 5: Improve capacity of district and local level health workers and community volunteers to deliver high quality FP, MNCH and nutrition services ...... 21 Objective 6: Improve knowledge, behavior, and use of health services among target population . 27 GESI Activites ...... 28 B. Major challenges and constraints faced during the performance period that resulted in delays of achievement of outcomes, if applicable ...... 29 C. Highlights of the internship program as described in Section C.2.8.1D ...... 31 D. Cumulative quantitative monitoring and evaluation data, including information on progress towards targets and explanations of any issues related to data quality ...... 33 Capacity-building benchmarks ...... 33 Performance Management Plan ...... 37 Performance Plan Reporting (PPR) Indicators ...... 43 Crosscutting Indicators...... 45 E. Information on the status of finances, including expenditure data based on the budget and accruals, as well as, when appropriate, analysis and explanation of cost overruns or high unit cost .. 47 F. Information on management issues, including administrative problems, or problems with beneficiary groups, or implementing partners and what steps or actions were taken to manage these and lessons learned for future ...... 48 G. Anticipated future problems, delays, or conditions that may adversely impact implementation of the project and what measures are in place to deal with these ...... 48 H. Information on security issues, especially as these affect program integrity and safety of beneficiary groups and implementing partner ...... 49 I. Other information, such as new opportunities for program expansion, lessons-learned and success stories, and prospects for the following year’s performance ...... 49 Annexes ...... 50 Annex 1: DoHS Risk Mitigation Action Plan...... 50 Annex 2: Joint Visits ...... 51 Annex 3: Maps and GIS data ...... 54
Health for Life— Annual Report iii LIST OF FIGURES Figure 1.1 Budget Allocation, Release and Expenditure of FY 2016-17 in Priority VDCs/HFs of Demonstration Districts ...... 6 Figure 1.2 Functionality status of HFOMCs in EQ-affected districts ...... 7 Figure 1.3 performance of HFOMCs in EQ-affected districts ...... 7 Figure 1.4 Budget Allocation, Release and Expenditure FY 2016/17 in high-priority VDCs of CORE Districts .... 7 Figure 1.5 Four ANC Visits, as Per Protocol, in High-priority VDCs in Core Districts ...... 8 Figure 1.6 Percentage of Institutional Deliveries in High-priority VDCs in Core Districts ...... 8 Figure 1.7 Utilization of key maternal service indicators in EQ-districts...... 10 Figure 1.8 Modern family planning method use in 10 EQ-districts ...... 10 Figure 1.9 Key health service indicators in EQ-districts ...... 11 Figure 2.1 Average scores for functional components of the data management system at 23 HFs ...... 13 Figure 2.2 Data verification: reports versus records ...... 13 Figure 4.1 Action Plans Implemented by QAWCs from FY 2013-14 to 2016-17 in Core districts ...... 19 Figure 4.3 HF QI action plan implementation status ...... 19 Figure 4.4 Service Readiness of Health Facilities ...... 19 Figure 4.2 Municipalities with HFs Implementing QI in Core districts ...... 19 Figure 4.5 Budget Allocation and Expenditure by Category ...... 20 Figure 4.6 Allocated vs. Expenditure for QI ...... 20 Figure 4.7 Case Study: Quality Improvement in Gotihawa, Kapilvastu ...... 20 Figure 5.1 Percentage of implant use: national vs Mid-Western region ...... 22 Figure 5.2 Implant use by wealth quintile ...... 22 Figure 5.3 percentage of FCHVs in remote areas treating pneumonia ...... 23 Figure 6.1 Percentage of students responding correctly in post-test ...... 27
LIST OF TABLES Table 1.1 Functionality and Performance Assessment Results of HFOMCS in 141 High-priority HFs of Core Districts ...... 5 Table 1.2 Council’s Allocation, Release and Expenditure of FY 2016-17 in High-priority VDCs/HFs of Core Districts ...... 6 Table 1.3 Local resource mobilization by HFOMCs for health services in EQ-affected districts ...... 10 Table 1.4 DHGSTF Allocation & Expenditure for FY 2016-17 in demo districts ...... 12 Table 5.1 CYP in core districts ...... 22
Health for Life— Annual Report iv ABBREVIATIONS AFN Antenna Foundation Nepal MoH Ministry of Health AHW Auxiliary Health Worker MSC Matri Surakshya Chhaki, i.e., misoprostol ANC antenatal care MWDR Mid-Western Development Region ANM Auxiliary Nurse Midwife MWRA married women of reproductive age ARI acute respiratory infection MWRHD Mid-Western Regional Health Directorate ASRH adolescent sexual and reproductive health NCASC National Centre for AIDS and STD Control AWPB annual work plan and budget NCP newborn care package BC birthing center NDHS Nepal Demographic and Health Survey BCC Behavior Change Communication NFCC Nepal Fertility Care Center CAP/R Community Action Promoter/Researcher NFHP Nepal Family Health Program CB-IMCI community-based integrated management of childhood NGO non-governmental organization illness NHEICC National Health Education, Information and CB-IMNCI community-based, integrated management of newborn & Communication Center childhood illnesses NHRC Nepal Health Research Council CBO community-based organization NHSP Nepal Health Sector Program CEONC comprehensive emergency obstetric and neonatal care NHTC National Health Training Center CF Collaborative Framework NSI Nick Simon Institute CH child health NSV non-scalpel vasectomy CHD Child Health Division OPD out-patient department CNCP Chlorhexidine Navi Care Program ORC outreach clinic COFP/C comprehensive family planning and counselling PFM public financial management COP Chief of Party PHA public health analytics CPR contraceptive prevalence rate PHAMED Public Health Administration, Monitoring and Evaluation CTEVT Council for Technical Education and Vocational Training Division D(P)HO District (Public) Health Office PHAT public health analytic techniques DDC District Development Committee PHCC Primary Health Care Center DHGSTF District Health Governance Strengthening Task Force PHCRD Primary Health Care Revitalization Division DoHS Department of Health Services PHD Population Health and Development DPC District Program Coordinator PHO Public Health Office EDP external development partner PMP Performance Management Plan FCHV Female Community Health Volunteer PMTCT prevention of mother-to-child transmission FHD Family Health Division PNC postnatal care FP family planning PPFP post-partum family planning FY fiscal year PPH post-partum hemorrhage GBV gender-based violence PPICD Policy, Planning and International Cooperation Division GESI gender equality and social inclusion PPR Performance Progress Report GIS geographic information system PSC Public Service Commission GiZ German Federal Enterprise for International Cooperation QA quality assurance GON Government of Nepal QACG Quality Assurance Coordination Group HA Health Assistant QAI-TWG Quality Assurance and Improvement Technical Working HCWM health care waste management Group HF health facility QAWC Quality Assurance Working Committee HFOMC Health Facility Operation and Management Committees QAWG Quality Assurance Working Group HFRS Health Facility Readiness Survey QI quality improvement HFQI Health Facility Quality Improvement QITAC Quality Improvement Technical Advisory Committee HMIS health management information system RH reproductive health HP Health Post RHCC Reproductive Health Coordination Committee HR human resources RHD Regional Health Directorate HW health worker RHTC Regional Health Training Center IEC information, education and communications RMNCH reproductive maternal, newborn and child health IFPSC Institutionalized Family Planning Service Centers RTI Research Triangle Institute INGO international nongovernmental organization SBA Skilled Birth Attendant IP infection prevention SIFPO Support for International Family Planning Organizations IPCC interpersonal communication and counseling SIR Strategic Information and Research IRHDTC Integrated Rural Health Development Training Center SLC School Leaving Certificate IUCD intrauterine contraceptive device SMP Safe Motherhood Program JAR Joint Annual Review SNL Saving Newborn Lives KAP knowledge, attitudes and practices SPSS Statistical Package for Social Sciences (data analysis KMC Kangaroo mother care software) LAFPM long-acting family planning methods SRH sexual and reproductive health LDO Local Development Office TA technical assistance LGCDP Local Governance and Community Development Program TOCAT technical and organizational capacity assessment tool LHGS local health governance system TOR terms of reference LHGSP Local Health Governance Strengthening Program ToT training of trainers LMIS logistics management information system TWG Technical Working Group M&E monitoring and evaluation TWG-HIM Thematic Working Group – Health Information M/DAG marginalized/disadvantaged group Management MCH Maternal and Child Health USAID United States Agency for International Development MD Management Division VDC Village Development Committee MICS Multiple Indicator Cluster Survey VHSAR village health situation analysis report MNCH maternal, newborn, and child health WASH water, sanitation and hygiene MNCHN maternal, newborn, and child health and nutrition WCDO Women and Children Development Office MNH maternal and newborn health WDR Western Development Region MoFALD Ministry of Federal Affairs and Local Development WHO World Health Organization
Health for Life— Annual Report v BACKGROUND Health for Life (Health for Life) is a $27.9 million, five-year project working in coordination with the Government of Nepal’s Ministry of Health (MoH) to support the testing and roll-out of national-level policies, guidelines, and programs. In addition to its national focus, the project works at the district level in 14 districts in the Mid- Western and Western regions, where it strengthens district and village health systems and helps identify and implement best practices. After the devastating earthquakes in April and May 2015, Health for Life began supporting the MoH in 10 of the 14 most-affected districts to improve health system governance, improve evidence-based planning, budgeting and policy making, and to institutionalize a national system for quality assurance and improvement. Additionally, in 2015, Health for Life started working in six ‘demonstration districts’ to assist in rolling out local health governance strengthening activities. The primary goal of Health for Life is to strengthen the Government of Nepal’s capacity to plan, manage, and deliver high-quality and equitable family planning, maternal, newborn, and child health services. Health for Life activities directly address key health system constraints in the following areas: local health systems governance; data for decision making and evidence-based policy development; human resources management; quality improvement systems; and knowledge and behavior change. Health for Life collaborates with a wide range of stakeholders, including academic and research institutions, training centers, media partners, and civil society. Health for Life’s objectives are to • Improve health system governance of district health offices and sub-district level facilities • Support development and implementation of national evidence-based policy • Strengthen national stewardship of the health sector • Institutionalize nationwide system for quality improvement • Improve the capacity of district and local health workers and community volunteers to deliver high- quality FP/MNCH and nutrition services • Improve knowledge, behavior, and use of health services among adolescents and marginalized groups This annual report covers the period July 1, 2016, to June 30, 2017. It documents activities conducted during the project’s fourth year. Following Health for Life’s s six objectives, it describes key achievements, analyzes progress and challenges to date, budget and expenditures, and other information. In October 2015, the Health for Life project was expanded to ten of the districts most adversely affected by the April 2015 earthquake. Within the ten districts - Dhading, Dolakha, Gorkha, Kavrepalanchowk, Makwanpur, Nuwakot, Ramechhap, Rasuwa, Sindhuli, and Sindhupalchowk, Health for Life collaborates with a wide range of stakeholders, including USAID-funded projects and projects funded by other EDPs, academic and research institutions, pre-service training centers, media partners and civil society. The project in the 10 earthquake-affected districts has been strengthening the MoH's capacity to coordinate recovery and reconstruction, and plan, manage and restore high-quality family planning, maternal, newborn and child health (FP/MNCH) services. Health for Life activities directly address key health system constraints in the following areas: local health systems governance; evidence-based planning, budgeting and policy making; and quality assurance and improvement at district and sub-district levels. TA to the 10 earthquake-affected districts is also restoring and improving the delivery of MNCH/FP services in selected areas. Near the end of FY 2016-17 federalism took root. The Government of Nepal established 753 rural and urban municipalities, sub-metropolitan and metropolitan cities, decentralizing multi-sectoral authority to them, and held elections for mayors and deputy mayors in six of the seven provinces. Consequently, Health for Life reorganized its staffing in Core and earthquake-affected districts by transferring staff formerly assigned to districts to municipal headquarters. Municipalities that included high-priority VDCs and their health facilities became high- priority municipalities including high-priority Wards and their health facilities. In FY 2017-18, Health for Life will prioritize 157 municipalities in 24 districts and support the Social Health Security Program in Chitwan, Jhapa, Kailali and Kaski, formerly demonstration districts.
Health for Life—Annual Report 4 A. ACCOMPLISHMENTS AND INTEN DED OUTCOMES FOR THE PERIOD
OBJECTIVE 1: IMPROVE HEALTH SYSTEMS GOVERNANCE OF DISTRICT OFFICES AND SUB-DISTRICT-LEVEL FACILITIES 1.1 HFOMC HOLD HEALTH PROVIDERS ACCOUNTABLE FOR DELIVERY OF SERVICES BY BETTER MOBILIZING AND MANAGEMENT OF LOCAL RESOURCES HEALTH FACILITIES IN HEALTH FOR LIFE DISTRICTS HAVE FUNCTIONING AND PERFORMING HFOMCs A total of 92 percent (130 out of 141) of Health TABLE 1.1 FUNCTIONALITY AND Facility Operation & Management Committees PERFORMANCE ASSESSMENT RESULTS OF (HFOMCs) in Health for Life’s Core districts met all HFOMCS IN 141 HIGH-PRIORITY HFS OF functionality criteria during this annual reporting CORE DISTRICTS period (Table 1.1). For those HFOMCs that did not HFOMC Functionality Criteria Jun 2016 (%) Jun 2017 (%) meet all criteria, the participation of women and Dalit HFOMCs formed according to guidelines/directives 99 98 members in HFOMC meetings seemed to be the HFOMCs meet on regular basis (at most commonly unmet indicator. In Dailekh, Jumla, least quarterly) 99 99.3 Kapilvastu and Surkhet the explanation for this was Meeting scheduled, agenda that Dalit’s and women’s workloads and schedules distributed in advance and minutes conflict with HFOMC meetings. H4L recommends documented 100 98.6 the newly elected Ward Chair include the Dalit and Participation of women and Dalit members in meeting 99 96.5 woman members of the Ward Committee in the Health facilities with the provision HFOMC or successor committee. of health services during regular When excluding the ‘social audit conducted’ hours (10:00 hrs.-15:00 hrs.) 99 99.3 indicator, more than 90 percent of HFOMCs in high- HFOMC Performance Criteria Jun 2016 (%) Jun 2017 (%) priority VDCs met all functionality criteria. Only 105 Provision of expanded health out of 141 high-priority VDCs conducted social services 91.5 92.2 audits this year, six percent less than the previous year Upgraded quality of services 96.4 95.7 (Table 1.1). Health for Life supported the Primary Additional resource mobilization 90.8 92.2 Health Care Revitalization Division (PHCRD) to Active involvement of Dalit and facilitate a two-day social audit training for D(P)HOs women members 93.6 96.5 and social audit focal persons in 28 districts Social Audit conducted 80.9 74.5 (including nine Health for Life Core districts) on the Prepared annual health plan 99.3 100 newly-revised Social Audit Guidelines 2017. Following the training, the PHCRD conducted 352 Source: Health for Life reports; Note that PHCRD sets targets for Social Audits and schedules. social audits in the 14 Core districts (85 new; 267 follow-up). Ninety-two percent of HFOMCs in high-priority VDCs have expanded health services and 96 percent have upgraded quality of services as shown in the table above. All 141 HFOMCs in high-priority VDCs prepared or updated their Village Health Situation Analysis Reports (VHSARs) and Local Health Plans for FY 2017-18. These health plans were discussed at the ward level and financial commitments were secured from councils in most of the high-priority VDCs. Recent changes in government structures and local elections, however, delayed the annual planning cycle by about 6 months. During this reporting period, a total of NPR 50.6 million (approx. USD 506,000) was allocated by 141 high- priority VDCs based on local health plans and 85 percent of these funds were released. Out of the released funds, 96 percent was spent by HFOMCs. By district, all released funds were spent in Arghakhanchi, Dailekh, Dang, Kalikot and Kapilvastu, and more than 95 percent was spent in Jajarkot, Jumla, Pyuthan, Rukum, Salyan and Surkhet (Table 1.2). In Jajarkot, Jumla, Kapilvastu and Pyuthan districts, more funds were released than committed by the respective councils. In Kapilvastu, HFOMCs in high-priority VDCs were able to leverage more resources upon receiving
Health for Life—Annual Report 5 TABLE 1.2 COUNCIL’S ALLOCATION, RELEASE additional funds for the newly-formed AND EXPENDITURE OF FY 2016-17 IN HIGH- municipalities (refer to section B), whereas in PRIORITY VDCS/HFS OF CORE DISTRICTS Jajarkot, Jumla and Pyuthan, funds were Allocated Released Spent released through the districts to address health District FY 2016-17 FY 2016-17 FY 2016-17 plans that needed immediate attention, such 3,039,000 2,096,000 2,096,000 Arghakhanchi as 2,962,000 2,283,000 1,955,000 Banke construction of an immunization center in 6,536,000 5,970,000 5,311,000 Bardiya Pyuthan and support for an ambulance and 7,691,000 3,235,000 3,235,000 Dailekh essential health commodities in Jumla. 4,191,000 3,266,000 3,266,000 Dang* In the six Demonstration districts, a total of 2,178,000 2,382,000 2,322,000 Jajarkot NPR 47.9 million (approx. USD 479,000) was 1,583,000 1,898,000 1,864,000 Jumla* allocated. Seventy-five percent of the allocated 2,716,000 2,331,000 2,331,000 Kalikot funds were released, out of which 95 was 2,598,000 6,394,000 6,394,000 Kapilvastu spent (Figure 1.1). 1,954,000 2,228,000 2,188,000 Pyuthan The total number of sanctioned clinical 3,237,000 2,872,000 2,419,000 Rolpa positions in high-priority VDCs in Core 4,166,000 2,543,000 2,489,000 Rukum districts increased from 734 in June 2016 to 3,189,000 2,955,000 2,950,000 801 in June 2017. Out of this total, 92 percent Salyan 4,593,000 2,742,000 2,738,000 (n=735) of positions were filled by the Public Surkhet Service Commissions (permanent positions) Total NPR 50,633,000 43,192,000 41,558,000 or by the government (short-term contracts) Total USD 506,000 432,000 416,000 in FY 2016-17 compared to 72 percent the * Dang and Jumla districts are also Demonstration districts Source: Health for Life Reports year before. In addition, the District Development Committees (DDCs), VDCs and FIGURE 1.1 BUDGET ALLOCATION, RELEASE municipalities hired 94 clinical staff in high-priority AND EXPENDITURE OF FY 2016-17 IN VDCs, and a total of 318 clinical staff in all VDCs PRIORITY VDCS/HFS OF DEMONSTRATION in Core districts. DISTRICTS 20,000
CARRY OUT FUNCTIONALITY AND 15,000 PERFORMANCE SELF-ASSESSMENTS AND MONITOR PROGRESS BY ('000) 10,000 HFOMCs IN HIGH-PRIORITY VDCs IN NPR 5,000 CORE AND EQ-AFFECTED DISTRICTS Health for Life continued its efforts to improve - performance and functionality in the original 110 Chitwan Dang Jhapa Jumla Kailali Kaski VDCs in the 10 EQ-affected districts during this reporting period through its technical assistance to Allocated Released Spent D(P)HOs and HFOMCs. In Dhading, Gorkha and Ramechhap Health for Life supported the D(P)HOs to revitalize three HFOMCs that had not completed the process in the previous project year. Additionally, during the second half of this reporting period, Health for Life expanded its technical assistance programs to an additional 51 VDCs, and an additional 36 HFOMCs (Dhading-3, Dolakha-4, Gorkha-7, Kavrepalanchowk-2, Ramechhap-5, Rasuwa-4 and Sindhupalchowk-5) were revitalized. PERFORMANCE AND FUNCTIONALITY 159 high-priority VDCs have Development Associates (DAs) and Community Health Assistants (CHAs) deployed in the community who are able to work closely with their respective HFOMCs to improve functionality and performance, and the functionality and performance measure criteria were regularly assessed. The updated HFOMC assessment report from June 2017 showed that 92 percent (n=101) of the initial 110 HFOMCs in the ten EQ-affected districts met all functionality criteria and are fully functional. The functionality of the 51 HFOMCs which were added in the second half of this reporting period was not included in this analysis since the project’s assistance only recently started. However, field staff are continuing to work with these HFOMCs and progress will be reported in the future.
