Annual Health Report 2075/76

ANNUAL HEALTH REPORT

2075/76

Government of Province Province No. 5 Ministry of Social Development Health Directorate, Butwal Phone no: 071-420490 Email: [email protected] Website: www.hd.p5.gov.np

MESSAGE FROM HONOURABLE MINISTER OF SOCIAL DEVELOPMENT

MESSAGE FROM SECRETARY OF MINISTRY OF SOCIAL DEVELOPMENT

MESSAGE FROM DIRECTOR OF HEALTH DIRECTORATE

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TABLE OF CONTENTS Message from Honourable minister of social development ...... i Message from Secretary of ministry of social development ...... ii Message from Director of Health Directorate ...... iii Table of Contents ...... iv Executive Summary ...... vi Abbreviations and Acronyms ...... xi Health Services Fact Sheet ...... xvi Chapter I: Introduction ...... 1 General Information ...... 1 Health Service Delivery Units ...... 3 Status of Human Resource in Health ...... 4 Chapter II: Public Health Programs ...... 5 Immunization ...... 5 Nutrition ...... 16 Integrated Management of Newborn and Child Health ...... 27 Family Planning and Reproductive Health ...... 31 Safe motherhood ...... 38 Adolescent Sexual and Reproductive Health ...... 47 Primary Health Care Outreach Clinic ...... 50 Female Community Health Volunteer ...... 53 Malaria ...... 56 Kala-azar...... 60 Dengue ...... 61 Lymphatic Filariasis ...... 62 Tuberculosis ...... 63 Leprosy ...... 67 HIV/AIDS and STI ...... 71 Disaster Management ...... 74 Chapter III: Curative Health Services ...... 76 Major Services Available in Hospitals ...... 76 Status of Human Resource in Hospitals ...... 78 Contact List of Hospitals Under Province: ...... 79 Infrastructure and Equipment ...... 81 Major Hospital Indicators ...... 84 Diagnostic Services ...... 90

Social Service Unit ...... 92 One-Door Crisis Management Center ...... 95 Health Care Waste Management ...... 98 Minimum Service Standard ...... 101 Major Issues and Recommendations ...... 102 Hospital Services Expansion Plans: ...... 106 Chapter IV: Ayurveda and Alternative Medicine ...... 108 Chapter V: Health Management Information ...... 114 Chapter VI: Province Health Logistics Management Centre ...... 117 Chapter VII: Province Health Training Centre ...... 120 Chapter VIII: Province public health laboratory...... 121 Chapter IX: Health Insurance ...... 123 Chapter X: Contribution of the Local Level Government and Community ...... 126 Chapter XI: Programs Carried out by Province in FY 2075/76 ...... 128 Chapter XII: Program of FY 2076/77 ...... 130 Chapter XII: External Development Partners ...... 132

EXECUTIVE SUMMARY Introduction This is the first ever annual report of the Health Directorate, Province 5 after establishing this organization. This report highlights the comparative analysis of important public health indicators, curative service indicators and Ayurveda health services indicators. In addition, the report identifies the issues/problems raised and recommendations made by the stakeholders during provincial annual health review of the Province. In Province no. 5, health services have been delivered to the people of the Province through various levels of health institutions. The Province has 3 central level hospitals governed by federal government, 13 hospitals governed by provincial government and 4 hospitals governed by local level government, similarly, 1 provincial Ayurveda Chikitsalaya, 2 Ayurveda Chikitsalay and 8 Ayurveda health centers are governed by provincial government. The Province also has 30 PHCCs, 45 Ayurveda ausadhalaya, 570 health posts, 97 Urban Health Centers (UHCs), 66 Community Health Units (CHUs), 15 Basic Health Units which all are governed by local level government. In Province 5, there is 14 Comprehensive Emergency Obstetric and Neonatal Care Centers (CEmONCs), 32 Basic Emergency Obstetric and Neonatal Care Centers (BEmONCs), 363 Birthing Centers (BCs), 2704 Expanded Program on Immunization (EPI) clinics, 1942 Primary Health Care Out Reach Clinics (PHC/ORCs) and 8994 Female Community Health Volunteers (FCHVs). As the policy of the federal government is to establish one health institutions in each wards of newly created wards of Rural Municipality/Municipality/Sub Metropolitan City/Metropolitan city, 275 wards in the Province have no any health facility out of total 983 wards. Immunization The National Immunization Program (NIP) formerly Expanded Program on Immunization (EPI) was started in FY 2034/35 and is a priority 1 program. It is one of the successful public health interventions of Ministry of Health and Population. It made a large contribution to Nepal's achievement of Millennium Development Goal 4 and 5 by reducing morbidity and mortality among children and mothers from vaccine preventable diseases. Nepal's constitution has assured access to basic health care services as a fundamental right of the people. The Immunization Act endorsed (BS 2072 Magh 12) has ensured the right to access quality vaccines to every child. National Immunization Program has included several underused and new vaccines in program and currently there are eleven antigens–BCG, DPT-HepB-Hib (penta), PCV, OPV (bOPV), Measles and Rubella (MR) and Japanese Encephalitis. The coverage of all antigens except JE in the Province increased in 075/76 compare to 074/075. The highest coverage was of BCG (98%), DPT-HepB-Hib3 (90%), oral polio vaccine 3 (90%), which were all more than or equal to the previous year. The measles rubella second dose coverage was lowest among antigen for children (84%) in FY 2075/76, however increased by 5% compared to previous year's coverage (79%). Fully immunized district declaration initiative is one of new advocacy and ownership taking approach by government of Nepal, which is found to be effective in ensuring resource allocation, public awareness and service delivery. In Province no. 5, Rukum East, Kapilvastu, Banke and Bardia districts were yet to be declared as fully immunization districts.