Health for Life—Annual Report 6 FIGURE 1.2 FUNCTIONALITY STATUS OF Similarly, assessments of performance of the HFOMCs IN EQ-AFFECTED DISTRICTS original 110 HFOMCs in the ten EQ-affected districts in June 2017 show that 86 percent (n=94) 100 of HFOMCs met all five performance measure 80 60 criteria. Because the quota of social audits set by 40 the government was unknown during the HFOMCs 20 of reporting period, Health for Life decided to 0 exclude social audits from this assessment. A
Percent summary of HFOMCs performance is presented Met all 5 criteria below. Regular meeting Minutes held documented Formed as per guidelines STRENGTHENING HFOMCs Presenence of Provision Women/Dalit of regular services The HFOMCs in every Health for Life high- priority VDC in the 10 EQ-affected districts Result as of June 2016 Result as of July 2017 played a key role in updating Village Health FIGURE 1.3 PERFORMANCE OF HFOMCs IN Situation Analysis Reports, preparing Village EQ-AFFECTED DISTRICTS Health Recovery Plans and mobilizing local resources to increase access and utilization of 100 services. The result has been that PHC/ORC and 80 EPI clinics in all Health for Life high-priority 60 VDCs were made functional through the support HFOMCs 40
of 20 of field staff, and Health Mothers' Groups in all 0 high-priority VDCs have been revitalized as well. D(P)HOs reported that H4L staff have helped Percent regularize PHC/ORC and EPI clinic operations in Met all criteria Health for Life-supported VDCs in the EQ- Quality improvement Resource mobilization Health services expansion Leadership demonstarted affected districts. Participation of women/Dalit The majority of activities planned to strengthen Result as of June 2016 Result as of June 2017 the capacity of HFOMCs in the 10 EQ-districts were implemented as stipulated in the annual work FIGURE 1.4 BUDGET ALLOCATION, RELEASE plan, with only a few exceptions, as detailed in AND EXPENDITURE FY 2016/17 IN HIGH- Section B. PRIORITY VDCs OF CORE DISTRICTS 20,000 1.2 LOCAL HEALTH GOVERNANCE 15,000 STRENGTHENED TO REDUCE
('000) 10,000 INEQUALITIES OF ACCESS AND USE OF HEALTH SERVICES IN NPR 5,000 HEALTH FOR LIFE DISTRICTS -
Others LEVERAGE MORE LOCAL Equipment Infrastructure Child health RESOURCES THROUGH THE 14-STEP FCHV Program Family Planning Human Resources Safe motherhood PLANNING PROCESS, INCREASE Quality improvement Medicine & Supplies ACCESS TO AND USE OF QUALITY Allocated Released Spent SERVICES IN HIGH-PRIORITY VDCs IN CORE, EQ-AFFECTED AND DEMONSTRATION DISTRICTS Health for Life focused its technical support on supporting HFOMCs to produce evidence-based health plans and to submit those health plans to the councils through ward-level discussions as a way to leverage more local resources for quality improvement and service delivery. During this reporting period, high-priority VDCs in the Core districts spent a total of. NPR 41.5 million (approx. USD 415,000) on health-related activities (Figure 1.4). Health facility service registers in the 141 high-priority VDCs show that the average number of 4 ANC visits, as per protocol, increased in Bardiya, Dang, Jajarkot, Jumla, Kapilvastu, Pyuthan, Rolpa and Rukum in the first eight
Health for Life—Annual Report 7 1 FIGURE 1.5 FOUR ANC VISITS, AS PER months of the reporting period (Figure 1.5). PROTOCOL, IN HIGH-PRIORITY VDCs IN CORE While the district average for 4 ANC visits DISTRICTS remained at 47 percent in both periods, ANC visits in Dailekh decreased by 36 points. This 100 decline was because only 68 percent of eligible 80 pregnant women completing all 4 ANC visits 60 received cash incentives in FY 2015-16. Other Percentage 40 eligible women did not because funds were yet to 20 be available early in the fiscal year. - Dang Jumla Overall, institutional deliveries increased in high- Banke Bardiya Dailekh Jajarkot Kalikot Puythan Rolpa Rukum Salyan Kapilvastu Surkhet Arghakhachi priority VDCs in all Core districts except Banke, Dailekh, Dang and Salyan. On other hand, 14 Districts average institutional deliveries in high-priority VDCs in Jul 2015 to Feb 2016 Jul 2016 to Feb 2017 Banke, Dailekh and Salyan were higher than the average for all high-priority VDCs. In Dang, the FIGURE 1.6 PERCENTAGE OF INSTITUTIONAL percentage of women delivering in an institution DELIVERIES IN HIGH-PRIORITY VDCs IN CORE was relatively low because a sub-regional hospital, DISTRICTS a zonal hospital and a teaching hospital are located 100 nearby in Banke. 80 CAP/Rs identified, tracked and referred registered 60 pregnant women for institutional delivery and 40 HFOMCs also hired local ANMs to provide 24- percentage 20 hour service delivery at birthing centers. These efforts contributed to significant progress in - institutional delivery in high-priority VDCs/HFs Dang Jumla verage Banke Bardiya Dailekh Jajarkot Kalikot Puythan Rolpa Rukum Salyan A Kapilvastu Surkhet in Jajarkot, Jumla, Kalikot, Pyuthan, Rolpa, Arghakhachi Rukum and Kapilvastu districts (Figure 1.6). Jul 2015 to Feb 2016 Jul 2016 to Feb 2017 Compared to the data from February 2016, the number of family planning users (pills, injectables, IUCDs and implants) have increased in most high-priority VDCs in the Core districts as of February 2017. The increase in the number of implant users was especially significant, mainly due to an increase in trained health workers on long-acting family planning methods and the availability of the required equipment at health facilities.
VILLAGE HEALTH SITUATION ANALYSIS REPORTS Out of the 110 HFOMCs in 108 high-priority VDCs in the 10 EQ-affected districts, every single one prepared Village Health Situation Analysis Reports (VHSARs) and used the evidence from them to prepare VHRPs. This process of engaging community-level groups and authorities and integrating VHRPs into the general local development plans will help VHRPs gain wider recognition and establish health as a priority during the local development planning process. Furthermore, 51 newly-added VDCs also prepared VHSARs. VILLAGE HEALTH RECOVERY PLANS Health for Life focused its support on evidence-based local health recovery planning in 63 high-priority VDCs (health recovery plans in 45 high-priority VDCs were completed in the previous reporting period), working closely with VDCs/municipalities, community-based organizations and the LGCDP’s Social Mobilizers to improve access to and utilization of health services. In the 63 high-priority VDCs that had not completed health recovery plans previously, all HFOMC members, along with FCHVs, local leaders and Ward Citizen Forum members participated in the local health recovery planning process during this reporting period. These Village Health Recovery Plans (VHRPs) focused on restoring health activities to improve coverage, quality, and utilization of health services. A total of 63 VHRPs (Dhading 9, Gorkha 12, Kavre 10, Nuwakot 2, Ramechhap 5, Makwanpur 7,
1 The complete data for June 2017 is yet to be reported, so the comparison of 2 trimesters (July to October and November to February) of each reporting year is provided in this section.
Health for Life—Annual Report 8 Rasuwa 3, Sindhuli 5, and Sindhupalchowk 10) were drafted by the HFOMCs and approved by the respective councils during this reporting period. An additional 36 VHRPs were prepared in the newly-added VDCs.
Health for Life—Annual Report 9 TABLE 1.3 LOCAL RESOURCE MOBILIZATION BY HFOMCs FOR The planning process also HEALTH SERVICES IN EQ-AFFECTED DISTRICTS enables HFOMCs to leverage
% of Commitme Released Expenditure % additional resources for health Category released nt NPR Funds NPR NPR Released activities to increase access to spent and improve quality of health Human Resources 5,494,000 3,278,643 2,628,663 60 80 services. A total of NPR 72,362,614 (USD 723,626) FCHV Program 5,955,136 2,685,044 2,607,744 45 97 Safe Motherhood was allocated for health Program 3,790,715 1,182,715 1,390,315 31 118 services in the 159 high- priority VDCs this reporting Child Health 2,650,430 1,450,430 1,633,430 55 113 period; NPR 44,969,832 Family Planning 112,800 17,800 19,800 16 111 (62%) was released and NPR 41,761,652 (93%) has been Quality Improvement 1,538,300 692,300 629,800 45 91 spent according to the health Infrastructure 34,445,225 22,900,925 20,817,925 66 91 plans. Expenditures may be greater than the amounts Equipment 3,996,853 2,633,820 2,060,820 66 78 released because funds are Medicine & Supplies 984,000 447,000 292,000 45 65 borrowed from other budget line items and later settled. Other 13,395,155 9,681,155 9,681,155 72 100 Total 72,362,614 44,969,832 41,761,652 62 93
DISTRICT HEALTH RECOVERY AND RECONSTRUCTION PLANS Health for Life also provided technical assistance and support to the 10 EQ-affected districts to prepare District Health Recovery and Reconstruction Plans (DHRRPs). DHRRPs were prepared and endorsed by the District Disaster Relief Committee in all 10 of the EQ-affected districts. Following request from MoH, Health for Life has also been providing technical assistance and support to develop DHRRPs in Okhaldhunga, Kathmandu, Lalitpur and Bhaktapur. Health for Life is working closely FIGURE 1.7 UTILIZATION OF KEY MATERNAL with the D(P)HOs from these four districts to SERVICE INDICATORS IN EQ-DISTRICTS develop DHRRPs and will finalize the plans by July 50 2017. The MoH will use the DHRRPs to guide reconstruction activities, as will the newly formed 40 women municipalities.
of 30 OTHER SYSTEMS STRENGTHENING 20 ACTIVITIES 10 During this reporting period, Health for Life percentage 0 provided technical assistance in Dhading, Rasuwa, ANC 4 visit as Institutional PNC ist visit Nuwakot, Sindhuli, Kavrepalanchowk and per protocol delivery within 24 hours Makwanpur for 89 HF In-charges from high- priority VDCs on basic bookkeeping and June 2016 June 2017 accounting training. Similarly, Health for Life provided technical assistance in the preparing FIGURE 1.8 MODERN FAMILY PLANNING calendars of operation in all districts but METHOD USE IN 10 EQ-DISTRICTS Kavrepalanchowk and Gorkha. Lastly, leadership training for HFOMC Chairpersons and HF In- 15000 charges was conducted in Sindhuli.
users There has been a significant reduction in the
of 10000 number of vacant clinical positions over the past year. Compared to June 2016, when only 57.5% of 5000 Number sanctioned clinical posts were filled, 85.4 percent of positions in Health for Life high-priority VDCs in 0 the 10 EQ-affected districts were filled as of June Pills Injectables Implants IUCDs 2017. Hiring clinical staff through local contracts has also increased significantly compared to the June 2016 June 2017 previous reporting period.
Health for Life—Annual Report 10 Health for Life provided technical assistance to D(P)HOs in 10 EQ-affected districts for a one-day workshop for Local Development Officers, Social Development Officers and all Secretaries in Health for Life high-priority VDCs. Local health recovery plans were discussed during these workshops and lobbied to allocate funds through VDCs councils. District Health Governance Strengthening Task Forces were formed and orientated in all 10 EQ-affected districts and these task forces have met at least two times to discuss health issues of the districts.
Health for Life is regularly tracking key health services data through facility registers since July 2016 and they show a significant increase in service utilization by the population in the VDCs where Health for Life is providing technical assistance. Four ANC visits, institutional delivery and first PNC visit within 24 hours have all increased dramatically during this reporting period and are above district averages. Four ANC visits, in particular, grew FIGURE 1.9 KEY HEALTH SERVICE dramatically among Dalit and Janajati women, and INDICATORS IN EQ-DISTRICTS disparities in service utilization by ward have fallen significantly. 50
40 FAMILY PLANNING
30 Use of modern contraceptives including pills, injectable, implant and IUCD has also increased 20 Percent significantly in Health for Life high-priority EQ- 10 affected VDCs compared to a year ago. Health for Life provided support to D(P)HOs and 0 collaborated with the Family Planning Association 4 ANC visits CPR Institutional of Nepal to conduct satellite camps for providing delivery implant and IUCD services. A total of 42 satellite District average H4L high-priority VDCs camps were conducted, with 1,170 implants and 85 IUCDs inserted. The contraceptive prevalence rate (CPR) in Health for Life high-priority VDCs is estimated at 31 percent as of June 2017 more than double the rate in July 2016 (11.7%) and significantly higher than the district average of 18.2 percent. A total of 530 newborns were treated with antibiotics, 12,799 under-five children received treatment for diarrhea and 5,451 children aged 2 months to 5 years received treatment for pneumonia during this reporting period from in high-priority VDCs of the EQ-affected districts. 1.2 LOCAL HEALTH GOVERNANCE STRENGTHENED TO REDUCE INEQUITIES OF ACCESS AND USE OF HEALTH SERVICES IN HEALTH FOR LIFE DISTRICTS LEVERAGE MORE LOCAL RESOURCES THROUGH 14-STEP PLANNING PROCESS, INCREASE ACCESS TO AND USE OF QUALITY SERVICES IN PRIORITY VDCs OF CORE, EARTHQUAKE-AFFECTED AND DEMONSTRATION DISTRICTS VILLAGE HEALTH PLANS ARE PREPARED USING EVIDENCE AND APPROVED BY VILLAGE COUNCILS AS AN INTEGRAL PART OF VILLAGE DEVELOPMENT PLAN All 141 HFOMCs in high-priority VDCs prepared VHSARs and local health plans. The councils committed a total budget of NPR 51.3 million (approx. USD 513,000) for FY 2017-18, except for 3 VDCs in Kalikot and 1 in Rukum. The 3 in Kalikot subsequently allocated funds. Likewise, NPR 38.4 million (approx. USD 384,000) was committed by the councils in 151 priority VDCs in the six Demonstration districts. However, after local elections, the newly-elected municipal assemblies are still in the process of endorsing annual work plans and budgets, and it is yet to be seen how they endorse previous council decisions in regards to health (refer to section B). In this context, Health for Life is providing technical support to the 82 new local government units that previously included the 141 high-priority VDCs to reinforce evidence-based planning to leverage local resources. DISTRICT HEALTH GOVERNANCE STRENGTHENING TASK FORCES (DHGSTFs) ARE FUNCTIONAL AND EFFECTIVE Health for Life coordinated with the DDC’s Social Development Committee and provided technical assistance to form DHGSTFs in all Core and Demonstration districts. DHGSTFs’ prioritize VDCs to receive flexible health grants based on district-based criteria. All thirteen Core districts (except Dailekh) have functional DHGSTFs, and a total of 28 meetings were held during this reporting period. DHGSTF meetings were held three times in
Health for Life—Annual Report 11 Kapilvastu and Kalikot, and twice in the other Core districts. In the Demonstration districts, a total of seven DHGSTF meetings were held—three in Chitwan, two in Kailali and one each in Jhapa and Kaski. The DHGSTF teams visited 11 health facilities in Core districts and five health facilities in Demonstration districts, and encouraged HFOMCs to prepare VHSARs, evidence-based local health plans, and to secure approval from the respective councils through the 14-step planning process. REVIEW AND UPDATE DISTRICT CALENDARS OF OPERATIONS D(P)HOs of all 14 core districts reviewed and updated their District Calendars of Operations, and four Demonstration districts prepared District TABLE 1.4 DHGSTF ALLOCATION & EXPENDITURE Calendars of Operations for FY 2016-17 FOR FY 2016-17 IN DEMO DISTRICTS having health activities of GoN, # HFs DHGSTF receiving allocated amount Expenditure INGOs/NGOs and other stakeholders FHG FY 2016-17 FY 2016-17 working within the district. The primary Districts FY 2016-17 (NPR in '000) (NPR in '000) purpose of this is to consolidate and create Chitwan 16 1,780 1,463 synergy between D(P)HOs and partners’ Dang 33 1,322 1,103 activities. Jhapa 25 1,830 1,720 Jumla 30 1,250 1,250 DHGSTF ALLOCATED Kailali 31 1,890 1,820 RESOURCES RECEIVED BY HFs IN Kaski 16 1,634 1,450 DEMONSTRATION DISTRICTS Total NPR 151 9,706 8,806 Of 308 health facilities (HFs) in the six Total USD 97 88 Demonstration districts, 151 received Flexible Health Grants in FY 2016-17 as a result of Health for Life’s technical assistance on the evidence-based local health planning process. This technical assistance also focused in QI self-assessments, gaps identification, preparation of action plans and addressing gaps through available resources. In FY 2016-17, Management Division provided a total of NPR 10 million (approx. USD 100,000) to the six Demonstration districts in the form of Flexible Health Grants. Ninety-seven percent of funds were allocated to 151 VDCs/HFs through DHGSTF meetings based on district-specific criteria. The remaining funds were used for monitoring and supervision of planned activities. By the end of June 2017, 91 percent of released funds had been spent (Table 1.4).
OBJECTIVE 2: DEVELOP AND IMPLEMENT NATIONAL EVIDENCE-BASED POLICY 2.1 GUIDELINES DEVELOPED AND IMPLEMENTED FOR NATIONAL AND REGIONAL PERFORMANCE REVIEW MEETINGS OF MOH PROGRAMS (A FRAMEWORK FOR ANALYSIS) IMPROVE HMIS USING EVIDENCE FROM HMIS DATA QUALITY ASSESSMENTS IN CORE AND EARTHQUAKE-AFFECTED DISTRICTS
Health for Life—Annual Report 12 Health for Life continued working with the Public Health Administration, Monitoring and Evaluation Division (PHAMED) of the Ministry of Health (MoH) and other partners supporting the health sector (including WHO, GIZ, DFID/NHSSP) to institutionalize the Routine Data Quality Assessment (RDQA) process. The tool, which was adapted for Nepal in July of 2016 was piloted in Nuwakot in January 2017. Health for Life provided technical support in piloting, reviewing and updating the tool, and implemented it in selected facilities in high-priority VDCs between April and June 2017. RDQA IN CORE DISTRICTS Altogether, Health for Life staff visited 23 health facilities in Core district high-priority VDCs to carry out RDQAs. District teams composed of a D(P)HO focal person(s) and Health for Life staff together with the HF In-charge carried out the assessment in each facility. During the process, staff were interviewed and data was verified for four indicators covering the period of November 2016 to March 2017 (second trimester FY 2016-17). A debriefing session was held after the assessment to share the findings with HF staff, HFOMC members and the QI team. In addition, an action plan was prepared based on identified issues with timelines and responsibilities. One major aspect of the RDQA is data management, where five components were observed through several indicators. Indicators were labelled ‘completely met,’ ‘partially met,’ ‘not met at all’ and ‘not applicable.’ For each category, average scores were measured and a spider diagram was prepared (Figure 2.1). The results of data verification show that observed values in facility records fell within 10 percent of the reported values across all four indicators. Of the four indicators, current FP users was seven percent over-reported and diarrhea treated with ORS and zinc was one percent over-reported. 4 ANC Visits as per Protocol and Pneumonia Treated with Antibiotics were underreported by three percent and six percent, respectively. Based on these results, 76 areas of improvement were planned. The most common area of improvement was error and inconsistencies in data recording; 45 percent of (34 out of 76) issues were related to data error, incomplete data entries, the unavailability of forms or a lack of formal training on its use. Another area with frequent issues was a lack in data verification; 22 percent (17 out of 76) of issues were related to the lack of a proper system of data validation and verification. Data variations were discovered at a majority of facilities when checking registers, monthly progress reports, tally sheets and monthly monitoring sheets. RDQA IN EQ-AFFECTED DISTRICTS During this reporting period, at the request of the Child Health Division and together with PHAMED, Health for Life provided technical support in developing tools and guidelines on use of the RDQA tool followed by a workshop on its use. A total of 14 health facilities in four EQ-affected districts (Dhading, Gorkha, Nuwakot, Rasuwa) were visited to carry out the RDQA, in coordination with a D(P)HO focal person(s), and Health for Life staff together with the HF In-charge. During the process, staff were interviewed and data verification was conducted for four different indicators. Findings compiled during the RDQA were shared with the respective health workers, including D(P)HO staff and other stakeholders with the goal of improving data quality, preparing action plans, and to inform immediate onsite coaching to minimize errors and increase data quality in the future.
FIGURE 2.1 AVERAGE SCORES FOR FUNCTIONAL COMPONENTS OF THE DATA FIGURE 2.2 DATA VERIFICATION: MANAGEMENT SYSTEM AT 23 HFs REPORTS VERSUS RECORDS
120 106 103 99 100 93
80
% 60
40
20
0 FP current user- 4 ANC visit as Pneumonia Diarrhoea cases Depo per protocol treated with treated with antibiotic ORS and zinc
Health for Life—Annual Report 13 As in the Core districts, the assessment showed that some data were over-reported (FP Current User-Depo) by 10-15 percent and some were underreported (Diarrhea Treated with ORS and Zinc) by 10 percent, whereas, Pneumonia Cases Treated with Antibiotics matched exactly in most health facilities. TECHNICAL SUPPORT TO PHAMED ON UPDATING DISTRICT PERFORMANCE EVALUATION CRITERIA AND INDICATORS Health for Life supported PHAMED in developing/updating evaluation criteria, indicators and guidance that will be used for annual district and municipal health performance evaluations and rankings. At a workshop this past June, participants from MoH and partners documented evaluation processes carried out so far, finalized indicators for evaluation and refined definitions of some indicators. The MoH’s district performance evaluation was completed using 35 key indicators from 18 areas including program, logistics, financial management, planning, reporting, remoteness and internal evaluations. PROVIDE FEEDBACK TO DISTRICTS AND VDCs FOR IMPROVEMENTS BASED ON FINDINGS FROM ANNUAL PERFORMANCE REVIEWS USING STANDARD PHAT CHECKLIST IN CORE AND EARTHQUAKE-AFFECTED DISTRICTS Health for Life continued its technical assistance to the D(P)HOs and Regional Health Directorates for district- and regional-level Annual Review Meetings in this reporting period and to prepare presentations and manage meetings. We also conducted assessments of the District Annual Review Meetings using the Public Health Analytics Tool (PHAT), sharing feedback among stakeholders to improve the review process. The KEY FEATURES OF NHRC’s NEW WEB assessment revealed that the annual reviews of seven PORTAL districts were categorized as “model” (Kapilvastu, Rukum, Dang, Banke, Surkhet, Dailekh and Kalikot), More user-friendly design with accessibility features for - and four districts’ annual reviews were categorized as people with visual and auditory impairment “progressive” (Arghakhanchi, Pyuthan, Rolpa and - More access to information about NHRC management, interactive figures, research activities and capacity Jajarkot). The remaining three districts were classified as development program. “acceptable.” - Integrated platform for users to access the online Additionally, Health for Life actively provided technical application system for ethical clearance, online assistance to the D(P)HOs of all 10 earthquake-affected journal management system and digital library. districts during district review meetings. Health for Life - Dedicated pages for research ethics to inform public about NHRC’s regulatory functions including IRCs location maps also provided technical assistance to the Central and contacts. Regional Health Directorates’ office during the regional - FQAs, news, updates, useful links review meeting. The data was shared with respective stakeholders for evidence-based planning and decision making by the D(P)HO and Regional Directorates’ Office. 2.2 NHRC PRIORITIZES, OVERSEES AND REGULATES RESEARCH BASED ON ESTABLISHED PRACTICE OF HEALTH SECTOR PLANNING AND BUDGETING UPLOAD 300+ ABSTRACTS ON NHRC’S WEB PORTAL FOR PUBLIC ACCESS Health for Life continued its support of the Nepal Health Research Council (NHRC) in building capacity for research networking and knowledge management during this reporting period. The health research consultant provided by Health for Life reviewed abstracts to check publication dates and prepared to upload them to the current NHRC webpage for public access in November 2016. A total of 254 final abstracts, categorized into priority areas, were uploaded and are publicly available at http://nhrc.gov.np/priority-area. STRENGTHEN NHRC’S KNOWLEDGE MANAGEMENT CAPACITY THROUGH UPGRADED WEB PORTAL (TO MAKE IT MORE ACCESSIBLE TO ITS RESEARCH NETWORK PARTNERS) An important aspect of the support provided to the NHRC to enhance its knowledge management capacity was to develop their web portal, combining various previous systems. Health for Life hired Rooster Logic, a
Health for Life—Annual Report 14 Kathmandu-based firm, in January 2017 that worked closely with the NHRC to upgrade systems. The work was completed following a series of consultative meetings and technical reviews between the NHRC and Health for Life staff. Secretary of the Ministry of Health officially launched the new web portal (http://nhrc.gov.np/) in a function held at NHRC on June 25, 2017. TECHNICAL SUPPORT TO HEALTH MANAGEMENT INFORMATION SYSTEMS (HMIS) ON DATA QUALITY Health for Life continued working with the DoHS, Management Division, and HMIS and was successful in developing program-specific data validation rules for its DHIS-2 HMIS database for the major program components including child health, reproductive health, disease control, hospitals/OPDs, HIV/AIDS and the TB program. ORIENTATION ON NEPAL DHIS 2 TO THE PARTNERS WORKING IN HEALTH SECTOR IN NEPAL The Ministry of Health formally launched Nepal DHIS 2 as the official HMIS database on November 17, 2016. While orientation for D(P)HO and hospital staff on the new system was carried out by the HMIS unit, Health for Life, in coordination with the HMIS unit, organized a one-day orientation for USAID partners working in the health sector (Suahaara/HKI, Linkages/FHI360, Jhpiego, JSI, etc.) in December 2016. The orientation provided a general overview of basic functions, how to share reporting, use of the dashboard and provided a demonstration so that partners can use data from the new systems.
Health for Life—Annual Report 15 TECHNICAL SUPPORT TO HMIS FOR ANNUAL TARGET TIMELY RELEASE OF TARGET ESTIMATES ESTIMATE The HMIS section circulated its annual target Each year, the DoHS requires population estimates by age for estimates for FY 2017-18 to all districts on the each program component at VDC/municipal levels and district first day of the beginning of the fiscal year. The level. Given the recent restructuring of local governance units, task of estimating annual targets was carried out estimates were adjusted and recalculated accordingly. These by Health for Life’s subcontractor, OPM, and population estimates are provided to each program division, approved by the Ministry of Health on July 13, 2017. It was circulated to the districts the center and municipality, and health facilities across the country following day, marking the first time the where they are used to set program-specific targets, to design estimates were available from the first day of general and the targeted program interventions and in monitoring the fiscal year. and evaluation of programs. At the request of the Management In addition, guidelines to estimate the target Division, DoHS, Health for Life has provided support to the population were developed by OPM that will HMIS section in estimating annual targets for districts and health be used by the HMIS section to estimate annual facilities for FY 2016-17 and projected targets for the next five targets in the coming years. years.
OBJECTIVE 3: STRENGTHEN NATIONAL-LEVEL STEWARDSHIP OF THE HEALTH SECTOR 3.1 MOH’S NEXT NEPAL HEALTH SECTOR STRATEGY (2016-2021) DEVELOPED IN COLLABORATION WITH EDPs AND TECHNICAL ASSISTANCE PROGRAMS TECHNICAL ASSISTANCE TO STRENGTHEN NATIONAL LEVEL STEWARDSHIP OF THE HEALTH SECTOR The Nepal Health Sector Strategy (2015-2020) has provided a framework to achieve the country’s goal of providing a basic package of quality health services to all of its citizens free of cost. In this context, Health for Life’s support is important for the development of national stewardship of the health sector. Health for Life support is particularly useful in developing local health governance, evidence-based planning, efficient use of available resources and strengthening the overall health system. Health for Life hired an expert technical advisor to support the MoH to advance the following policy initiatives: • Supported the Honorable Health Minister and high-level committees of MoH • Supported senior officials of the MoH/GoN to roll out national-level policies, guidelines and programs • Supported the Honorable Health Minister to strengthen the following five health system priority areas
NATIONAL HEALTH BILL, 2017 Health for Life provided technical assistance to National Health Bill Drafting Committee to develop National Health Bill, 2017 which aims at ensuring the rights of people to access and utilize quality health services as provisioned in the constitution of Nepal. The final draft is under review by the Ministry of Law and Justice and other line ministries for their feedback. Draft is attached. NEPAL HEALTH INSTITUTION QUALITY ASSURANCE AUTHORITY Technical assistance was provided in the preparation and finalization of draft document to improve quality of care at all health facility levels. This act also aims at establishing an autonomous accreditation unit within the Council. The final draft is under review by the Ministry of Law. POLICY ON PUBLIC PRIVATE PARTNERSHIP IN HEALTH SECTOR (STATE AND NON-STATE PARTNERSHIP POLICY) A draft that was originally prepared by the Ministry of Health in 2013 has been finalized and will be shared with the National Planning Commission and Ministry of Finance. Technical Assistance was provided during the process. Draft is attached. TRANSITION MANAGEMENT PLAN IN THE FEDERAL CONTEXT The Ministry of Health under the leadership of the Policy, Planning and International Cooperation Division (PPICD) is working on a transitional and long-term plan for positioning health in the federal governance system. The newly-formed Health Federalization Implementation Unit at the MoH will coordinate all activities and monitor the implementation of the activities with regard to the federal system. Technical Assistance was provided to the Honorable Minister and various technical committees.
Health for Life—Annual Report 16 Ministry of Health identified coordination among interested organizations and partners supporting federal health system as a huge issue. Risks and opportunities need to be identifying while changing to a federal system. Based on this, a systematic plan with a timeline is required for immediate, midterm and long term activities. It is a high priority of the Secretary of Health. POLICY FRAMEWORK FOR THE ESTABLISHMENT, OPERATION AND MONITORING OF URBAN HEALTH PROMOTION CENTERS The approved budget was sent to 10 Urban Health Promotion Centers through the PHCRD, DoHS. Several meetings were held to develop the following documents: • TOR for Training manual/package development, • TOR for Implementation Guidelines • Ward-level periodic Plan for Urban Health Promotion Centers • TOR to develop SOP and Urban Health Promotion Centers
Staff recruitment has been finalized in Janata Swasthya Kendra and the D(P)HO of Kathmandu has started work. Establishment of Urban Health Promotion Centers should be linked with the structuring of the federal health system. ENSURE TIMELY AND APPROPRIATE DISBURSEMENT, IMPLEMENTATION AND REVIEW OF USAID-SUPPORTED “REDBOOK" FUNDS BY EMBEDDING LONG-TERM PUBLIC FINANCIAL MANAGEMENT (PFM) ADVISOR TO THE DOHS Health for Life provided support to the DoHS and facilitated the design, preparation and organization of regional workshops on public financial management (PFM) in five regions. A total of 257 Office In-Charges and Account Officers from all districts and regions working under the DoHS were trained and updated/sensitized on the requirements and procedures of public procurement, clearance of audit irregularities and budget authorization and release systems. The workshops also included updates on USAID audit issues and its reimbursement modality. Following recent amendments, Health for Life reviewed and updated the training manual on public financial management for printing and distribution during regional workshops. In coordination with the Finance Sections and other respective Divisions/Centers of the DoHS and USAID, Health for Life provided technical support in planning and budgeting for FY 2017/18, especially for USAID reimbursement contributions. Preparation of activities and a budget sheet description for the work plan and budget of USAID’s Implementation Letter (IL) is in its final stage. However, addressing the USAID reimbursement grant allocated to municipality level activities, which would be beyond the scope of USAID contribution to MoH/DoHS, is a pending issue. Several rounds of meetings with the respective Divisions and USAID have already been initiated, and resolutions to the issue, including reallocation by transferring funding sources of some activities to cover USAID grants, were discussed. Health for Life supported, coordinated and facilitated the USAID audit of FY 2015-16 by conducting three joint field visits with DoHS officials and USAID commissioned auditors in Arghakhanchi, Baitadi, Dadeldhura, Darchula, Gulmi, Kailali, Kapilvastu, Morang and Sunsari. During those joint visits, the DoHS finance team from the Center supported and coordinated the resolution of existing audit queries between D(P)HOs and the USAID commissioned auditors. Health for Life provided support during the USAID commissioned audit of 2015-16 which was successfully completed with few questioned costs, mainly due to intensive follow-up with the D(P)HOs and Divisions/Centers for documentation and justifications, as well as number of meetings with the Auditor and DoHS officials to clarify outstanding audit issues. The submission of a management representation letter from DoHS to the Auditor has also been introduced. Joint monitoring visits in Kailali (Seti Zonal Hospital) and Sarlahi (DHO) were undertaken with DoHS officials to follow-up on the audit findings and provide onsite coaching to resolve audit irregularities raised in USAID’s 2014- 15 audit report. Based on the audit reports, drafts of Risk Mitigation Action Plans (RMAPs) for FY 2016-17 and FY 2017-18 were prepared in consultation with the DoHS finance team and submitted to USAID for action.
Health for Life—Annual Report 17 In addition, three more on-site coaching visits were undertaken jointly with DoHS and USAID officials in five districts (Baitadi, Dhanusa, Kapilvastu, Myagdi and Nawalparasi) with high allocation of USAID reimbursement grant districts in-line with the DoHS RMAP. D(P)HO officials were also oriented on requirements for USAID- funded activities jointly by the DoHS and USAID. Based on information collected from Divisions and Centers and the Financial Administration Section, Health for Life provided assistance in preparing Trimester Reimbursement Claims, financial report and Trimester Progress Reports of activities supported by the USAID reimbursement contributions for FY 2016-17, for submission to USAID. All reports, memos and letters from the Regional Inspector General/Manila and USAID, and the USAID- commissioned audits of USAID reimbursement contributions to the DoHS were compiled and reviewed for the period of FY 1995-96 to FY 2014-15. Questioned Costs were categorized by year and shared with USAID and the DoHS to settle unreconciled items recorded by the Financial Comptroller General Office (FCGO). The compilation sheet of the Questioned Costs has become a useful document for the DoHS while dealing with the FCGO in relation to fund release. 3.2 POTENTIALLY COST-EFFECTIVE STATE/NON-STATE PARTNERSHIPS IDENTIFIED IN HEALTH FOR LIFE DISTRICTS FOR MOH SCALE-UP Health for Life partnered with UNFPA and GIZ to develop an adolescent sexual and reproductive health mobile app based on UNFPA’s existing global platform, Youth Connect. Radio Bahas, conducted in partnership with Antenna Foundation and 14 local radio stations, has been reinstated to positive effect. For more, see Objective 6.