Nutrition The national nutrition programme is also the priority one programme of the government of Nepal. It aims to achieve the nutritional well-being of all people so as they can maintain a healthy life and contributed to the country's socioeconomic development. There is high level commitment from provincial government in improving the nutritional status especially of women and of young children. In 2075/76, the proportion of new born with low birth weight was (9%), found to be decreased by 3% compared to previous year (11%) in the Province. Almost 100 percent children were registered for new growth monitoring visit, however the average number of growth monitoring visits in the Province among 0-23 month’s children was 3 in FY 2075/76 which was same as previous year. More than 4 percent of children aged 0-23 months registered for growth monitoring were found underweight in this FY, which was same as previous year (4.1%). Integrated management of Childhood Illness In October 2014 the childhood (CB-IMCI) and newborn (CBNCP) care programmes were merged into the Community Based Integrated Management of Childhood Illness (CB-IMNCI) programme to give a more integrated approach. It is an integrated package of child-survival interventions and addresses major newborn care conditions including birth asphyxia, bacterial infection, jaundice, hypothermia, low birth weight, and encouragement of breastfeeding. It addresses the major illnesses of 2 to 59 month old children — pneumonia, diarrhoea, malaria, measles and malnutrition, in a holistic way. The institutional delivery rate in the Province is 79% but only 85 percent newborn born in the institution got chlorhexidine jel. The incidence of ARI and diarrhea among under 5 years children is 579/1000 U5 children and 404/1000 U5 children respectively. The incidence of pneumonia was 76/1000 U5 children and the proportion of children with diarrhea treated by ORS and Zinc is 94 percent. Family planning In order to provide Family Planning services to the reproductive age population choose them when to have children or with options to limit or space births, various modern contraceptive methods are made available under the national health services delivery system. Family planning services are provided through different health institutions at various levels through static clinics as well as mobile outreach services and through visiting providers where necessary especially to marginalized communities settlement area and geographically remote area. FP micro plans are undertaken to tackle the demand and supply side bottlenecks for accessing and utilization of FP services in Rural/ Municipalities where the FP service utilization rate and CPR is low in the Province. The Contraceptive Prevalence Rate (CPR) is one of the main indicators for monitoring and evaluating the Family Planning Program. The contraceptive prevalence rate (CPR) for modern family planning method in the Province is 43% in fiscal year 2075/76, slightly increased from 41 percent in previous year. Condom and Depo remained two most common modern method preferred by new acceptors. Safe Motherhood The goal of National Safe Motherhood Program is to reduce maternal and neonatal morbidity and mortality and improve maternal and neonatal health through preventive and promotive activities and by addressing avoidable factors that cause death during pregnancy, childbirth and the postpartum period. Pregnant women attending at least 4 ANC visits as well as institutional delivery as percentage of expected live births continuously increased from last two years. In other hand the PNC three visits remained challenging as the proportion of three PNC visits was in decreasing trend from 22 percent vii in 2074/75 to 19 percent in 2075/76. Looking at the safe abortion services, more than 17 thousands safe abortion service were provided and 1437 CAC services were provided to less than 20 years women. A huge proportion of abortions was expected which could be done illegally and unsafe in the Province. Female Community Health Volunteers The major role of the Female Community Health Volunteers (FCHVs) is promotion of safe motherhood, child health, family planning, and other community based health services to promote health and healthy behavior of mothers and community people with support from health workers and health facilities. At present there are 8994 FCHVs in the Province actively working. FCHVs contributed significantly in the distribution of oral contraceptive Pills, Condoms and Oral Rehydration Solution (ORS) packets and counseling and referring to mothers in the health facilities for the service utilization. FCHVs have distributed a total of 2026684 packets of Condom, 158067 cycles of pills, and 187123 iron tablets in FY 2075/76. Service statistics also show that 11849 pneumonia cases of 2 to 59 months child were treated by FCHV using cotrim, 11935 diarrheal cases were treated by FCHVs in the Province. Primary Health Care Outreach Clinics Based on the local needs PHC/ORCs are conducted every month at fixed locations on specific dates and time. The clinics are conducted within half an hour's walking distance for the population residing in that area. Primary health care outreach clinics (PHC/ORC) extend basic health care services to the community level. Total number of clinics expected to run in a year 23304 (1942 PHC/ORC Clinics x 12 times). However, only 95% clinics were conducted in FY 2075/76. On an average 22 clients were served per clinic during the fiscal year 2075/76. Malaria Nepal has surpassed the Millennium Development Goal 6 by reducing malaria morbidity and mortality rates by more than 50% in 2010 as compared to 2000. Therefore, Government of Nepal has set a vision of Malaria free Nepal in 2025. Current National Malaria Strategic Plan (NMSP) 2014- 2025 was developed based on the epidemiology of malaria derived from 2012 micro- stratification. The aim of NMSP is to attain “Malaria Free Nepal by 2026”. Total positive cases of malaria in the Province slightly decreased from 239 in 2074/75 to 219 in 2075/76. Out of 219 cases in 2075/76, 45 cases were indigenous and 174 cases were imported. Plasmodium falciparum cases accounted for 4 percent of total cases among which only 1 case is indigenous. Kala-azar Kala-azar is a major public health problem in terai districts of Nepal and to eliminate Kala azar in Nepal set goal to improve the health status of vulnerable groups and at risk populations living in kala-azar endemic areas of Nepal. In Province 5 cases of kala-azar were found 61 cases in 2075/76 and 65 cases in FY 2074/2075. Few years back, kala-azar was considered as the public health problem of 12 eastern terai districts but the disease was found to be travelled from east to west and climbed to hilly districts. A total of 15 cases were found in Rupandehi, 42 cases were found in Banke and 4 cases were found in Palpa in FY 2075/76.

Dengue Dengue, a mosquito-borne disease emerged in Nepal in since 2005. The goal of national Dengue control program is to reduce the morbidity and mortality due to dengue fever, dengue haemorrhagic fever (DHF) and dengue shock syndrome (DSS). Frequent outbreaks were reported viii in Province no. 5 in the past. While comparing the number of cases, numbers of cases were increased by more than 6 times as the numbers of cases were 114 in 2018, more than 300 times as numbers 3454 in 2019(Up to December 1st 2019). Lymphatic Filariasis Lymphatic Filariasis (LF) is a public health problem in Nepal. The goal of national Lymphatic Filariasis programme is the people of Nepal no longer suffer from lymphatic filariasis. Government of Neal has adopted MDA as an important strategy to eliminate Lymphatic Filariasis. However, cases were identified even after 6 round of intensive mass drug administration in two districts: Banke and Bardia. A total of 249 cases were reported in Province 5 and Arghakhanchi district accounted for the highest number of cases (86) among 12 districts in the Province. While looking at the trend, the number of cases identified in 2075/76 (249 cases) were more than compared to 2074/75 (185 cases). Tuberculosis Tuberculosis (TB) is still a major public health problem in Nepal. Directly Observed Treatment short course (DOTS) has successfully been implemented throughout the country since April 2001 and a total of 644 DOTS treatment centers are providing TB treatment service throughout this Province. In Fiscal Year 2075/76, total of 5877 cases were registered in Province no.5. Out of total cases, 59.09 percent were new and relapse pulmonary smear positive cases, 24.23 percent were extra pulmonary TB cases, 13.08 percent cases were pulmonary clinically diagnosed and 1.08 percent cases were smear positive retreatment cases. The case notification rate in the Province decreased to 118/100000 population in FY2075/76 compared to 136/100000 population, however it was under the target need to be achieved as set by National Tuberculosis Center. The treatment success rate was 89 percent in 2075/76, slightly increased from 87 in 2074/75. A total of 118 cases were detected as MDR TB cases in FY 2075/76 Leprosy During the reporting year 2075/76, a total number of 691 new leprosy cases were detected and put under Multi Drug Therapy (MDT) in Province no.5. The prevalence of the leprosy in the Province was higher than the national figure as its prevalence in national level was below 1/10000, whereas, the provincial prevalence rate is 1/10000. Rupandehi district had highest number of leprosy cases (130 cases) under treatment at the end of this FY 2075/76 among total cases 486. Banke reported the highest disability grade -2 as 10 percent new cases were found with disability grade-2.

HIV/AIDS and STI With the first case of HIV identification in 1988, Nepal started its policy response to the epidemic of HIV through its first national policy in 1995. A new National HIV Strategic Plan 2016-2021 is recently launched to achieve ambitious global goals of 90-90-90. By 2020, 90% of all people living with HIV (PLHIV) will know their HIV status by 2020, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy and by 2020, 90% of all people receiving antiretroviral therapy will have viral suppression. In Province no.5, 21231 cases were tested for HIV and 417 cases were found positive with HIV in 2075/76 which was slightly lower in compared to previous year. A total of 95825 women during ANC and labor stage were tested for HIV for prevention of mother to child transmission and 38 pregnant women were found positive. Curative Services Curative health services were provided to outpatients, including emergency patients, and inpatients. Outpatient services was provided through OPD of Health Post, PHCC, different level of public Hospitals, Medical Colleges, NGO/INGO led hospitals and private hospitals whereas Inpatient ix services were provided different level of public hospitals including INGOs/NGOs, Private medical college hospitals, nursing homes, and private hospitals. The percentage of new OPD visits was 81 percent in the Province in FY 2075/76. Average Bed Occupancy Rate (BOR) of the hospitals in this Province is 69 percent. A total of 22225 major and 33321 minor surgeries were performed in the different hospital in the Province. Out of 87706 deliveries conducted in health institution about 15 percent delivered through cesarean section in FY 2075/76. Ayurveda and Alternative Health Services Ayurveda health system is considered world's oldest health system with scientific evidences. Despite, the low priority in past years, Ayurveda and alternative medicine has been taking important place in national health system. National policies and programs have now prioritized the Ayurveda and alternative medicine as important part of the system. A range of Ayurveda health institutions are providing outpatient as well as inpatient health services in the Province. About 6% of total populations of this Province were served by Ayurveda Health institutions in FY 2075/76. A. Health Insurance Program Social Health Security program is being implemented in 9 districts of Province 5 namely Bardiya, Banke, Rukum East, Rolpa, Pyuthan, Arghakhanchi, Kapilvastu, Palpa and Rupandehi. Out of 3737013 population, 416129 population from 118562 households are insured across 9 social health insurance implementing districts in Province 5 which constitutes 11.13 percent of total population.