OBJECTIVE 4: INSTITUTIONALIZE NATIONWIDE SYSTEM FOR QUALITY IMPROVEMENT 4.1 CONSENSUS BUILT ON NATIONAL QI SYSTEM AND PILOTED IN SELECTED HEALTH FOR LIFE DISTRICTS FOR MOH SCALE-UP MAINTAIN DISTRICT QAWC BY SUPPORTING D(P)HOs IN CORE DISTRICTS Health for Life continued its support of D(P)HOs to activate and systematize regular Quality Assurance Working Committee (QAWC) meetings by providing technical assistance with setting meeting agendas, developing action plans and supporting their implementation. 41 QAWC meetings were held in the 14 Core districts over the past year, resulting in the successful preparation of 41 action plans. In addition, six meetings were organized specifically for the preparation of an AWPB and/or orientation on the HF QI system. In the course of the project to date, 170 action plans have been prepared, 157 (92%) of which have been implemented. An additional 10 are ongoing, and 3 have not yet been implemented. Throughout the project districts, action plans played a key role in mobilizing a variety of materials and improvements ranging from IP equipment such as autoclaves and stoves to blood pressure sets, scales, and installing water tanks (see following section, HFOMCs/VDCs Allocated Funds for Quality Improvement). HEALTH FACILITY QUALITY IMPROVEMENT With the support of Health for Life, D(P)HOs introduced the HF QI system in 274 HFs (141 high-priority and 133 general VDCs) and 6 IFPSC/MCH clinics in the 14 Core districts. Every one of the 82 municipalities in Health for Life’s 14 Core districts (52 rural, 30 urban) now has at least four HFs in which the QI system has been implemented, with the exception of Nepalgunj Municipality in Banke. Furthermore, out of the 469 birthing centers in the Core districts, 158 have implemented the HF QI system.
Health for Life—Annual Report 18 FIGURE 4.1 ACTION PLANS IMPLEMENTED BY Based on the findings of the QI assessment, the QI QAWCS FROM FY 2013-14 TO 2016-17 IN teams reviewed quality of services in 131 of the CORE DISTRICTS high-priority VDCs. The 10 high-priority VDCs of 100 Surkhet were unable to conduct a review or develop 90 action plans due to a health worker strike in the 80 second trimester. An additional 47 general VDCs in 70 Dang (30) and Jumla (17) also conducted follow percentage 60 ups to the QI assessment, bringing the total 50 number of health facilities that followed up and Banke Dang Jumla Kailali Rolpa Rukum Salyan Bardiya Dailekh Jajarkot Kalikot Puythan Kapilvastu Surkhet submitted QI reports to the QAWC/D(P)HO to Arghakhachi 178. These 178 plans list 484 activities, out of which % action plan implemented 60 percent have been completed, 25 percent are ongoing and 15 percent have not yet been initiated FIGURE 4.2 MUNICIPALITIES WITH HFs due to inadequate resources available to the IMPLEMENTING QI IN CORE DISTRICTS HFOMCs, HFs and QAWCs. 15 A total of 380 readiness assessments were conducted at the 141 HFs in the Core districts in 10 the past year. Based on the latest readiness assessment, the readiness index has increased to 67 Number 5 from a baseline of 41 in FY 2013-14. Major 0 contributors to improvements were the Dang Jumla Banke Dailekh Jajarkot Kalikot Puythan Rolpa Rukum Salyan Bardiya Kapilvastu Surkhet procurement of basic equipment and medicine and Arghakhachi commodities). Urban Municipality Rural Municipality In addition to the progress made in the Core districts, quality improvement also advanced in the FIGURE 4.3 HF QI ACTION PLAN Demonstration districts. In Kailali, Jhapa, Kaski IMPLEMENTATION STATUS and Chitwan, D(P)HOs organized QAWC 100% meetings: three in Kailali and one each in the other 80% districts. Additionally, D(P)HOs introduced the QI 60% system in 26 more Demonstration district HFs and 40% oriented 420 HFOMC members and HF QI team 20% members. All 138 HFs that have been introduced 0% to the QI system developed action plans, with 130 Dang Jumla Rolpa Banke Bardiya Dailekh Jajarkot Kalikot Puythan Rukum Salyan Kapilvastu of them incorporating QI information into their Arghakhachi VHSARs.
Completed Initiated Not initiated HFOMCS/VDCS ALLOCATED FUNDS FOR HF QUALITY IMPROVEMENT FIGURE 4.4 SERVICE READINESS OF HEALTH A key outcome of the QI self-assessments has been FACILITIES that findings have been incorporated into the VHSARs with the result that HFOMCs are more 100 successful in advocating for resources to improve 80 the quality of health services. In the past year, 97 60 percent of VHSARs incorporated information from 40 the QI self-assessments, and VDCs allocated a total percentage of NPR 4,581,800 for improvements to service and 20 readiness in the 14 Core program and four 0 Readiness Basic amenities Basic Infection Medicines and Demonstration districts. Most of this funding went Index equipment prevention commodities to infrastructure improvements, followed by expanding human resources. Expenditure patterns FY 13/14 (Baseline review) FY 16/17 followed budgeting in all categories.
Health for Life—Annual Report 19 These efforts to address gaps in quality have resulted in greater compliance with standards of care, as shown by the follow-up QI self-assessments.
FIGURE 4.5 BUDGET ALLOCATION AND FIGURE 4.6 ALLOCATED VS. EXPENDITURE BY CATEGORY EXPENDITURE FOR QI
16000 5,000 12000 4,000 ('000) 8000 3,000 ('000)
NPR 4000 2,000
0 NPR QI 1,000
Equipment - Child health Infrastructure Family Planning FCHV Program Safe motherhood Dang Jhapa Kaski Human Resources Jumla Rolpa Kailali Banke Medicine & Supplies Salyan Rukum Kalikot Bardiya Dailekh Jajarkot Surkhet Chitwan Pyuthan Kapilbastu Allocated Spent Arghakanchi Allocated Spent
FIGURE 4.7 CASE STUDY: QUALITY IMPROVEMENT IN GOTIHAWA, KAPILVASTU
PROCESS BEFORE H4L: ACTIVITIES: AFTER H4L: -Mobilized local resources -No separate room for ANC/PNC -Revitalized HFOMC and established -FP services provided by satellite -No HFOMC, No QI Team QI Team and VSC outreach -Poor IP/HCWM -Prepared VHSAR and Health Plan -Separate ANC/PNC room and -Low utilization of FP services (CPR IP/HCWM maintained <7%) RESULT
PROVIDED TECHNICAL ASSISTANCE TO MANAGEMENT DIVISION Health for Life technical assistance to the HFD&Q section, MD, yielded the following outcomes: • Finalized the HFD&Q section of the NHSS-IP (QAI activities, IP and HCWM and physical asset management) • The FY 2016-17 National Program Implementation Guidelines were released, and include Health for Life inputs to the PHCC budget (MD allocated NPR 250,000 for QI), the Expenditure Guidelines and the District QA Budget Expenditure Guidelines • Oriented FP supervisors from the Western region on the HF QI system, December 2016 • Oriented over 200 newly-hired medical officers on the HF QI system (January 2017) • The Quality Assurance Authority Act has been revised following inputs from Health for Life and is currently under review for legislation • The HF QI system for family planning services strengthening is being successfully implemented by Support for International Family Planning Organizations (SIFPO) following Health for Life’s technical support to the MD • The QAI TWG moved ahead with development of the QIMIS and the Quality of Care Annual Report
Health for Life—Annual Report 20 • Assisted the MD in coordinating with partners and presenting QI activities carried out by the HFD&Q Section to the QA Steering Committee in December 2016. Health for Life coordinated with the Chief of the HFD&Q Section to update the MD’s existing QI activities in October 2016. Topics included policy and strategy related to quality, structures and functions of the different committees, a progress update, QI monitoring and key challenges. FINALIZATION OF QAI GUIDELINES & TOOLS Health for Life is assisting the process of updating the Quality Assurance and Improvement Guidelines to align with the NHSS-IP, including the implications of federal restructuring. Intended to be a clear and accessible reference document to be used at the HF level, the QI tools represent an important transfer of technology and promise to clarify the process of identifying gaps in quality. Based on what was learned from implementing the HF QI system, Health for Life has made a number of key revisions to the existing QI tools and, at the request of the MD, developed QI tools for malaria, HIV and tuberculosis. In addition to the clinical QI tools, Health for Life developed tools for management (Governance, Finance Management, Information Management and Quality Management) and service readiness (Infrastructure, Amenities, Commodities, Clinical Equipment, Infection Prevention) along with corresponding users’ guides. QUALITY IMPROVEMENT MANAGEMENT INFORMATION SYSTEM The QIMIS, a system of collating and analyzing data on the quality of health services, is under development and will be a key element of the national QI system. Health for Life has been successful in developing a consensus around the need for a QIMIS through ongoing discussions with Divisions, Centers and partners. While some details remain unresolved, there is widespread support for developing and implementing the system at the national level in the coming year. It is expected that the QMIS will be piloted in Health for Life’s districts pending USAID approval. Furthermore, Health for Life successfully lobbied for making the QIMIS the primary information source for all MD (and some CHD) activities in the NHSS-IP. Health for Life is also working with the MD to develop a QI dashboard that will be incorporated into the DoHS website. The QI dashboard will synthesize quality-related information from the HMIS, LMIS, MPDSR, NHFS and NDHS, serving as an interactive tool for program divisions and centers to conduct planning. In the past year, quality of care indicators have been defined, and it is envisioned that QIMIS data will be incorporated into the dashboard once the subcontractor overseeing development and implementation of the QIMIS has been approved by USAID. SUPPORT OF THE HEALTH FACILITY DEVELOPMENT & QUALITY SECTION Because the HFD&Q in the MD does not have adequate human resources to fulfill its scope of work pertaining to quality as outlined in NHSS, Health for Life has been assisting the secretariat in coordinating efforts with Divisions, Centers and external development partners and to carry out QI-related activities, including the QIMIS. This has resulted in developing the QIMIS, QI Tools and a draft of the QAI Guidelines. And as members of the Patient Safety Assessment Committee, Health for Life staff has helped to carry out a national assessment of patient safety and preparation of the report. Dissemination is expected early next year. Work on developing the MD’s first Quality of Care report is ongoing, with Health for Life providing technical assistance to further analyze the data from the 2015 Nepal Health Facility Survey for inclusion in the Quality of Care report. The process of hiring a consultant to conduct said analysis is ongoing.
OBJECTIVE 5: IMPROVE CAPACITY OF DISTRICT AND LOCAL LEVEL HEALTH WORKERS AND COMMUNITY VOLUNTEERS TO DELIVER HIGH QUALITY FP, MNCH AND NUTRITION SERVICES 5.1. COMMUNITY-LEVEL HEALTH INNOVATIONS AND PROGRAMS DELIVERING MNCHN/FP SERVICES SCALED-UP AND MAINTAINED; FCHVs ENHANCED FAMILY PLANNING LAFP SERVICES IN BIRTHING CENTERS Health for Life continued to provide technical assistance to D(P)HOs to expand long-acting family planning (LAFP) services, especially IUCDs and implants, in FY 2016-17. Since the project’s inception, the overall number of HFs in Core districts that have birthing centers (BCs) has grown from 352 to 469, 350 (75%) of which offer at
Health for Life—Annual Report 21 least one form of LAFP services, up from 165 (47%) at the project’s start. During the same period, the percent of service sites in Core districts providing IUCDs rose from 23 to 39, and sites providing implants grew from 23 to 48 percent. Additionally, satellite clinics in six of the Core districts, with support from Health for Life, provided 433 clients (more than 82% from M/DAGs) with LAFP services. Health for Life technical assistance also played a role in significantly increasing service availability in high-priority VDCs. Since the project started in 2013, out of the TABLE 5.1 CYP IN CORE DISTRICTS 141 high-priority VDCs, the number of health Method Quantity CYP Factor Total CYP facilities with a birthing center has grown from 95 Condoms 6,642,122 120 55,351 to 123, 111 (90%) of which offer at least one form Pills 261,884 15 17,459 of LAFP services, up from 58 (61%) at the project’s start. HFs offering IUCD services grew Depo 202,975 4 50,744 from 29 percent in 2013 to 61 percent in 2017, and IUCDs 5,020 5 23,092 HFs offering implant services grew from 19 to 67 Implants 19,988 4 75,954 percent. Sterilization 2,606 13 33,878 These achievements contributed to significant Total CYP (10 months) 256,478 increases in the use of implant and IUCD services in the Mid-Western Region where most of the 10 months target 227,783 Health for Life districts are, as shown in the Achievement against 10-month target (%) 113 following figures. Annual Target 273,340 Health for Life also supported and facilitated voluntary surgical contraception (VSC) preparatory meetings in nine districts, and supported a pre-VSC interaction program in 92 high-priority VDCs aligned with USAID’s Redbook support in a further eight districts. Although the CPR fell short of the target, the CYP for FY 2016-17 is 113 percent for the first 10 months (94 percent of the annual target), which indicates we are likely to achieve annual target. It is interesting to note that implants were the highest contributing factor of all FP methods as of April 2017 (Table 5.1). US ABORTION AND FP REQUIREMENTS Health for Life project has continued to follow US abortion and FP requirements. Monitoring for compliance
FIGURE 5.1 PERCENTAGE OF IMPLANT FIGURE 5.2 IMPLANT USE BY WEALTH USE: NATIONAL vs MID-WESTERN QUINTILE REGION 5
4 use 3
2 implant
% 1
0 NDHS 2001 NDHS 2006 NDHS 2011 NDHS 2016 National Mid-West with US abortion and FP requirements was conducted in 158 HFs during this reporting period. HFs had no set targets or quotas for particular FP methods, did not provide any incentives or financial rewards and informed choice posters were displayed prominently. FP service providers did counseling on all available FP methods and they referred the clients for the methods that were not available in their facility. No women were excluded from other services for not accepting FP. The performance of service providers was monitored by supervisors and no incentive were offered based on the number of clients served. SAFE MOTHERHOOD PREVENTION OF PPH AT HOME BIRTH (MSC) PROGRAM Health for Life supported prevention of PPH at home birth in Bardiya, thereby completing implementation in all 14 Core program districts. Considering the high degree of institutional delivery in Bardiya, Health for Life
Health for Life—Annual Report 22 supported roll-out of the MSC program in five VDCs with relatively low institutional delivery. Additionally, Health for Life staff continued to follow up and discuss the MSC program among HWs and FCHVs. In the 14 Core districts, a total of 7,463 women who delivered at home took MSC in the first 10 months of this reporting period, making up 14 percent of uterotonic coverage. Based on lessons learned in Bardiya, Health for Life provided technical assistance to the FHD to revise the MSC program guidelines under approval by the MoH. As per the revised guidelines, the MSC program will be maintained or expanded based on two criteria: remoteness (where community members must travel more than 2 hours to reach the nearest public birthing center), and institutional delivery (clusters where institutional delivery is below 80%) rather than a blanket approach. CEONC REFERRAL Health for Life also worked with the FHD to revise the National Referral Guidelines for Maternal and Newborn Health by incorporating learning from CEONC referral implementation in Dang. These guidelines are in the process of being approved. CHILD HEALTH IMNCI DISTRICT IMPLEMENTATION Health for Life collaborated with the CHD/DHOs to roll out the CB-IMNCI program in four more Health for Life districts (Kapilvastu, Salyan, Bardiya and Dailekh), thus completing implementation in all Core districts. Health for Life facilitated the development of the IMNCI program implementation plan, training of trainers (TOT) and HW training; a total of 758 D(P)HO staff and HWs and 844 FCHVs are trained in FY16-17
FIGURE 5.3 PERCENTAGE OF FCHVs IN The Health for Life district team visited 89 REMOTE AREAS TREATING PNEUMONIA reporting clusters in the reporting period. In addition, staff supported the D(P)HOs in eight 80 Core districts to review the CB-IMNCI program which improved the IMNCI program and data 60 quality. Finally, the IMNCI program was reviewed at the regional level (Mid-Western region) where FCHVs 40 targets of of
% key IMNCI 20 program 0 indicators were set. Jumla Salyan Rolpa Rukum Surkhet Dailekh Kalikot Jajarkot Pyuthan
DEVELOPMENT AND IMPLEMENTATION OF REMOTE AREA GUIDELINES Health for Life supported the CHD to draft and finalize the Remote Area Guidelines, which were approved by the Director General on 8 November 2016. The CHD has allocated NPR 14 million to orient FCHVs on the use of amoxicillin through the Redbook in AWPB in FY 2017-18. IMNCI focal persons and D(P)HOs of the Mid- and Far-West were oriented on the guidelines. Implementation started and FCHVs from remote areas are now treating pneumonia with cotrimoxazole until oriented to treat with amoxicillin (Figure 5.3). Finally, Health for Life supported the CHD to develop a job aid for FCHVs on how to use amoxicillin that is pending approval by the Technical Committee-IMNCI.