B. Development Partner Support

Development partners support the government health system through a sector-wise approach (SWAp). The SWAp now supports the implementation of the new Nepal Health Sector Strategy (NHSS, 2016–2021). More than 20 development partners are working in the Province no. 5 in different sectors like strengthening health system to providing range of services from clinical to public health services. Role of development partners was crucial in achieving the health targets like SDG, NHSS targets.

ABBREVIATIONS AND ACRONYMS

AAHW auxiliary Ayurveda health worker ADRA Adventist Development and Relief Agency AEFI adverse event following immunization AES acute encephalitis syndrome AFP acute flaccid paralysis AGE acute gastroenteritis AHW auxiliary health worker AIDS acquired immuno-deficiency syndrome AMDA Association of Medical Doctors of Asia AMR antimicrobial resistance ANC antenatal care ANM auxiliary nurse-midwife API annual parasite incidence ARI acute respiratory infection ART antiretroviral therapy ASBA advanced skilled birth attendant ASRH adolescent sexual and reproductive health BC birthing centre BCC behaviour change communication BS Bikram Sambat (Nepali era) BTSC blood transfusion service centre CB-IMCI Community-Based Integrated Management of Childhood Illness programme CB-IMNCI Community Based Integrated Management of Neonatal and Childhood Illness CB-NCP Community Based Integrated Management of Newborn Care Programme CBO community-based organisation CB-PMTCT Community-Based Prevention of Mother to Children Transmission CDD control of diarrheal disease CEONC comprehensive emergency obstetric and neonatal care CHD Child Health Department CHX chlorhexidine CNR case notification rate CoFP Comprehensive family planning CPR contraceptive prevalence rate CRS congenital rubella syndrome DDA Department of Drug Administration DHF dengue haemorrhagic fever DHIS District Health Information System DoA Department of Ayurveda DoHS Department of Health Services DOTS Directly Observed Treatment Short Course

DPT diphtheria, pertussis, tetanus DQSA data quality self-assessment DSS dengue shock syndrome EDCD Epidemiology and Disease Control Division EDP external development partners EHCS essential health care services EmOC emergency obstetric care EOC essential obstetric care EPI Expanded Programme on Immunization EQA external quality assurance EWARS Early Warning and Reporting System FCHV female community health volunteer FWD Family Welfare Division FSW female sex worker FY fiscal year G2D grade 2 disability GIS geographic information system GIZ German Society for International Cooperation (Deutsche Gesellschaft für Internationale Zusammenarbeit) GoN Government of Nepal HA health assistant HD Health Directorate HFOMC health facility operation and management committee HIIS Health Infrastructure Information System HIV human immunodeficiency virus HMIS Health Management Information System HO Health Office ICD International Classification of Diseases ICT immunochromatographic test IDA iron deficiency anaemia IDD iodine deficiency disorder IEC information, education and communication IFA supplementary iron folic acid IMAM Integrated Management of Acute Malnutrition IMCI integrated management of childhood illness INGO international non-governmental organizations Ipas International Pregnancy Advisory Services IPV inactivated polio vaccine IRS indoor residual spraying IT information technology IUCD intrauterine contraceptive device JE Japanese encephalitis LAPM long acting and permanent methods LARC Long acting reversible contraceptive xii

LCD Leprosy Control Division LLIN long lasting insecticidal (bed) nets LMD Logistics Management Division LMIS Logistics Management Information System LTF lost to follow-up M&E monitoring and Evaluation MA medical abortion MAM Management of Acute Malnutrition MB multibacillary leprosy MCH maternal and child health mCPR modern contraceptive prevalence rate MCV measles-containing vaccine MD Management Division MDA mass drug administration MDG Millennium Development Goal MDGP Doctor of Medicine in General Practice MDIS Malaria Disease Information System MDR multi-drug resistant MDT multi-drug therapy MDVP multi-dose vaccine vials MIYCN Maternal, Infant, and Young Children Nutrition programme MNCH maternal, newborn and child health MNH maternal and newborn health MNP Micro-Nutrient Powder MoFAGA Ministry of Federal Affair and General Administration MOHP Ministry of Health and Population MOSD Ministry of Social Development MPDSR maternal and perinatal death surveillance and response MR measles/rubella MSM men who have sex with men MSNP Multi-sector Nutrition Plan MVA manual vacuum aspiration MWDR Mid-Western Development Region NAHD National Adolescent Health and Development (Strategy) NCASC National Centre for AIDS and STD Control; NCD non-communicable disease NCDR new case detection rate NDHS Nepal Demographic and Health Survey NGO non-governmental organizations NHIP National Health Insurance Programme and Nepal HIV Investment Plan NHSP-IP Nepal Health Sector Programme-Implementation Plan NHSS Nepal Health Sector Strategy (2015-20), NHSSP Nepal health Sector Support Programme NHTC National Health Training Centre xiii

NIP National Immunization Programme NMC Nepal Medical Council NMICS Nepal Multiple Indicator Cluster Survey NTC National Tuberculosis Centre NTP National Tuberculosis Programme OPD outpatient OPV oral polio vaccine ORS oral rehydration solution PB paucibacillary leprosy PBC pulmonary bacteriologically confirmed PCD pulmonary clinically diagnosed PCV pneumococcal conjugate vaccine PDR perinatal death review PEM protein energy malnutrition PEN Package of Essential Non-communicable Diseases Pf Plasmodiumfalciparum PHCC primary health care centre PHC-ORC primary health care outreach clinics PHCRD Primary Health Care Revitalisation Division PLHIV people living with HIV PMTCT prevention of mother to child transmission PNC postnatal care PPH postpartum haemorrhage PSBI possible severe bacterial infection Pv Plasmodium vivax PWID people who inject drugs QI quality improvement RDT rapid diagnostic tests RTI reproductive tract infection SAHW senior auxiliary health worker SARC short acting reversible contraceptive SARI severe acute respiratory infection SBA skilled birth attendant/attendance SHSDC Social Health Security Development Committee SRH sexual and reproductive health SS+ smear positive STI sexually transmitted infections Td tetanus and diphtheria TT tetanus toxoid TTI transfusion transmissible infection UNFPA United Nations Population Fund UNICEF United Nations Children Fund USG ultrasonogram VA verbal autopsy and visual acuity xiv

VAD vitamin A deficiency VBDTRC Disease Training and Research Centre VPD vaccine-preventable disease VSC voluntary surgical contraception WASH water, sanitation and hygiene WDR Western Development Region WHO World Health Organisation WHO/IPD WHO Immunization Preventable Diseases WPV Wild poliovirus WRA Women of reproductive age

HEALTH SERVICES FACT SHEET Province 5 Programme Indicators 2073/74 2074/75 2075/76 REPORTING STATUS % of public hospitals reporting to HMIS 99 100 100 % of primary health care centres reporting to HMIS 100 99 100 % of health posts reporting to HMIS 100 100 100 % of PHC ORC Clinics reporting to HMIS 94 94 95 % of EPI clinics reporting to HMIS 98 97 99 % of Female Community Health Volunteers (FCHVs) reporting to 91 91 93 HMIS % of private health facilities reporting to HMIS 35 42 29 IMMUNIZATION % of children under one year immunized with BCG 92 98 98 % of children under one year immunized with DPT-HepB-Hib3 87 87 90 % of children under one year immunized with OPV 3 87 87 90 % of children under one year immunized against measles/rubella 67 79 84 2nd Dose % of children under one year immunized against Japanese 72 90 89 encephalitis Immunization programme: Dropout rate DPT-Hep B-Hib 1 vs 3 4 5 4 coverage NUTRITION % of low birth weight 9 11 9

% of children aged 0-23 months registered for growth monitoring 79 79 82 % of children aged 0-23 months registered for growth monitoring 4.4 4.1 3.9 who were underweight Average no. of visits among children aged 0-23 months registered 3.0 3.2 3.4 for growth monitoring % of children aged 0-6 months registered for growth monitoring 37.3 45.3 53.2 exclusively breastfed for the first six months Percentage of pregnant women received 180 tablets Iron 57.5 56.7 60.7 Integrated Management of Neonatal and Childhood Illness (IMNCI) % of newborns applied CHX gel 97 95 85 % of PSBI Cases (0-2 months) received complete dose of 64 61 51 Gentamycin Incidence of acute respiratory infection (ARI) per 1,000 children 576 560 579 under five years (New Visit) Incidence of Pneumonia among children under five years (per 110 80 76 1,000) Proportion of Pneumonia among U5 years New ARI registered 24 22 18 children (HF & ORC) Percentage of severe Pneumonia among new cases 0.22 0.19 0.19 Diarrhoea incidence rate among children under five years 411 403 404