Health for Life—Annual Report 23 CONTINUE IMPLEMENTATION OF MOBILE TRACKING OF PREGNANT WOMEN IN THE 39 CORE SENTINEL SITES & EXPAND TO 30 SENTINEL SITES IN EARTHQUAKE-AFFECTED DISTRICTS (UNDER OBJECTIVE 2 IN EARTHQUAKE- AFFECTED DISTRICTS) SERVICE UTILIZATION BY PREGNANT WOMEN AT 39 CORE SENTINEL SITES MONITORED USING MOBILE TECHNOLOGY (A SERVICE DELIVERY AND ICT INNOVATION REPORTED IN OBJECTIVE 2) To increase equitable service utilization of antenatal care (ANC), institutional delivery, postnatal care (PNC) and family planning by women, Community Action Promoters/Reporters (CAP/Rs) have been working at the VDC level in collaboration with HFOMCs at 39 sentinel sites. Service utilization by pregnant women is monitored through mobile phones, from the moment a pregnancy is confirmed to 90 days postpartum. As of June 2017, 12,545 pregnant women have been registered and tracked. This means that 77 percent of the expected pregnant women at these 39 sentinel sites were registered and tracked (ranging from 59 percent in Jajarkot to 100 percent in Kapilvastu) in the approximately twenty-six months since the program was started in the Core districts. 7,710 of them delivered live births, among whom 6,237 delivered at a health facility (81 percent). Of the total registered pregnant women, 38 percent are Brahmin/Chhetri followed by Janajatis (22 percent) and Dalits (21 percent), corresponding to the caste/ethnic composition recorded in the 2011 census, with a slightly higher instance of Brahmin/Chhetri, Madhesi and Muslim women registered. REGISTERED WOMEN WHO HAD FOUR ANC VISITS, INSTITUTIONAL DELIVERY, AND 24 HOURS PNC CHECKUP AMONG ALL LIVE BIRTHS AT 39 CORE SENTINEL SITES AS OF JUNE 2017 73 percent of the women who were registered and delivered live births completed all four ANC checkups, as per protocol, ranging from 58 percent in Rukum to 85 percent in Surkhet. Live births delivered at a health facility, (81 percent of all live births) ranged from 70 percent in Dailekh to 92 percent in Dang. First PNC checkups within 24 hours of delivery averaged 81 percent, ranging from 63 percent in Kalikot to 90 percent in Dang. USE OF FAMILY PLANNING IN CORE DISTRICTS Of the 6,441 women whose cases were closed upon completing the 90-day postpartum period of tracking, nearly 49 percent decided to use a modern family planning method after being counselled on the different methods available. Family planning use was highest among Brahmin/Chhetri, Madhesi and women of a caste or ethnicity not identified. D(P)HO ENHANCED FCHV KNOWLEDGE AND SKILLS IN CB-IMNCI, AND FP COUNSELING AND SERVICES IN ALL 14 HEALTH FOR LIFE DISTRICTS Health for Life project built the capacity of LAFP service providers through onsite clinical coaching in health facilities, with a focus on BCs of high-priority VDCs. Since the beginning of the project, 138 HWs from 101 HFs have been coached on LAFP as of June 2017. This has contributed to increasing the number of LAFP service sites from 165 in 2013 to 350 in 2017. SAFE MOTHERHOOD SBA COACHING Health for Life supported D(P)HOs in all districts but Rolpa, and 135 ANMs/SNs (50% of them had no SBA training) from 65 birthing centers of high-priority VDCs were coached. As a result, most of their clinical skill gaps were addressed, contributing to improvements in MNH services. CHILD HEALTH IMNCI HEALTH WORKERS AND FCHVS COACHING Health for Life continued strengthening CB-IMNCI programs in Health for Life Core districts. Health for Life supported D(P)HOs to enhance the capacity of HWs and FCHVs. Health for Life district staff made 203 visits to HFs jointly with D(P)HO staff, and a total of 1,181 HWs and 846 FCHVs were coached on CB-IMNCI, contributing to management of childhood illness, as per the updated CB-IMNCI protocol. FCHVs’ ability to recite three home rules for the treatment of diarrhea increased in this reporting period from 87 percent (N=975) to 98 percent (N=924). As a result, 7,386 newborns received antibiotics for infections, 108,457
Health for Life—Annual Report 24 under-5 children received antibiotics for pneumonia and 222,889 children diagnosed with diarrhea received ORS and zinc in the Core districts during the first 10 months of FY 16-17. IMNCI TRAINING SITE DEVELOPMENT AND INSTITUTIONALIZATION In July 2017, the CHD certified the Mid-Western Regional Hospital in Surkhet as Nepal’s first IMNCI clinical training site. Health for Life played a crucial role through its technical assistance, collaborating with the CHD and RHTC to conduct baseline and follow-up assessments, clinical coaching, action plan development and implementation. Furthermore, at Health for Life’s suggestion, the CHD has allocated NPR 30 million to IMNCI training through the Redbook in the AWPB for FY 2017/18. In addition, more than NPR IMNCI chief presenting a certificate to the 1 million has been allocated to strengthen IMNCI clinical training Medical Superintendant of the Mid-Western sites. Starting in FY2017-18, Regional Hospital in Surkhet upon becoming the all IMNCI trainings will be first certified IMNCI Clinical Training Site in Nepal. conducted at IMNCI clinical training sites rather than at D(P)HOs. The expansion of IMNCI training sites to six more provinces has been included in the CHD section of the NHSS-IP, based on Health for Life’s suggestions and experience gained from establishing the training site in Surkhet. Next year’s CHD Program Implementation Guidelines, at Health for Life’s urging, requires that onsite coaching of IMNCI in the 10 Health for Life Core districts must be carried out by coaches developed by the CHD. DEVELOPMENT OF MEDICAL STANDARDS FOR NEWBORNS AND CHILDREN The National Medical Standards for Care of Newborns and Children, conceptualized and created through Health for Life’s technical assistance, has been finalized and is awaiting submission to the IMNCI Technical Working Group for approval. TECHNICAL ASSISTANCE TO FHD, NHTC AND CHD Health for Life continued to provide technical assistance to the FHD, NHTC and CHD to implement FP-related activities with following key outcomes: FHD • 13th National FCHV day celebrated, including publication of newsletter and messages in newspapers • 3rd Family Planning day celebrated, including publication of FP factsheet and messages in newspapers. • Family planning, maternal and newborn health and training section of the NHSS-IP finalized • Prepared orientation packages on FP, FCHV, Safe Motherhood and ASRH for newly-elected municipal officers • Sub-committees (FP-SC, FCHV-SC, ASRH-SC, SM-SC) met on regular basis to discuss issues and find out solutions • Prepared annual plan and budget for Family Planning, safe motherhood and ASRH programs • Prepared final draft of ASRH strategy • Submitted FP section for RH bill for endorsement • Input for revision of FCHV strategy collected considering the changed context • Finalized materials (facilitation and educational) for fertility awareness • D(P)HOs of 14 Core districts carried out 38 District Reproductive Health Coordination Committee (DRHCC) meetings NHTC • No-Scalpel Vasectomy training package finalized and 180 sets provided to NHTC and now being used in training • Finalized comprehensive Family Planning and Counseling (CoFP/C) training package
Health for Life—Annual Report 25 • Finalized National Health Training Strategy (Nepali) for submission. Additional information compiled for need and importance of in-service training. • Provided support to NHTC to institutionalize LAFP coaching and FP trainings on IUCDs and implants • Designed and implemented FP training QI data management system at training sites • 10 doctors enrolled in Self-Paced No-Scalpel Vasectomy (NSV); 3 doctors have completed the training. CHD • NHSS-IP, Nepal Every Newborn Action Plan –Implementation Plan (NENAP-IP), IMNCI and CB-IMNCI program planning for the current fiscal year and AWPB for next fiscal year developed and approved by MoH • Developed facility-based IMNCI package • Revised guidelines for the free treatment of sick newborns in Aama Tatha Nabajat Sishu Surakshya Karyakaram Guideline revised and is being implemented across the country • Finalized and published annual report on CB-IMNCI in the DoHS annual report • Selected CB-IMNCI service quality monitoring indicators for QIMIS (QI Indicators) • Drafted program implementation guidelines on IMNCI; activities will be conducted as per these guidelines throughout the country • Medicines needed for IMNCI program for next FY forecasted • Set data validation rule for CB-IMNCI program that is active in DHIS-2 IR 5.3 ANM PRE-SERVICE TRAINING (TEACHING AND LEARNING) IMPROVED IN 4 ANM SCHOOLS OF HEALTH FOR LIFE DISTRICTS (MUNICIPALITIES) After its interventions in the previous years including curriculum development and its implementation, Health for Life carried out a follow-up assessment in this reporting period. The assessment showed that the average knowledge score of faculty members increased from 66 percent to 75 percent, and that the average knowledge score among students dropped slightly from 55 percent to 53 percent. Faculty members showed a tremendous increase from 15 percent to 61 percent scoring 80% or above in the skill score; and students also improved, with those scoring above 80 percent rising from 6 to 27 percent. Health for Life followed up with all ANM schools, for action plan implementation (prepared in December 2016). Schools in all districts but Jumla have implemented parts of their action plans. The schools were able to conduct activities which did not require many resources, but they are still seeking external support for more expensive activities. High turnover is still a huge problem for most ANM schools, and most of them expressed a need for more supportive supervision from the CTEVT. Getting public hospitals to provide ANM students with enough on-the-job training opportunities remains a major challenge. Health for Life also supported the preparation, printing and distribution of supplementary materials for ANM students (in midwifery, family planning and child health) to all 46 ANM schools and stakeholders. These supplementary materials have reportedly been very useful. Health for Life has now completed its contribution to ANM education as planned by the project. Health for life organized a final stakeholder meeting on 22 March 2017. This workshop, at which stakeholders (CTEVT, MOH, ANM schools, ANM faculty, NHTC, FHD, CHD, NNC, NAN, NESOG and development partners) planned their future contributions to ANM PSE in Nepal, yielded the following commitments, outcomes and recommendations. • MOH will facilitate regular CTS/SBA/newborn care training to ANM schools • CTEVT representative to be made part of the NNC accreditation & monitoring supervision committees and joint monitoring and supervision and reporting instituted • NNC will make criteria that teacher should have minimum of 2 years of clinical experience. It will start competency-based licensing examination of ANM. • There is need to advocate and involve more donors & partners in pre-service education • The ANM schools will try their best to fulfill criteria and job security and dignity of the faculty members.
Health for Life—Annual Report 26 OBJECTIVE 6: IMPROVE KNOWLEDGE, BEHAVIOR, AND USE OF HEALTH SERVICES AMONG TARGET POPULATION 6.1 DEMAND FOR AND UTILIZATION OF MNCHN/FP SERVICES INCREASED AMONG M/DAGS AND ADOLESCENTS/YOUTH In this reporting period, HFOMCs in Health for Life’s Core districts decided to continue 133 CAP/R positions out of the initial 138. The CAP/Rs have been widely credited with increasing maternal and newborn service utilization, earning them praise from HFOMCs throughout the Core districts. During this reporting period, CAP/Rs continued to drive service utilization, mobilization of pregnant women, and contributed significantly to increasing ANC, institutional delivery, PNC and postpartum family planning utilization. The use of mobile tracking paired with face-to-face interaction has proved to be an exceptionally effective approach. Health for Life’s IEC/BCC activities reached 11,832 target audience members (mostly from M/DAG population) in this reporting period through health exhibitions, street drama, health song competitions and interaction programs. Directly following these events, a total of 272 women received implants, 22 received IUCDs and 3,205 received general health services. Under the leadership of the Nepal Health, Education, Information and Communication Center (NHEICC), Health for Life partnered with UNFPA and GIZ to develop an adolescent sexual and reproductive health mobile app based on UNFPA’s existing global platform, Youth Connect. The app is ready to launch and as soon as NHEICC manages an appropriate time, it will be launched. It is expected that the app will be popular among adolescents on both urban and rural areas of Nepal. RADIO BAHAS Radio Bahas, which was immensely successful in responding to community health concerns through a public forum, was reinstated in 2017. Health for Life partnered with Antenna Foundation Nepal to conduct Radio Bahas in 14 districts through 14 radio stations. By June 2017, a total of 146 Radio Bahas had been conducted and aired on local radio stations. These Radio Bahas programs are especially important in the context of federalism, to better inform newly-elected officials on local issues. Some specific results related to Radio Bahas follow. • Tatopani rural municipality, Hanku, Jumla-health post received 5 sets of rubber chairs and two sets of stretchers. • Lalu health post, Kalikot has used its internal funds to buy and distribute (the discontinued) warm bags for newborns. Also, the number of patients coming for OPD has increased. • In the PHCC in Kumalgaun, Kalikot due to the pressure from community people, the DoHS has sent two doctors. One health assistant has also been appointed. • In Nanikot health post and Ramkot, Kalikot health post appointed one Auxiliary Nurse Midwife (ANM). • In Surkhet district, in Ghatgaun health post all medicines are now available. Solar electricity in the health post is being installed. The community pulled together to bring drinking water to the HF. All the materials needed for the birthing center were made available. Budget has been allocated to build an additional HP in a location nearer to the settlement. FIGURE 6.1 PERCENTAGE OF STUDENTS RESPONDING CORRECTLY IN POST-TEST A community health unit has been established to provide services on immunization, and free medical 100 treatment to elderly citizens suffering from high 80 blood pressure and diabetes will be provided. 60 SCHOOL HEALTH 40 Continuing its successful intervention at district 20 level, Health for Life conducted a two-day correct responses orientation on the School Health Education
% 0 Program for 166 health workers and teachers. Rolpa Dang Banke Jumla Pyuthan Rukum Salyan Bardiya Surkhet Dailekh Jajarkot Kalikot Kapilvastu Those trained returned to provide eight two-hour Arghakhanchi sessions to a total of 8,913 adolescent students from Legal age of marriage HTSP definition 1 HTSP definition 2 grade 8, 9 and 10, the majority of whom are from M/DAGs. Note: HTSP definition 1: Adolescents who could answer a) Appropriate age of pregnancy and b) appropriate spacing between two children; HTSP definition 2: To evaluate change in student knowledge on various Adolescents who could answer a) Appropriate age of pregnancy, b) appropriate spacing between two children, AND c) identify at least 3 aspects of sexual and reproductive health, pretests consequences of early pregnancy and post-tests were conducted, and the results
Health for Life—Annual Report 27 suggest improvements in knowledge, as seen below. The legal age of marriage and spacing of pregnancies showed particular improvement. In partnership with the Antenna Foundation, Health for Life developed a poster on delayed marriage and healthy timing of pregnancy as additional IEC material for the school health session. A total of 1000 posters were printed and sent to all the 85 schools and HFs in those VDCs. A further 700 posters were sent to the D(P)HOs to support their activities on adolescent health.
GESI ACTIVITIES FOCUS GROUP DISCUSSIONS AMONG M/DAGS AND HARD-TO-REACH IN HIGH-PRIORITY VDCS IN CORE AND EARTHQUAKE-AFFECTED DISTRICTS FINDINGS INCORPORATED INTO VHSARs AND GESI TWG AND QW AC ACTION PLANS Health for Life supported HFOMCs and HFs to use quantitative and qualitative data to improve understanding of gender and social inequalities and develop local plans and budgets to address gaps and reach M/DAGs. The district teams helped to conduct 34 focus group discussions among M/DAG women and at sentinel VDCs this reporting period. Findings were incorporated into the 35 VHSARs and village health plans. The result has been an increase in service utilization, particularly ANC, LAFP and institutional delivery. In Dang, the HFOMC in Gadhawa selected Muslim FCHVs for Wards 4 and 6 to promote health-seeking behavior within the Muslim community. For easy access and to assure zero home delivery, the HFOMC has implemented two-way free ambulance services in Gadhwa and Gangaparaspur. With the help of a VDC grant and Flexible Health Grant, three health facilities have initiated audio and visual privacy for FP/MNCH services by partitioning spaces at the facilities. Through a VDC grant, the HFOMC in Rajpur expanded to two Community Health Units to improve access for hard-to-reach communities. NATIONAL-LEVEL GESI ACTIVITIES Health for Life supported the PHCRD by facilitating a two-day social audit training for 64 D(P)HOs, social audit focal persons and Regional Health Divisions on newly revised social audit guidelines 2017. GESI COORDINATION AMONG USAID PARTNERS The GESI coordination group for USAID partners (Suaahara II, Shajhedari Bikas, Health for Life , Hariyo Ban, KISAN, SABAL, PAHAL, PANI, Baliyo Ghar, CS: MAP, IWMI, ELIVES) held meetings to share information on their respective programs and support each other’s efforts. Terms of reference for GESI Coordination Group have been finalized and is in the process of dissemination to the concerned. Health for Life supported Hariyo Ban to review and provided input from GESI perspectives on 'National Water Resources Policy 2017 ' for the Water and Energy Commission (WEC).
Health for Life—Annual Report 28 HEALTH FOR LIFE STAFF COMPOSITION
Dalit Muslim 60% 55% 2% Other 1% 3% 50% Expatriot 40% Madhesi 1% 8% 30% 24% 20% 8% 9% 10% Janajati 1% 3% 26% 0% Bhramin/Chettri Female Male Female Male Female Male 59% Senior staff Mid-level staff Support staff
Ethinicity of staff, by program Gender composition, by employment 80% 70% 70% 60% 51% 60% 50% 60% 40% 40% 22% 40% 30% 30% 30% 20% 11% 9% 20% 10% 3% 3% 0% 0% Female Male Female Male Female Male Program Admin/Finance Support Program staff Finance and Support staff Non-M/DAG M/DAG Admin staff
B. MAJOR CHALLENGES AND CONSTRAINTS FACE D DURING THE PERFORMAN CE PERIOD THAT RESULTED IN DELAYS OF ACHIEVE MENT OF OUTCOMES, IF APPLICABLE ELECTIONS Local elections had a number of impacts on Health for Life activities during this reporting period. The code of conduct imposed by the Election Commission in the run-up to elections barred government officers from participating in a number of activities, including: leadership and management training planned for HFOMC Chairpersons and Secretaries, basic accounting and bookkeeping training planned for HF In-charges, preparing calendars of operations in the earthquake-affected districts, and development of annual work plans and budgets by Councils (primarily affecting budget commitments for FY 2017-18 in Kalikot and Rukum, where Council meetings had yet to be held). Similarly, the GoN froze the accounts of all local bodies immediately before elections, which affected the release of funds for FY 2016-17. This also affected local health plan budget and expenditure tracking. However, after restructuring, the GoN provided NPR 10 million (USD 100,000) to each of the newly-formed local government units, with the result that some high-priority VDCs were able to leverage more resources based on local health plans. FEDERAL RESTRUCTURING As Nepal adopts the federal system, it is expected that restructuring will have far-reaching impacts on the health system, the effects of which began to affect Health for Life activities in this reporting period. Decisions made by previous Councils, for example, were called into question. The GoN instructed Municipal Assemblies to pass work plans and budgets for FY 2017-18 by July 14, 2017 for municipalities elected during the first phase, and end
Health for Life—Annual Report 29 of July 2017 for municipalities that held elections during the second phase. This timeline did not ascertain whether Municipal Assemblies have endorsed or made any alterations to health budgets committed by previous Councils. In the same vein, the shifting structure requires adjustments to the Quality Improvement and Assurance System, leading to delays in quality-related activities. Revisions to the FCHV strategy gained momentum once the new Director and focal person (FHD) took over. Progress slowed, however, primarily due to the need to adapt it to the new federal structure and restructuring of DoHS/MoH. Similarly, the National Health Training Strategy was also delayed significantly while it was adapted. STAFFING & STRUCTURAL CHANGES WITHIN GOVERNMENT The momentum of some HFOMCs was disturbed as the MoH attempted to replace the existing (Cabinet- approved) HFOMC Guidelines with the 2017 version (Ministerial decision) according to which the HFOMC Chairperson and Vice-Chairperson are appointed by the MoH directly. Changes in government staffing are an ongoing issue that the project must address, and FY 2016-17 was no different. Fifty percent of D(P)HOs in Health for Life’s Core districts and many in EQ-affected districts, for example, were changed during the reporting period. Changes in QAI TWG focal persons from Divisions and Centers such as the NHEICC, FHD, PHCRD, LMD, NPHL and NCASC contributed to delays in organizing the QAI TWG. The NHSS and its Implementation Plan emphasizes quality of care and quality system in output 2 and its outcomes. Because of this, each Division and Center must develop its own quality of care and system-related indicators and activities. Defining the roles and responsibilities of each division and center for each of their programs and realigning them with the NHSS IP delayed quality-related activities. Similarly, the process of establishing an autonomous Quality Council (now Health Institution Quality Management Authority) created uncertainty regarding the roles of the existing HFD&Q section and new structure under the Quality Council. Directors of the CHD and FHD and some of the key focal persons of these Divisions were changed with the result that some activities were delayed or dropped. Development of CH medical standards was delayed as the CHD wanted greater engagement of NEPAS (Nepal Pediatric Society) and other professional organizations. Development of IMNCI coaching sites and PPFP implementation guide were dropped. Some HFOMCs in Dang, Arghakhanchi, Dailekh and Salyan decided not to continue using CAPs due to a lack of VDC support. This hindered local health promotion activities. However, the newly formed municipal governments will likely fund CAPs in H4L’s priority municipalities. A training for D(P)HO staff on public health analytics was not carried out in nine EQ-affected districts since most GoN staff had already been trained by the HMIS section of the DoHS. RECONSTRUCTION EFFORTS TAKE PRIORITY The leadership and management training planned for HFOMC Chairpersons and Secretaries could not be implemented during this reporting period in part because VDC Secretaries were occupied providing grants to communities for the reconstruction of houses. HEALTH WORKER STRIKE A health workers strike lasting from late January to early March of the reporting period resulted in high absenteeism among health workers at HFs in all Health for Life districts, and caused delays to several HF-level activities. In a related issue, ongoing disputes about who is in charge at HFs between the HA and Sr. AHW, meant that some elements of HFOMC meeting were not conducted and meeting protocol/guidelines were not respected. The meetings mostly focusing on urgent agenda items and were conducted by whatever HFOMC members were present which sometimes impacted participation of women and Dalits. GESI ACTIVITIES AND REVITALIZATION OF GESI TWG IN EQ-AFFECTED DISTRICTS: GESI activities, including revitalization of the GESI TWG, could not be carried out in earthquake-affected districts. Following extensive meetings to explore hurdles to implementation, it was discovered that GESI-related program activities were discontinued by the Population Division.
Health for Life—Annual Report 30 The D(P)HOs are strongly in favor of reinstating funding for GESI-related activities, including GESI TWG meetings. Health for Life explored this possibility with PHAMED, the new GESI Secretariats and other EDPs, but no funding was available and they were unable to support this activity.
C. HIGHLIGHTS OF THE INTERNSHIP PROGRAM AS DESCRIBED IN SECTION C.2.8.1D With the purpose of building the professional capacity of individuals from marginalized groups, was hired as an intern in Chitwan for one year. Her testimonial appears below: Introduction I had my schooling from Shree Antyodaya Janajati Aawasiya Vidhyalaya up to class 8, established by the late Kishor Kagi Dhungana, and I passed the SLC from Shree Khairahani Higher Secondary School, Chitwan. After my SLC, realizing the poor health situation of my remote village, I decided to study nursing. I was successful in pursuing my PCL nursing degree at Shree Medical Technical College in Bharatpur, and decided that the improvement of health is not merely a clinical matter, but a field that benefits from preventive and promotive approach. Fortuitously, Health for Life provided me with an excellent opportunity to explore this approach more fully as an intern in Chitwan. This internship gave me the opportunity to collect some of the most valuable experiences of my life, improving my skills and knowledge in many areas. As my interest was on quality improvement, I was grateful that Health for Life’s work had such a strong emphasis on solutions at the local level, exposing me to QI in a practical way. To this day, I feel that this opportunity allowed me to support QI part of health service delivery. I am grateful for my Health for Life family, and want to extend my thanks to the district team, the D(P)HO and the peripheral health units for providing a supportive and fruitful milieu to hone my skills and giving me the chance to fulfill what I dreamed about during my earlier days. What I did with Health for Life This internship was great opportunity for me to understand INGOs and their supportive role in the health sector, along with how quality matters with activities and the approaches being used to improve quality of services. As it was field-based work, I visited different VDCs, where I was exposed to the actual situation of health facilities that was only theory-based for me before. I participated in HFOMC revitalization and meetings and helped to identify the functionality status of HFOMCs and their concerns around quality health services. I also conducted FCHV readiness assessments, through which their knowledge and skills were reviewed and onsite coaching was provided, according to their needs. I examined how FCHVs are reaching out to M/DAGs (I am myself from a small ethnic minority) encouraged them to make a particular effort to reach out to M/DAGs. Being especially interested in quality improvement, I was happy that I was able to prepare and conduct orientation at health facilities on the QI system and QI tools for the QI team and HFOMC members. I also worked on identifying gaps, provided inputs for carrying out self-assessments using the QI tools and assisted HFOMC members to prepare action plans to address gaps. I reviewed QI meetings minutes, the regularity of meetings, agenda setting, decision-making and follow-up on previous action plans. I also conducted client exit interviews about the family planning and its effectiveness to know about quality of family planning services. I supported raising QI issues at HFOMC meeting for implementation. Lastly, I also supported the district team to compile information on respective VDC files to ease recording and reporting. What I learned This internship exposed me to so many new things, so there was a lot to learn. Before this opportunity, I was only clinic-based, so my experiences in the field visiting HFs and VDCs was a great learning experience. I came to know that health facilities play a great role for service utilization and coverage along with the planning process, staffing patterns and their roles and responsibilities, target-setting and recording and the reporting process. Other skills I have acquired include using the QI tools, how the quality of service can be improved by mobilizing local resources and identifying the best solution to a problem. In addition, I learned to work in a team and to be cooperative in the changing environment for quality service and better output. I also learned that without the involvement and the concern of local forums like FCHVs, mothers’ groups, QITs and HFOMCs, quality change in health service is impossible. In the past, HF staff were more concerned with service delivery than in quality of care. But with the introduction of the QI tools, they have been able to plan, identify resources, manage the situation and assure coverage and quality of services delivered as well as document the evidence. I am now able to conduct QI reviews and follow-ups independently, carry out FCHV readiness and on-site coaching, analyze service coverage among M/DAGs, participate in meetings and support agenda setting, decision- making and record and report performed work with proper documentation. My expectations for the future My year with Health for Life has been very influential. I have a greater understanding of quality improvement, as well as knowledge of how to work effectively with local organizations. My responsibilities with Health for Life in Chitwan district have boosted my confidence and enabled me to conduct QI assessments, planning and follow-up of the pre-planned events in terms of review and share it with DQAWC. My leadership and organizational skill have improved, and I now feel confident working independently on QI issues. Almost as important as the skills I gained are the relationships that I have built. My colleagues at Health for Life have become good friends; I expect their professional support will be invaluable in the future. It has truly been a pleasure to work with the team and I really appreciate their selfless support and expect the same in the future. My intention is to put the skills I have gained through this internship to greater use at health facilities in my own community. I expect to continue learning more in this field so that I can serve Nepal.
Another intern, continued her internship in Surkhet during this reporting period.
Health for Life—Annual Report 31 She is gaining practical experience in GESI and learning more about health service utilization by M/DAGs and the barriers they face. She has been working on collecting and analyzing health facility service data and attending HFOMC, GESI TWG, DHGSTF and D(P)HO meetings and discussing findings and gaps identified from service registers.
Health for Life—Annual Report 32 D. CUMULATIVE QUANTITATIVE MONITORING AND EVALUATION DATA, INCLUDING INFORMATION ON PROGR ESS TOW ARDS TARGETS AND EXPLANATIONS OF ANY ISSUES RELATED TO DATA QUALITY
CAPACITY-BUILDING BENCHMARKS OBJECTIVE 1: IMPROVE HEALTH SYSTEMS GOVERNANCE OF DISTRICT HEALTH OFFICES AND SUB-DISTRICT LEVEL FACILITIES Year-4 Benchmark Status of as of 30 June 2017 Key Component Remark (July 2016--June 2017) (July 2016--June 2017) HFOMC HFOMC’s performance has led to health HFOMCs of high-priority VDCs in two core districts (Dang and Salyan) met all 6 Due to uncertainty of Social Performance facilities adopting all 6 performance criteria performance criteria. All 141 HFOMCs in high-priority VDCs prepared or updated Village Audit quota provisioned by GoN thereby making services more accessible Health Situation Analysis Reports (VHSARs) and local health plans. Ninety-two percent of to districts, H4L excluded social and available HFOMCs in high-priority VDCs expanded health services; 96 percent upgraded quality of audit from performance measure Measurement: HFOMC performance criteria are services; 92 percent mobilized additional resources; 97 percent HFOMCs in high-priority criteria in EQ affected districts. applied to HFOMCs at 39 sentinel sites in Core VDCs had active involvement of Dalit and Women members; 75 percent conducted social districts, and to 30 in EQ districts, HFOMCs in audits. Benchmarks in coming year will other high-priority VDCs, and other HFOMCs in focus on orienting Ward VDCs visited In EQ districts, 86 percent of HFOMCs met all five performance criteria. 90 percent of committees in their roles and [EQ Districts to follow Core District Year-2 HFOMCs expanded the health services. 39 HFOMCs (three from initial VDCs and 36 from responsibilities and achieving all Benchmarks] expanded VDCs) were revitalized during this reporting period in EQ affected districts. performance criteria where applicable.
Districts implement MoFALD block grants, local resources, and In Core districts, a total of NPR 50.6 million (approx. USD 506,000) was allocated by 141 Benchmarks in later years will new MoH/ MoH flexible funds where available are high-priority VDCs based on local health plans of which 85 percent of the funds were focus on implementing new local MOFALD local allocated to the health sector and utilized released and 96 percent of the released funds were spent by HFOMCs on health activities. governance policy. governance policy in based on annual local health plans In demonstration districts, a total of NPR 47.9 million (approx. USD 479,000) was allocated VDCs to strengthen by respective Councils of priority VDCs. Seventy-five percent of the allocated funds were HFOMCs and health Measurement: Allocations verified by VDC released out of which 95 was spent based on local health plans. facilities Executive Committee and approvals by VDC A total amount of NPR 10 million (approx. USD 100,000) was allocated by MoH to 151 HFs Councils of 6 demonstration districts as FHG. Ninety-seven percent of funds were allocated to 151 VDCs/HFs and 91 percent of funds were spent on health activities. [EQ Districts to follow Core District Year-2 Benchmarks] In EQ districts, a total of NPR 70.3 million (approx. USD 761,711) was allocated by 159 high-priority VDCs based on local health plans. Of the allocated amount, 62 percent was released and 93 percent of the released funds were spent by HFOMCs on health activities. 63 local health recovery plans have been approved by respective councils of local bodies during this period in EQ affected districts. In addition, 36 local health plans have been prepared in newly expanded VDCs.
Health for Life—Annual Report 33 OBJECTIVE 2: DEVELOP EVIDENCE-BASED HEALTH POLICY
Year-4 Benchmark Status of as of 30 June 2017 Key Component Remarks (July 2016--June 2017) (July 2016--June 2017) Analytical capacity D(P)HO uses HMIS data and other data report All the D(P)HOs used the PHAT manual as reference to analyze data from HMIS and Benchmarks in later years will of District (Public) on the past year’s accomplishments; on data other sources. focus on expansion, data Health Offices quality issues; and to prioritize for next year’s quality, annual municipal and Using the PHAT review checklist, an assessment of district review meetings was completed. plan and budget regional reviews where After categorizing 14 core districts, 7 were “model,” 4 were “progressive” and 3 were applicable, including Health facilities and D(P)HOs introduce a “acceptable.” interpretation and actions. QIMIS in H4L sentinel sites to make accurate In addition, all 10 EQ districts used the PHAT review template as well. Based on the data available and analyzed for key MNCH/FP assessments, eight districts have achieved “Progressive” status. indicators to improve quality H4L also conducted data quality assessments using the standardized RDQA tool in 37 Measurement: Assessment reports of district and health facilities across Core (12) and EQ (4) districts by involving D(P)HO officials and regional performance reviews by using PHAT review health facility staff. checklist developed jointly with HMIS and other partners); and QIMIS reports All H4L districts report on QI using paper based system which are also reported to Management Division. NHRC NHRC’s knowledge management capacity is The web-portal has been upgraded with new features, functions and interface. A total of Benchmarks for NHRC in collaborative enhanced by an updated web-portal 254 final abstracts categorized into priority areas were uploaded and are available on later years will focus on an research network NHRC’s new web portal http://nhrc.gov.np/priority-area/ for public access. expanded knowledge Measurement: Updated web-portal functional and knowledge management role that supports and in use management the AWPB and online ethical (Last year focused on completing abstracts for review training. new publications; no progress made toward developing web-portal; scope of work under discussion)
OBJECTIVE 3: STRENGTHEN NATIONAL LEVEL STEWARDSHIP OF THE HEALTH SECTOR Year-4 Benchmark Status of as of 30 June 2017 Key Component Remark (July 2016--June 2017) (July 2016--June 2017) MoH policy making NHSS 2016-20 (NHSP III) approved and NHSS IP was prepared this year and is being implemented. H4L’s objectives are in line with Benchmarks in later years will implementing partners aligned accordingly NHSS’s outcome areas. focus on adaption of NHSS in new federal structure.
Measurement: H4L reporting supports NHSS and follows its results framework
Health for Life—Annual Report 34 OBJECTIVE 4: INSTITUTIONALIZE NATIONWIDE SYSTEM FOR QUALITY IMPROVEMENT Key Components Year-4 Benchmark Status of as of 30 June 2017 Remark (July 2016--June 2017) (July 2016--June 2017) QA/QI system Field tests are evaluated, expansion continues Assessment of field test completed; expanded in 10 EQ districts; all H4L districts report on Alignment with NHSS and its to 10 EQ-affected districts, and plan to QI; subcontracted local firm to develop QIMIS and dashboard. Implementation Plan, initiating nationalize is implemented process of establishing quality council and delay in selection of organization to support Measurement: QIMIS reports from sentinel sites in core development of QIMIS has and EQ-affected districts delayed (see sections B and F)
OBJECTIVE 5: IMPROVE CAPACITY OF DISTRICT AND LOCAL HEALTH WORKERS AND COMMUNITY VOLUNTEERS TO DELIVER QUALITY FAMILY PLANNING, MATERNAL, NEWBORN AND CHILD HEALTH, AND NUTRITION SERVICES Key Components Year-4 Benchmark Status of as of 30 June 2017 Remark (July 2016--June 2017) (July 2016--June 2017)
Family Planning At least one LAFP method is available at ≥ In the 141 high-priority VDCs there are 123 birthing centers among which 90 % (n=111) Benchmarks in later years will 60% of health facilities have at least one LAFP method available. focus on expanding long-acting FP, particularly remaining BCs which do not have LAFP service Measurement: Availability of LAFP methods by if sites meets the requirements. birthing center in high-priority VDCs ANM school Final assessment and report completed Assessment (follow-on) completed and write-up with recommendations completed. This activity has been strengthening discontinued but final recommendations and learnings Measurement: Report on current status and have been discussed with recommendations stakeholders.
Health for Life—Annual Report 35 OBJECTIVE 6: IMPROVE KNOWLEDGE, BEHAVIOR AND USE OF HEALTH SERVICES AMONG TARGET POPULATION Key Components Year-4 Benchmark Status of as of 30 June 2017 Remark (July 2016--June 2017) (July 2016--June 2017) Awareness through D(P)HOs will, together with local FM radio 143 Radio Bahas programs have been aired across 14 Core districts. Benchmarks in later years will focus Mass Media stations, continue to produce and air health on continuing public hearing programs and Public Service Announcements programs and airing Radio Bahas. (PSA) throughout the year, including public hearings in high-priority VDCs
Measurement: Frequency of airing radio programs and PSAs per day throughout the year at FM radio stations and public hearings District D(P)HOs continue to develop annual This year in 12 core districts, BCC plans were made and linked with district-level annual Benchmarks in later years will focus communication intervention plans with district stakeholders calendars of operations. on Municipalities developing their strategies and and schedule community-based communication annual communication plans and annual intervention interventions to reach M/DAG populations implementing plans
Measurement: Number of such interventions developed and executed by D(P)HO and district stakeholders mHealth for ASRH NHEICC, with support from H4L, GiZ and A mobile-based app for ASRH is ready to be launched, which is being managed by Benchmarks in later years will focus UNFPA, develops a mobile application to UNFPA. on NHEICC providing messages reach and better inform adolescents and youth to and supporting VASPs for on ASRH targeted populations.
Measurement: Record of adolescents and youth using the application
Health for Life—Annual Report 36 PERFORMANCE MANAGEMENT PLAN Year 4 (Jul 2016- Jun % of Program 2017) SN Indicator Definition Source Baseline annual Status Justification Area target Target Actual OBJECTIVE 1-Improve health system governance of district health offices and sub-district level health facilities Intermediate Result 1.1 : HFOMCs hold health providers accountable for delivery of services by better mobilizing and management of local resources Sub-Intermediate Result 1.1.1 Health Facilities in 24 H4L districts have functioning HFOMCs. Percent of health Core High numbers contributed by Surkhet (50), Dang (33), facilities that undertook Districts District report 30% 30% 42% 140% Surpassed Bardiya (38) and Rolpa (34) districts. Social Audits in the last EQ- Priority Government increased quota of social audits in EQ-affected 1 12 months VDCs District report 6.5% 20% 23% 115% Surpassed districts.