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Province 5 Programme Indicators 2073/74 2074/75 2075/76 % of children under five years with diarrhea treated with zinc and 89 95 94 ORS Percentage of children U5 years with diarrhea suffering from 0.57 0.74 0.51 Severe dehydration SAFEMOTHERHOOD % of pregnant women who received TD2 and 2+ 71 71 73 % of pregnant women attending first ANC Visit as per protocol 76 79 80 % of pregnant women attending four ANC visits as per protocol 58 61 65 % of postpartum mothers who received vitamin A supplements 84 72 65 % of institutional delivery 69 75 79 % of deliveries conducted by a skilled birth attendant 65 70 73 % of women who had three PNC check-ups as per protocol 25 22 19 % of PP Mother Receiving-Vitamin A cap 84 72 65 % of PP Mother Receiving- 45 Iron tab 55 52 49 FAMILY PLANNING FP Methods New acceptor among as % of MWRA 17 16 18 Contraceptive Prevalence Rate 41 41 43 FEMALE COMMUNITY HEALTH VOLUNTEERS Total no. of ARI cases managed by FCHVs among ARI cases in 171864 165463 164822 children under five years % of mothers group meeting 95 100 99 MALARIA AND KALA-AZAR Annual blood slide examination rate (ABER) per 100 1.14 1.67 1.61 Annual parasite incidence (API) per 1,000 population at risk 0.08 0.07 0.06 Slide positivity rate 0.7 0.4 0.4 % of PF cases 13.8 11.3 4.1 TUBERCULOSIS Case notification rate (all forms of TB) 131 136 118 Treatment success rate 90 87 89 LEPROSY New case detection rate (NCDR) per 100,000 population 17.6 16.4 13.8 Prevalence rate (PR) per 10,000 1.5 1.4 0.97 HIV/AIDS and STI Number of HIV testing 125227 131466 117301 Number of new positive cases 504 526 417 CURATIVE SERVICES % of population utilizing outpatient (OPD) services 69 73 81 Bed Occupancy rate 57.3 64 69.2 Average length of stay 3.4 4.3 5.2 Average number of laboratory tests per day 7908 10239 19356 Physical and financial (Total Province in Health) % of Physical progress 87 Total Budget allocated in Health (Rs. Thousand) 1480061 % of Financial progress 75 Budget implementation and expenses institute 40

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CHAPTER I: INTRODUCTION General Information According to the decision of the Council of Ministers, Province 5, the Ministry of Social Development was established on 2074 Falgun 3. Health sector is one of the major 7 sectors of this Ministry. It is within the jurisdiction of the Ministry to formulate a strategy according to the phased strategy to achieve short-term and long-term goals with the sole purpose of social development and welfare. This Province covers 22,288 sq. km or 15% of National area and about 17 % of National population. This Province is still in the phase of development of its short-term and long term strategy to sustain the progress and achieve the higher level of health. National health policy 2076 and Nepal Health Sector Strategy 2015-2020 (NHSS) are the primary instrument for the Province. Nepal Health Sector Strategy adopts the vision and mission set forth by the National Health Policy and carries the ethos of Constitutional provision to guarantee access to basic health services as a fundamental right of every citizen. It articulates nation’s commitment towards achieving Universal Health Coverage (UHC) and provides the basis for garnering required resources and investments This report analyses the performance and achievements of Province 5 in fiscal year 2075/76 (2018/2019). It focuses on performance in 2075/76 and the following areas that provide the basis improving performance in subsequent years:  Program’s policy statements, including goals, objectives, strategies, major activities and achievements.  Program’s indicators.  Problems, issues, constraints and recommendations on improving performance and achieving targets. This report also provides information on the contributions of the Department of Ayurveda and External Development Partners and stakeholders on contemporary issues in the health sector as well as the progress of major programs implemented by MOHP, Ministry of Social Development, health offices, Public and non-public hospitals and health facilities. Health Management Information System (HMIS) is the main source of information for this report. The report also uses information from other Management Information Systems (MISs), disease surveillance systems. The main health sector MISs includes the DHIS 2, the Logistics Management Information System (LMIS), the Financial Management Information System (FMIS), and the Ayurveda Reporting System (ARS). Likewise, this report also incorporated the information collected and compiled from municipalities in the districts and from external development partners within the Province. This report has twelve chapters and two annexes. Chapter I covers the background of annual report preparation, sources of information used for preparing this annual health report. Chapters II cover Public Health Programs, Chapter III cover Curative Health Services, Chapter IV presents the programmes of the Ayurveda and Alternative Medicine; Chapter V provides Health Information System. Chapter VI covers the Province Health Logistic Management Center, Chapter VII covers Province Training Center, Chapter VII covers Province Public Laboratory, Chapter IX covers Program carried out by Province, Chapter X covers Health Insurance Program, Chapter XI provides Disaster Management and Chapter XII presents the details of external development partners in health sector in the Province. The preparation of this report follows the twelve district level annual performance review workshop and three days provincial annual performance review workshop held on 24-26 1

Mangshir, 2076 in Butwal. These workshops were attended by Social Development Minister, MOSD Province 5, Secretary of MOSD, Director Generals of Department of Health Services, senior personnel from Ministry of Health and Population, Department of Health services, Central Health Centers, Health Directorates, MOSD, district health offices, public hospitals, Mayer and Deputy Mayer from four district’s Municipalities, Chief executive administrators from four district’s Municipalities, Health co-coordinators from three district’s Municipalities, representative of private hospitals and representatives of External Development Partners (EDPs); national and international non-governmental organizations (NGOs and INGOs). Workshop participants reviewed the policy statements of each program and analyzed data generated by the DHIS-II and from other sources on selected indicators. These data were interpreted during the presentations and discussions. The objectives of Provincial Annual Performance Review Workshop were to:  Review the program implemented in fiscal year 2075/76 and draw lessons learned  Develop action plan to be implemented in coordination with Municipalities (Palika), Province and Federal Government in current fiscal year and in the next fiscal year.  Orient district managers on policy/management issues and new programs

Health Service Delivery Units In the Province, there are 20 Public hospitals including under federal government (3), under provincial government (13) and under local level government (4). 30 primary health care centers and 570 health posts are also delivering the basic health care services to the communities in Province 5 of which 363 are birthing centers. To increase the access and utilization of health care services, 97 urban heath centers, 66 community health units, 15 Basic Health Center, 1942 PHCORCs and 2704 Immunization clinic are functional within the Province. Similarly, 8994 FCHVs are being mobilized for public health promotion and prevention activities.