Intermediate Result 1.2 : Local health governance strengthened to reduce inequities of access and use of health services in Health for Life districts Sub-Intermediate Result 1.2.1 Village health plans are prepared using evidence and approved by Village Councils as an integral part of Village Development Plan Sub-Intermediate Result 1.2.2 District Health Governance Strengthening Task Forces (DHGSTFs) are functional and effective Core – Priority Percent of HFOMCs VDCs District report 59% ≥80% 86% 108% Achieved mobilizing resources to EQ - H4L TA has led to better-performing HFOMCs, and HFOMCs support health services Priority are more receptive to evidence-based health plans. 2a in the last FY VDCs District report 32.4% 70% 100% 143% Surpassed All – Priority Timely release of funds from VDCs to HFOMCs led to better Percent of mobilized VDCs of implementation of health plans. resources spent to Core, EQ Released: NPR 126,949,664 support health services and Demo Spent: NPR 117,521,735 2b in last FY Districts District report 66.2% 70% 93% 133% Surpassed
Sub-Intermediate Result 1.1.2 Best practices in local health governance scaled up in Health for Life districts
Core District report 80% 90% 92% 102% Achieved Percent of clinical staff EQ Priority 3a positions filled VDCs District report 54% 80% 85% 106% Achieved Core – All 318 (all) and Priority 94 Number of additional VDCs only District report 321 341 (priority) 93% Achieved clinical staff hired EQ – Local bodies were responsive to HFOMCs’ requests to locally (in all and Priority provide more clinical staff for quality service delivery. 3b priority VDCs) VDCs only District report 18 55 61 111% Surpassed Ramechhap and Makwanpur hired more clinical staff locally. Intermediate Result 1.2 Local health governance strengthened to reduce inequities of access and use of health services in Health for Life districts (restore services and repair/reconstruct damaged health facilities in Health for Life EQ districts)
Sub-Intermediate Result 1.2.1 District health recovery and reconstruction plans prepared using evidence and implemented in collaboration with partners Health for Life—Annual Report 37 Number of Districts that prepared health recovery & 4 reconstruction plans EQ Districts District report NA 10 10 100% Achieved
Sub-Intermediate Result 1.2.2 Village health recovery plans are prepared using evidence and approved by Village Councils as an integral part of the Village Development Plan Number of high-priority VDCs that prepared 78 An additional 36 Village Health Recovery Plans were health recovery plans in EQ- Priority (144 of prepared in VDCs added in the first expansion 5 EQ districts VDCs District report NA 78 159) 100% Achieved Number of local health plans prepared and approved by Councils Demo – where flexible local Priority 6 health grant is provided VDCs District report 0 150 150 100% Achieved OBJECTIVE 2- Develop and implement national evidence-based health policy
Intermediate Result 2.1 Guidelines developed and implemented for National and Regional Performance Review Meetings of MoH programs (A Framework for Analysis) Comprehensiveness of MoH’s information system as measured by Very HISPIX Score 25 is Very Good but scored 23, Good (23/25). Health Information System Good Good So achieved 92% 7 Performance Index (HISPIX) Multiple Good (25/30) (23/30) 92% Achieved 11 Managerial issues from previous years were resolved, Number of District (4 Core leading to more effective TA (Municipal) reviews 8/14 progressive Districts District report NA Progressive 7 model) 138% Surpassed conducted in accordance with PHA 8/9 8 performance EQ Districts District report NA NA districts Achieved
Sub-Intermediate Result 2.1.1 Data routinely used at all levels to review program performance, identify prioritized actions, and develop plans to improve performance Percent of HFs Core – Health for Life provided data display flexes in Years 1 & 2, displaying up-to-date Priority HF Readiness which were intended for multi-year use. monthly service VDCs Assessment 18% 75% 86% 115% Surpassed coverage information EQ – 19% (HF on wall on the day of Priority readiness 9a visit VDCs District report 2015/16) 100% 97% 97% Achieved Percent of health facilities in 10 earthquake-affected districts submitting complete HMIS reports to the district on time EQ – 94% by high-priority and Priority HF 9b other VDC VDCs District report Readiness 100% 95% 95% Achieved
Health for Life—Annual Report 38 Intermediate Result 2.2 NHRC prioritizes, oversees and regulates research based on established practice of Health Sector Planning and Budgeting NHRC policy role revised to reflect management of health sector research Revised New web portal for network and expanded knowledge NHRC better access to 10 management Project report NA policy research Achieved OBJECTIVE 3-Strengthen national level stewardship of the health sector Intermediate Result 3.1 MoH’s next Nepal Health Sector Strategy (2016-2020) developed in collaboration with EDPs and TA programs
NHSS (2016- Nepal Health Sector Strategy (NHSS) 2021) IP 11 2016-2020 developed Project report NA developed NHSS IP developed Achieved Intermediate Result 3.2 State Non-State Partnerships are identified in H4L districts documented and shared for MoH scale up NHEICC and/or D(P)HOs establish Partnership developed with NHEICC for school health; partnerships with Telecom and/or FM List of NHEICC, GIZ, UNFPA for Mobile App; and NHEICC, Radio to develop and implement Partnerships partnerships Antenna Foundation and Local FM Stations for Radio Bahas 12 mHealth and/or radio BCC activities Project report NA formed formed Achieved OBJECTIVE 4-Institutionalize nationwide system for quality improvement Intermediate Result 4.1 Consensus built on National QI system and piloted in in H4L districts for MoH scale up Number of District Core (Municipal) QAWC that Districts District report 0 14 14 100% Achieved carry out action plan in the last reporting 13 period (four-monthly) EQ Districts District report 0 10 10 100% Achieved Progress proceeded cautiously to ensure that the QI Number of HF QI teams assessment process was clear and that HFOMCs and HFs are formed and functional prepared to implement. Also, H4L staffing was limited. Demo where local health plan Demo - districts and priority VDCs are no longer in our work plan. is prepared and flexible Priority New indicators included in new municipal plans and 14 grant is provided VDCs District report 0 150 113 75% Not achieved budgets, as well as for 17 PHCCs in SHSP districts. Intermediate Result 4.2 D(P)HO rolls out facility-based QI system in all H4L districts Core – Strengthened coordination with D(P)HOs and close TA to Priority HF Readiness high-priority facilities by H4L staff led to rapidly improved VDCs Assessment 41 60 67 112% Surpassed readiness in this year. General Service EQ - Readiness Index of Priority HF Readiness 15 health facility VDCS Assessment 16 50 47 94% Achieved OBJECTIVE 5- Improve capacity of district and local health workers and community volunteers to deliver quality family planning, maternal, newborn and child health, and nutrition services
Intermediate Result 5.1 Community level health innovations and programs delivering MNCHN/FP services scaled-up and maintained
Health for Life—Annual Report 39 A slight improvement compared to the past; shortfall due to underreporting (10 months only) and no reports from hospitals, such as Surkhet Regional Hospital.
Moderate improvement with 12 months of data. The achievement is comparable to results from NDHS 2016 that Percent of deliveries conducted by shows 49% delivered by SBA in Mid-Western Region. In skilled birth attendant (doctor, nurse 46.3% 69% sentinel sites where there is mobile tracking the % deliveries 16a or ANM) HMIS 42% 67% 54.4% 81% Not achieved by SBA is significantly higher. Percent of deliveries conducted by Mobile skilled birth attendant (doctor, nurse tracking NA ≥80% 82% 103% Achieved or ANM) in sentinel sites (live births Mobile tracking was much more effective at tracking 16b among registered women) EQ NA ≥50% 76.2% 152% Surpassed pregnant mothers to use delivery services by SBA A slight improvement compared to the past; shortfall was due mainly to underreporting of data (10 months only) and Percent of newborns receiving no reports from hospitals such as Surkhet Regional Hospital. postnatal health check-up within 24 50.4% 84% Not achieved 17 hours of birth HMIS 50% 60% 58.1% 97% Achieved Achieved with 12 months of data. Sub-Intermediate Result 5.1.1 D(P)HO managed/implemented Matri Surakshya Chakki program in 1 district and CB-IMNCI program in 8 Health for Life districts Number of Districts implementing a comprehensive integrated management of childhood illness and 18 newborn care (CB-IMNCI) package District Report 0 11 11 100% Achieved Percent of pregnant women protected 63% 90% 19 from PPH HMIS 47% 70% 70.2% 100% Achieved Intermediate Result 5.2 D(P)HO enhanced FCHV knowledge and skills in CB-IMCI, and FP counseling and services in all 14 Health for Life districts Number of people trained on FP/RH 20 and MNCH for the reporting period Project report NA NA Achieved Annual protection against pregnancy afforded by contraceptives distributed 21 (couple-years of protection) HMIS 250,072 273,340 256,478 94% Achieved 24%2 Percent of women of reproductive age (HMIS) 91% achieved if we consider NDHS result, 51% with HMIS in union who are currently using a 43% 43% result. 36% recorded by HMIS for July or 77% of target. modern method of contraception (NDHS (NDHS 22 (CPR) HMIS 2011) 47% 2016) 91% Achieved Sub-Intermediate Result 5.2.1 Knowledge and skills of FCHVs enhanced
2 Actual of indicator 22 is based on data from Chaitra 2073 (i.e., April-May 2017) Health for Life—Annual Report 40 HF Readiness Assessment Readiness assessment (N= 924) non-representative (TA (non- visits) Percent of FCHVs able to recite 3 representative 23 home rules for treatment of diarrhea for baseline) 83% >90% 98% 108% Achieved Sub-Intermediate Result 5.2.2 Knowledge and skills of health workers enhanced HF Readiness Assessment Readiness assessment (N= 102) non-representative (TA Percent of health workers who (non- 40% visits). Of the 102 counseling sessions observed, 63% performed required actions during FP representative (priority followed five of the six steps. 24 counseling for baseline) VDCs) 80% 63% 79% Not achieved Intermediate Result 5.3 ANM pre-service training improved in 4 ANM schools of Health for Life districts Considering the findings of the in-depth assessment that revealed serious weaknesses in faculty knowledge and skills, other deeper and longer-term solutions that are outside the scope of Health for Life will be required to improve the quality of teaching.
A longer term solution would include comprehensive training of faculty and preceptors, and upgrading of skill labs Percent of ANMs with high level of Assessment 36.6% and practicum sites, as well as TA to CTEVT and the nursing 25 proficiency in core SBA skills Report (2015) 90% 50% 56% Not achieved council to improve the monitoring and examination system. OBJECTIVE 6-Improve knowledge, behavior and use of health services among target populations Intermediate Result 6.1 Demand and utilization for MNCHN/FP services increased among M/DAG and Adolescents/Youths Percent of Dalit women who delivered 26.4% 45% 113% Achievement has consistently surpassed target each year. 26a at health facility HMIS NDHS 2011 40% 47% 118% Surpassed Last year it was 120%. Baseline target was low.
Core: NA ≥80% 81% 101% Achieved Percent of Dalit women who delivered Mobile Mobile tracking was very effective at encouraging Dalit 26b at health facility in sentinel sites tracking EQ: NA ≥50% 82% 164% Surpassed women to deliver at institutions Sub-Intermediate Result 6.1.2 Equitable use of services increased and adolescents and youths adopt health seeking behaviors It is a composite index of three questions, reporting for the Percent of adolescents exposed to first time. Students who took the post-test (N=5,140) scored school health program having high in recalling appropriate age and appropriate spacing knowledge on healthy spacing and (98%) but low in recalling at least 3 consequences of early 27 timing of pregnancy (HTSP) Self- NA >90% 36% 40% Not achieved pregnancy (36%). Percent of adolescents and youth that administered know the legal age of marriage for survey at 28 men and women school 10% >90% 86% 96% Achieved Intermediate Result 6.2 Missed opportunities reduced at service delivery points to provide education and counseling on healthy behaviors for MNCHN/FP Percent of post-partum women 90% Readiness assessment (N= 37) non-representative (TA visits). receiving counseling on HF Readiness (Observed 29 comprehensive FP services Surveys 58% and HF 76% 84% Not achieved Health for Life—Annual Report 41 Readiness Postpartum FP counseling is increased when pregnant survey) women that recently delivered are tracked following delivery for 90 days.
Health for Life—Annual Report 42 PERFORMANCE PLAN REPORTING (PPR) INDICATORS Baseline Year 4 (2016- 2017) Percent of Achievement SN Indicator annual Status Justification Data Source Target (July 2016- target May 2017) 1 Number of newborn infants receiving 4,742 7,386 140% IMNCI, a newborn-focused program, was rolled out in five more antibiotic treatment for infection through 5,285 Surpassed (HMIS 2012/13) 8,090 153% districts covering all core districts USG-supported programs 2 Number of women giving birth who SBA deliveries at major hospitals like Bheri Zonal Hospital and Mid- 50,290 54,329 73% Not achieved received uterotonics in the third stage of 74,569 Western Regional Hospital, Surkhet, were not reported and service (HMIS 2012/13) 72,775 98% Achieved labor through USG-supported programs utilization from other districts was also underreported. 3 Number of cases of child diarrhea treated Prevalence of diarrhea decreased from 14% to 8% nationally (NDHS in USG-assisted program 2011 and 2016). Similarly, the DoHS Annual Report 2015-16 reports that the incidence of diarrhea nationally fell over the last three years. This applies to all regions, including the MWDR. 347,896 222,889 66% 337,015 Not achieved (HMIS 2012/13) 256,485 76% Based on the decrease in prevalence reported by the NDHS 2016, the target should have been reduced to 198,301, which would lead to surpassing the target.
4 Number of children under five years of The prevalence of ARI fell from 5% to 2% nationally (NDHS 2011 and age with suspected pneumonia receiving 2016). Similarly, DoHS Annual Report 2015-16 reports that the antibiotics by trained facility or incidence of pneumonia fell nationally over the last three years. This community health workers in USG- applies to all regions, including the MWDR. assisted programs Revised HMIS records “antibiotic treatment only for pneumonia” and 248,425 108,457 60% 179,488 Not achieved data quality has been improving gradually. (HMIS 2012/13) 119,651 67% Based on the decrease in prevalence reported by the NDHS 2016, the target should have been reduced to 99,370, which would lead to surpassing the target.
5 Number of babies who received postnatal SBA deliveries at major hospitals like Bheri Zonal Hospital and Mid- care within two days of childbirth in USG- Western Regional Hospital Surkhet were not reported and service supported programs utilization from other districts was also under-reported. 53,033 43,488 61% 71,124 Not achieved (HMIS 2012/13) 60,229 85% Of all institutional deliveries in the 14 Core districts , 94% received postnatal care within 48 hours of delivery. Target should be adjusted accordingly. 6 Couple Years protection in USG supported 250,072 256,478 94% programs (in thousands) 313,821 Achieved (HMIS 2012/13) 320,473 102% (H4L districts) 7 Couple Years protection in USG supported 1,730 1,347,724 76% Not achieved NDHS 2016 showed that CPR fell from 43.2% in 2011 to 42.8% in 1,765,000 programs (in thousands) (National) (HMIS 2012/13) 2,432,994 138% Surpassed 2016.
Health for Life—Annual Report 43 Baseline Year 4 (2016- 2017) Percent of Achievement SN Indicator annual Status Justification Data Source Target (July 2016- target May 2017) 8 Percent of USG-assisted service delivery 100% sites providing family planning (FP) (628 out of 628 100% 100% 100% Achieved counseling and/or services (Numerator PHCC/HP/SHPs, (628/628) and Denominator) HMIS 2012/13) 9 Number of people trained in FP/RH through USG supported programs NA NA Achieved Activity was achieved by 2015 for life of project. Male Female 10 Number of people trained in Health 51 high-priority VDCs were added to the EQ district program and 36 System Strengthening through USG HFOMCs were revitalized. More participants were reached with QI supported programs (Custom PPR) training in demonstration districts. Male: 1,500 1,829 Female: Breakdown: NA Male- 1,062 122% Surpassed 750 QI training Demo: 515 (F: 248, M: 267) Core: 11 (F: 5, M: 6) Female- 767 750 HFOMC revitalization/basic: 22 (F: 12, M: 10) Leadership: 24 (F: 1, M: 24) School Health: 166 (F: 15, M: 151) EQ: 1091 (F: 486, M: 605) 11 Percent of USG-supported primary health 97% care (PHC) facilities that submitted All facilities in Core districts and priority VDCs in EQ districts reported (612 out of 628, 98% 100% 100% Achieved routine reports (HMIS) on time (Custom HMIS 9.3 to districts on time. HMIS 2012/13) PPR) 12 Percent of women that had four ANC NA 43% 70% Big hospitals like BZH and Mid-Western Regional Hospital did not check-ups as per protocol in USG- 61% Not achieved (HMIS) 52% 85% report (SBA delivery) or underreported. supported programs 13 Percent of women from marginalized 29% National 45% 102% groups that delivered in health facility (NDHS 2011 44% 43% Achieved 98% further analysis) (HMIS) 14 Number of newborns not breadthing at 1.5% of live births are expected to be born not breathing. 74 were birth who were resuscitated in USG- NA 83 52 63% Not achieved actually born not breathing so 70% were resuscitated. supported programs
Note: HMIS Data used in this table is for 10 months from July 16, 2016 – May 15, 2016 accessed from HMIS/DHIS2 Database on July 13, 2017. HMIS data used in this updated table is for 12 months from July 16, 2016 to July 15, 2017 from DHIS2 on September 4, 2017.
Health for Life—Annual Report 44 CROSSCUTTING INDICATORS Target (FY 2016-17) Baseline Achievement Percent of SN Indicator Status Justification /Source Target (July 2016 – annual target June 2017) 1 Number of joint monitoring visits in which More joint visits were carried out by GON district-level multiple USAID partners and/or GON participate staff jointly with H4L staff. (Breakdown: EQ–199, Core– 485; Demo–116). A significant number of visits (from NA 650 828 127% Surpassed Region/Center–26) made jointly with DoHS, MoH and USAID staff to support QI, IMNCI and preparation of JAR meeting, etc. 2 Percent of leadership positions in USG-supported community management entities that are filled 27% 27% 27% 100% Achieved by a women or member of a vulnerable group 3 Number of people trained on financial 300 346 104 257 people trained in PFM carried out by DoHS and 89 management systems with USG assistance Female-75 Female–31 115% Surpassed (FY 2015-2016) people trained in Bookkeeping in EQ districts Male-225 Male-315 4 Percent of USG supported CSOs and community Expenditure tracking was done in 400 out of 445 VDCs management entities engaged in public 80% where H4L worked in this fiscal year. >90% 90% 100% Achieved expenditure tracking (FY 2015-16) 84% (241 of 286 VDCs) in Demo and Core districts 100% in EQ districts (159 VDCs) 5 Numbers of Policies/Regulations/Administrative H4L assigned an Expert Technical Advisor at MOH to Procedures in each of the following stages of provide TA in strengthening national-level stewardship development as a result of USG assistance in each of the health sector by supporting development of 4 case: Stage 1: Analyzed; Stage 2: Drafted and new national policies. presented for public/stakeholder consultation; Stage 1: TOR developed for Policy Framework for the Stage 3: Presented for legislation/decree; Stage 4: Establishment, Operation and Monitoring of Urban Passed/approved; Stage 5: Passed for which Health Promotion Centers implementation has begun. 14 Stage 2 Policy on Public Private Partnership in Health Sector (State-Non-State Partnership policy): Shared Stage 1= 1 draft with National Planning Commission NA 11 Stage 2 = 2 127% Surpassed Stage 3 = 4 Stage 2 FCHV strategy: No change in status Stage 4 = 2 Stage 3 LAFP Coaching Skill Standardization Package: Stage 5= 5 Document prepared but no progress Stage 3 QAI Guidelines: Presented to MD for approval Stage 3 National Health Bill - 2074 (2017): sent for Ministry of Law and Justice Stage 3 Nepal Health Institution Quality Assurance Council: Sent for Ministry of Law and Justice
Health for Life—Annual Report 45 Target (FY 2016-17) Baseline Achievement Percent of SN Indicator Status Justification /Source Target (July 2016 – annual target June 2017) Stage 4 DQA Protocol/Guide (PHAMED and HMIS): Piloting completed, ready for implementation Stage 4 NHRC Web-portal Guide/Manual: NHRC Web- portal completed and dissemination event held Stage 5 Newborn training module: Already implemented: trained about 100 medical officers using this module Stage 5 NHSS-IP: Approved and now being implemented Stage 5 Remote Area Guideline: Passed and implementation ongoing. Stage 5 Revision of AMA Guideline; Passed and implementation ongoing. Stage 5 Training site QI reporting tools: Already implemented: FP Training Sites using it, no plan for publication 6 Amount of targeted DDC and VDC funds Released amount available from 159 VDCs in EQ leveraged for health, agriculture, environment, districts education, and/or GESI activities 135 VDCs in Core (one facility each from Bardiya; 2 from Dailekh; zero from Dang, Jajarkot and Rukum) NPR 48,840,825 112 VDCs in Demo districts 51,644,000 126,949,664 239% Surpassed (FY 2015-2016) Core and Demo: NPR 81,979,832 EQ: NPR 44,969,832
51 high-priority VDCs were added to EQ district program 7 Percent of targeted local institutions that have annual plans (health, forest, education, 84.2% >95% 100% 105% Achieved agriculture/livestock) with budget allocation (FY 2015-2016) specifically for marginalized groups
Health for Life—Annual Report 46 E. INFORMATION ON TH E STATUS OF FINANCES, INCLUDING EXPENDIT URE DATA BASED ON THE BUDGET AND ACCRUALS, AS W ELL AS, W HEN APPROPRIATE, ANALYSIS AND EXPLANATION OF COST OVERRUNS OR HIGH UNIT COST
Health for Life—Annual Report 47 F. INFORMATION O N MANAGEMENT ISSUES, INCLUDING ADMINISTRATIVE PROBLEMS, OR PROBLEMS W ITH BENEFI CIARY GROUPS, OR IMPLEMENTING PARTNERS AND W HAT STEPS OR ACTIONS W ERE TAKEN T O MANAGE THESE AND LESSONS LEARNED FOR FUTURE Additional Development Associates could not be recruited and deployed as planned due to delays in modifying the contract between Rolling Plans and RTI International. This in turn led to delays in the expanded VDCs. Delays in approval for video documentation of Radio Bahas and the School Health Program meant the program was delayed until the peak of monsoon season/end of school year. This presented some difficulties in compiling data and difficulty in filming.
G. ANTICIPATED FUTUR E PROBLEMS, DELAYS, OR CONDITIONS THAT MAY ADVERSELY IMPACT IMPLEMENTATION OF THE PROJECT AND W HAT MEASURES ARE IN PLAC E TO DEAL W ITH THESE Responsibility for service delivery, including health, has been given to the Municipalities in general and Ward Committees, in particular. Accordingly, local HFs (health posts and primary hospitals up to 15 beds), their properties, human resources and service provisions have been handed over to these municipalities and ward committees. As HFOMCs may not exist in the changed context, it has yet to be seen whether these Ward Committees will themselves take charge of management or appoint separate committees, such as HFOMCs. However, this process of understanding and fixing the issues will take some time, which will almost certainly affect normal operation of service delivery due to various management shortcomings. MoH is in process of deputing Municipal Health Officers and the indication is that existing AHWs of grade 6 and 7 are being sent to most rural municipalities. Public health strength at the municipal level is a low priority as these officers lack an understanding of the importance of public health in the changed context, and many do not have adequate drive as most of them are at retiring age. To deal with this situation, Health for Life has a plan to reposition district and hub staff in clusters to oversee municipalities and provide necessary technical support in close proximity of Wards and Municipalities. In addition, Health for Life is in the process of developing an Orientation and Municipal Health Planning Workshop package and a manual for Municipalities and Ward Committees. In Core and EQ-affected districts, orienting the elected executives and government officials on their roles and functions and the planning process is in progress. It is expected that normal services will continue without interruption, and the evidence-based planning process takes place to prioritize health as a local development agenda. Two more elections, provincial and federal, are planned within 7 months. These elections will have an impact on the functioning of local governments meaning they will have less time for Health for Life’s technical assistance, including management oversight and service institutions. The PPR and PMP indicators based on the HMIS will likely to be affected due to restructuring and changes in responsibilities at the D(P)HOs and reporting alignment at new local government units (municipal health units). The transition to the DHIS-2 platform this year, together with structural changes at the local level, will likely create confusion over the next reporting period. HMIS has not provided wide access to DHIS-2 data for partners yet because they want to build confidence in the data before providing access. Due to changes in the system, it will take time for users to understand the actual impact on indicator reporting. However, Health for Life will continue to coordinate with HMIS in Kathmandu and at the municipal level to understand the problems and provide solutions.
Health for Life—Annual Report 48 H. INFORMATION ON SE CURITY ISSUES, ESPECIALLY AS THESE AFFECT PROGRAM INTEGRITY AND SAFETY OF BENEFICIARY GROUPS AND IMPLEMENTING PARTNER Beneficiaries were prevented from getting health services during the health worker strike. Health for Life circulated information to other staff in an attempt to provide regular and continuous services.
I. OTHER INFORMATION , SUCH AS NEW OPPORTUNITIES FOR PR OGRAM EXPANSION, LESSONS-LEARNED AND SUCCESS STORIES, AND PROSPECTS FOR THE FOLLOW ING YEAR’S PERFORMANCE A results monitoring system based on a GIS application for selected indicators (linked to the work plan and activities) is being developed in collaboration with USAID. As a part of strengthening the NHRC’s knowledge management capacity, an online course for health research ethics will be developed for researchers applying for ethics approval. A number of stories featuring Health for Life’s work were published in this reporting period, including “Health Champion in the Hills,” a photo story featured on USAID’s Exposure account which recalls the work of Prakriti, a CAP/R in Rolpa, as well as a story on the HFOMC of Raniyapur “From Committee to Care,” featured on RTI’s Medium account. Furthermore, Health for Life’s page on RTI’s website has been updated to include past stories and technical briefs.
Health for Life—Annual Report 49 ANNEXES
ANNEX 1: DOHS RISK MITIGATION ACTION PLAN DOHS RISK MITIGATION ACTION PLAN (RMAP) FOR FY 2017/18 The Risk Mitigation Action Plan (RMAP) for FY 2017-18 was prepared based on the audit observations of USAID commissioned audit report 2015/16. The RMAP addresses the recommendations issued by USAID Regional Inspector General’s Office (RIG/Manila) for improvements that are identified by the audit. The following risk mitigation actions will be implemented jointly by DoHS and USAID/Nepal:
Audit Findings and Recommendations of Risk Mitigation Actions RIG/Manila
Recommendation No. 1 Allowability of and recovery of the questioned costs The Finance Administration Section, DoHS has already issued raised on the following issues: letters to the respective Centers and Offices in the districts • Expenditures charged not in accordance with the requesting to explain on the audit issues and submit necessary family health department directive. supporting documents as appropriate. • Operational expenditures not necessary to the award charged to USAID fund. Conduct joint monitoring visits of USAID and DOHS in the • Expenditures claimed not in accordance with the districts namely Gulmi (DHO), Kailali (DPHO) and Salyan (DHO) approved budget in the Implementation Letter (IL). to share the audit findings, obtain the necessary supporting documents as appropriate for resolving the questioned costs and • Value added tax payments explicitly prohibited by the discuss the remedial future actions. These districts had the highest agreement. magnitude of audit irregularities. • Insufficient supporting documents.
Recommendation No. 2 Conduct workshop/meeting to develop a common understanding 2.1 Internal Control Deficiencies among the respective Divisions/Centers on the budget and activity • Delay in issuance of release order execution, including the USAID requirements to implement the • Program expenses charged not as per the family Redbook supported activities as well as midterm review on the health directive status updated and challenges, in the context of a transitional phase • Insufficient supporting documents to a federal structure. • Operational expenditure charged to USAID fund Review the questioned costs raised in the USAID commissioned • Segregation of FHD and CHD expenditure not made audit reports in order for resolution process of the questioned costs • ‘Paid’ stamp not affixed Monitor the release order and burn rate through Transactional Accounting and Budget Control Systems (TABUCS) implemented by MoH 2.2 Instances of Noncompliance Initiate consultation with USAID to engage the Office of Auditor General (OAG) to conduct annual audit of the USAID support to • Expenditure outside of IL budget DoHS • Approved budget as per IL does not tally with the Organize regional/provincial level workshops on Public Financial budget of Financial Report of DoHS Management to the local/district level staff on GoN financial and • Value Added Tax (VAT) booked as expenses procurement rules and regulations and USAID requirements Conduct joint monitoring visits of USAID and DOHS in the districts with comparatively high USAID Redbook budget allocations in the NFY 2017/18 to monitor the financial transactions and to provide technical inputs for financial improvements. These districts will be selected once the activity budgets have been approved.
Health for Life—Annual Report 50 ANNEX 2: JOINT VISITS H4L AND GON JOINT VISITS FROM MOH/DOHS TO H4L DISTRICTS, JULY 2016 TO JUNE 2017 Name of Visitors from Date SN Organization Visitor from H4L Districts Purpose GoN and Partners From To 1 FHD Jul 14, 2016 Jul 15, 2016 Bardiya To conduct TOT of MSc as a part of MSC program implementation 2 FHD Arghakhanchi (DHO and To Monitor MSC program Jul 18, 2016 Jul 22, 2016 Dharapani HP) and Kapilvastu (DHO and Rajpur HP) 3 CHD/DoHS RMS Nepalgunj, Rolpa (DHO, To monitor IMNCI Program Sep 24, 2016 Sep 28, 2016 Khumel HP and Sulichaur PHC) and Banke (Kohalpur HP and Khajura PHC) 4 MD/DoHS DPHO Banke and Ganapur HP To monitor HF QI activities and QI MD/DoHS Sep 26, 2016 Sep 26, 2016 self-assessment process
5 MD/DoHS Bankatti HP, Banke and Dhikpur To monitor HF QI activities and QI and Manpur, Dang self-assessment process
Sep 27, 2016 Sep 29, 2016
6 MD/DoHS Oct 2, 2016 Oct 2, 2016 Sripur HP, Kailali To monitor HF QI activities and QI MD/DoHS self-assessment process 7 CHD/DoHS Surkhet (MWRH) To visit proposed IMNCI training site UNICEF Nov 11, 2016 Nov 24, 2016 SUAAHARA/CARE 8 CHD/DoHS Surkhet (MWRH) To support on IMNCI TOT SUAAHARA/CARE Nov28, 2016 Dec 2, 2016 SUAAHARA/CARE 9 CHD/DoHS Nepalgunj To support on CB-IMNCI program CHD/DoHS Dec 6, 2016 Dec 9, 2016 review SUAAHARA/CARE 10 Pyuthan DHQ, Bhingri and CBIMNCI one day review meeting and PHI, CHD, DoHS Jan 3, 2017 Jan 7, 2017 Okharkot RAG orientation
11
DPHO Surkhet Jan 18, 2017 Jan 18, 2017 Mehelkuna CBIMNCI one day review meeting
12 CBIMNCI district planning and PHI, CHD Teku Kathmandu Jan 24, 2017 Jan 30, 2017 DHQ, Salyan management training 13 PHO, CHD Teku Feb 6, 2017 8 Feb, 2017 DHQ, Kapilvastu CBIMNCI district planning Kathmandu Health for Life—Annual Report 51 Date Name of Visitors from SN Organization Visitor from H4L Districts Purpose GoN and Partners From To 14 CHD/DoHS Jajrkot (DHO Jajarkot and Kudu To orient stakeholders on Remote Area Mar 6, 2017 Mar 9, 2017 HP) Guideline-IMNCI
To monitor IMNCI program 15 District headquarter, Surkhet CAP review Meeting DPHA Mar 8, 2017 Mar 8, 2017 HETO
16 MO, CHD Mar 14, 2017 Mar 19, 2017 DHQ Arghakhanchi CBIMNCI review meeting 17 CHD/DoHS Bardiya (DHO, and To monitor IMNCI program WWRHD Mar 23, 2017 Mar 24, 2017 Mohammadpur HP DHO Bardiya Banke (DPHO) 18 Visit facility for H4L support in system CoR, USAID Mar 31, 2017 Apr 02, 2017 Pavera HP, Godavari HP strengthening and quality improvement, status of collaborative framework
19 CBIMNCI Officer_RHD Mar 31, 2017 Apr 2, 2017 DHQ Dailekh CBIMNCI district planning
20 PHI RHD Apr 3, 2017 Apr 5, 2017 DHQ Jajarkot CBIMNCI one day review meeting 21 FHD/DoHS Bardiya (DHO and To monitor MSC program FHD/DoHS Apr 20, 2017 Apr 22, 2017 Mohamadpur HP) FHD/DoHS 22 Rukum- Bafikot HP, Dang DHO Visit and meet HFOMC and QI Team Office and Urahari HP and for mobilization of health flexi grant SPHA, CF Focal Point/MD May 24, 2017 May 28, 2017 Salyan-Dhanabang & Tharmare and other resources from VDC and PHC others DoHS/CHD Kaski To organize preliminary discussion at UNICEF (WRHD and WRH, Pokhara, potential IMNCI Western Regional Hospital) training site in province 4 23 May 25, 2017 May 26, 2017 To orient WRHD staff on RDQA- IMNCI Planning and Monitoring 24 May 25, 2017 May 26, 2017 DHQ Pyuthan Program Monitoring visit officer (CHD) 25 CHD/DoHS Surkhet (MWRH) To visit provisional IMNCI training site UNICEF Jun 1, 2017 Jun 3, 2017 before certification UNICEF 26 Tharmare, Salyan Radio Bahas Program IMNCI Focal Person Jun 21, 2017 Jun 21, 2017
Keshab Baral NRA Ramesh Adhikari Chief Public Health Ram Sedhain Administrator, MoH 27 Jan 17, 2017 Jan 20, 2017 Rasuwa and Nuwakot Pre-JAR visit Giri Raj Subedi Senior Public Health Administrator, PHAMED, Pradeep Adhikari MoH
Health for Life—Annual Report 52 Date Name of Visitors from SN Organization Visitor from H4L Districts Purpose GoN and Partners From To Public Health Administrator, MoH Management Division, DOHS Family Health Division, DOHS Medical Officer, Child Health Division, DOHS Program Director, National Planning Commission MoFALD Chief, PHAMED, MoH
Under secretary, MoH Senior Public Health Administrator, MoH 28 Chief Planning and Jan 16, 2017 Jan 20, 2017 Jhapa and Saptari Pre-JAR visit Monitoring Section, Child Health Division, DoHS Chief, PPICD, MoH USAID USAID USAID UNFPA NHSSP
Health for Life—Annual Report 53 ANNEX 3: MAPS AND GIS DATA
Health for Life—Annual Report 54 Health for Life—Annual Report 55 Health for Life—Annual Report 56 Health for Life—Annual Report 57 Health for Life—Annual Report 58 Health for Life—Annual Report 59 Health for Life—Annual Report 60 Health for Life—Annual Report 61 Health for Life—Annual Report 62 Health for Life—Annual Report 63 Health for Life—Annual Report 64 Health for Life—Annual Report 65 Health for Life—Annual Report 66 Health for Life—Annual Report 67 Health for Life—Annual Report 68 GIS DATA SHEET, HEALTH FOR LIFE CORE DISTRICTS
s y n r
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o C
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I
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n c b A W p C e a S H R e n g s o i T i
P P YP l p e M _D _D A
_S _QA a _New _I _P _C _C a _H _L _M _C _D t _S a b a a 3 6 7 8 9 1 2 6 7 8 c i 1 2 2 3 9 1 1 1 1 1 2 2 2 2 2 r P P P P P P P P P P P P P P P t s i M M M M M M M M M M M M M M M D P P P P P P P P P P P P P P P Arghakhanchi 57 90 100 68 100 Yes 26 23 Yes 32 6985 15 18 21 84 Banke 15 100 86 94 90 Yes 61 66 No 67 31552 22 60 31 81 Bardiya 119 90 89 86 90 Yes 54 52 Yes 56 29301 29 52 40 79 Dailekh 0 82 100 85 73 Yes 48 70 No 54 13820 18 104 48 93 Dang 80 90 100 90 80 Yes 68 62 No 72 32443 31 26 23 74 Jajarkot 13 40 97 72 70 Yes 29 33 Yes 49 14343 24 35 29 64 Jumla 93 60 98 74 80 Yes 38 43 Yes 82 7574 14 41 29 89 Kalikot 27 100 100 71 80 Yes 59 65 Yes 73 8523 36 84 11 87 Kapilvastu 4 90 100 88 90 Yes 32 37 Yes 54 38018 22 24 43 89 Pyuthan 57 90 98 71 90 Yes 54 56 Yes 55 14262 27 37 43 58 Rolpa 67 100 42 76 100 Yes 38 51 Yes 52 16051 34 66 48 84 Rukum 0 90 98 93 90 Yes 34 38 Yes 39 8576 8 26 40 84 Salyan 15 90 100 88 90 Yes 42 41 Yes 56 12314 24 43 38 87 Surkhet 98 90 100 87 80 Yes 31 45 Yes 33 22713 21 63 33 89
Health for Life—Annual Report 69