Table 1.1.1: Service outlets within the Province

Service Outlets Dang Dang Palpa Palpa Total Total Rolpa Rolpa Gulmi Gulmi Banke Banke Bardiya Bardiya Pyuthan Pyuthan Province Province Kapilvastu Kapilvastu Rupandehi Rupandehi Rukum East East Rukum Nawalparasi Nawalparasi Arghakhanchi Arghakhanchi

Government Hospital 1 2 3 1 1 3 2 2 2 1 1 1 20 Primary Health Care 3 5 2 2 2 2 2 2 3 2 4 1 30 Center Health Post 30 64 73 46 49 36 36 62 44 39 76 15 570 Urban Health Center 12 15 6 3 8 26 4 5 8 1 9 0 97 Community Health 6 2 3 5 7 4 2 9 2 15 6 5 66 Unit PHC-ORCs 156 229 289 155 180 144 105 185 142 80 236 41 1942 Immunization Clinics 198 276 377 251 215 186 161 235 269 171 311 54 2704 FCHVs 841 1511 1106 441 459 902 346 615 789 845 995 144 8994 Private Health 10 71 19 5 5 20 12 8 29 7 6 0 192 Facilities No. of Outpatient 0 0 0 0 0 0 0 0 0 0 0 0 0 Therapeutic Center Stabilization Center 0 0 0 0 0 0 0 0 0 0 0 0 0 for SAM cases Nutrition 0 1 0 0 0 0 0 0 0 1 0 0 2 Rehabilitation Home Birthing Center 25 21 23 51 52 36 11 31 34 18 49 12 363 DR Center 0 1 0 0 0 0 0 0 1 0 0 0 2 Dr Sub Center 1 1 1 1 1 2 1 2 1 1 1 0 13 Gene-Xpert 1 1 1 1 0 1 1 1 2 0 1 0 10 ART Sites 1 2 2 1 1 2 1 1 1 1 1 0 14 Ost Sites 0 1 0 0 0 0 0 0 1 0 0 0 2 DR Hostel 0 1 0 0 0 0 0 0 0 0 0 0 1

Status of Human Resource in Health

Human Resource in Health (Technical and non-Technical)

SN Institutions Total Total Total Fulfilled Sanctioned Fulfilled Vacant % Post 1 Ministry of Social 7 3 4 42 Development 2 Health Directorate 32 25 7 78

3 Provincial Health Logistic 17 9 8 52 Management Center

4 Health Training Center 13 6 7 46 5 Provincial Public 11 3 8 27 Laboratory Center 6 Health Offices (12) 156 56 100 35

7 Hospital under Province 862 369 493 43

8 Ayurveda and alternate 104 64 40 61 medicine Total 1202 535 667 44.50

CHAPTER II: PUBLIC HEALTH PROGRAMS Immunization Program Background National Immunization Program (NIP) formerly Expanded Program on Immunization (EPI) was started in 2034 and is a priority 1 program. It is one of the successful public health interventions of Ministry of Health and Population that has achieved several milestones and contributed in reduction of morbidity, mortality and disability associated with vaccine preventable diseases. National Immunization Program works closely with other divisions of Department of Health Services, centres of Ministry of Health and different partners supporting routine immunization. EPI section is one of the sections among the three sections of Child Health Division which plans, executes and monitors several activities of immunization. Vaccine and cold chain section of Logistics Management Division procures, stores and distributes vaccine throughout the country as planned by EPI section of CHD, while NHEICC develops routine and supplementary immunization's IEC and social mobilization materials and conducts activities in close coordination with the EPI section. Capacity building of health staffs on routine immunization in close coordination with EPI section is executed through National Health and Regional Health Training Centres. Immunization related information is collected through HMIS section of Management Division and is shared quarterly for review and feedback. EPI section of Child Health Division coordinates several stakeholders of immunization to execute activities of the annual work plan. National Immunization Program has included several underused and new vaccines in program and currently there are eleven antigens–BCG, DPT_HepB_Hib (penta), PCV, OPV (bOPV), FIPV, Measles and Rubella (MR) and Japanese Encephalitis provided through 16,000 service delivery points in health facilities (fixed session), outreach sessions and mobile clinic (sessions). Inactivated Polio Vaccine (IPV) which was introduced in routine immunization in 2014 has stock out globally and has stopped temporarily but is in plan to be introduced in 2018 as fractional IPV (fIPV). Government of Nepal procures BCG, OPV, Td, JE, measles/rubella 1st dose and co-finances to GAVI supported vaccines DPTHepBHib, PCV and measles component of MR2. National Immunization Program has CMYP 2017-2021 aligned with global, regional and national guidelines, policies and recommendation to guide the program for five years. All the activities outlined in cMYP have been costed as well as have developed strategies for implementation. Guiding documents of national immunization program

There are several Global, Regional and National guiding documents for National Immunization Program. The main documents which have been taken in account and are incorporated in CMYP 2017-21 are–Global Vaccine Action Plan, SEARO Vaccine Action Plan, and Nepal Health Sector Support Program – NHSSP. Comprehensive Multi Year Plan of Action

The Comprehensive Multi Year Plan (CMYP) 2012-16 ended in 2016 and new CMYP 2017-21 is in place. The Province level activities are being carried out in line with the national policy. The previous CMYP 2012-16 has the goals and objectives as follows: Goals: To reduce child mortality, morbidity and disability associated with vaccine preventable diseases.

Objectives and strategies

Objective 1: Achieve and maintain at least 90% vaccination coverage for all antigens at national and district level by 2016 Objective 2: Ensure access to vaccines of assured quality and with appropriate waste management Objective 3: Achieve and maintain polio free status Objective 4: Maintain maternal and neonatal tetanus elimination status Objective 5: Initiate measles elimination Objective 6: Accelerate control of vaccine-preventable diseases through introduction of new and underused vaccines Objective 7: Strengthen and expand VPD surveillance Objective 8: Continue to expand immunization beyond infancy Most of the activities in past years were identified and carried out as per goal and objectives spelled in CMYP 2012-16, new CMYP (2017-21) in place now. Target population  Under-1year children for BCG, DPT-HepB-Hib, OPV, FIPV, PCV and Measles/ Rubella1 (MR1) vaccine.  Twelve months children for JE  15 months children for MR-II dose  Pregnant women for Tetanus Toxoid containing (Td) vaccine. National immunization schedule.

2.1. 1 Immunization Schedule of Nepal SN Number of Type of Vaccine Recommended Age Doses 1 BCG 1 At birth or on first contact with health institution 2 OPV 3 6, 10, and 14 weeks of age 3 DPT-Hep B-Hib 3 6, 10, and 14 weeks of age 4 FIPV 2 6, 14 weeks 5 PCV 3 6,10 weeks and 9 months of age 6 Measles-Rubella 2 MR1 at 9 months and MR2 at 15 months of age 7 Td 2 Pregnant women (2 doses of Td) 8 JE 1 12 months of age Immunization status of Province 5 The national immunization (NIP) is one of the government’s highest priority program. Immunization program made a large contribution to Nepal’s achievement. It is one of the successful public health interventions of Ministry of Health and Population. It played a great contribution to reduce the morbidity and mortality among children and mothers from vaccine preventable diseases. Nepal’s constitution ensures access to health care as fundamental right of the people The Immunization Act endorsed (BS 2072 Magh12) states that every child has the right to access quality of vaccines.

In line with the National Immunization program, this Province has included several underused and new vaccines in program. Currently there are 11 antigens-BCG, DPT-HepB-Hib (penta), PCV, OPV (boPV), FIPV, Measles and Rubella (MR) and JE provided through 2984 sessions (service delivery points in health facilities, outreach sessions and mobile clinics. Achievements against objective no. 1: Achieve and maintain at least 90% vaccination coverage for all antigens at national and district level by 2019. The table presented below shows the achievement status against objective no. 1:

2.1. 2 Immunization Coverage by antigens doses FY 2075/76 Target % SN Antigens Target Achievement Population achievements 1 BCG under 1 year 107874 105662 97.94 2 DPT-Hep B HIB1 under 1 year 107874 101449 94.04 3 DPT-Hep B HIB2 under 1 year 107874 98598 91.40 4 DPT-Hep B HIB3 under 1 year 107874 97392 90.28 5 Polio1 under 1 year 107874 98771 91.56 6 Polio2 under 1 year 107874 95512 88.54 7 Polio3 under 1 year 107874 93647 86.81 8 fIPV1 under 1 year 107874 80795 74.89 fIPV2 under 1 year 107874 66263 61.42 9 PCV1 under 1 year 107874 100822 93.46 10 PCV2 under 1 year 107874 97611 90.48 11 PCV3 under 1 year 107874 93999 87.13 12 Measles/Rubella 1st Dose under 1 year 107874 94696 87.79 Measles/Rubella 2nd 13 12-23 months 103240 87036 84.30 Dose 14 Japanese Encephalitis 12 months 107874 92301 85.57 15 Td2 and 2+ Pregnant Women 131316 95247 72.53

Access and Utilization of Immunization Services: The status of immunization service of districts can be seen in the table 2.1.3 from the accessibility and utilization perspective. The scale CAT 1 to 4 (measuring benchmark) is a national framework for the categorization of districts based on the immunization coverage (whether service has reached to all and has been utilized by all) of immunization services. Immunization Categorization The following map 1.1 below clearly highlights that 2 districts were under category-I which have good accessibility as well as utilization of immunization services. For the categorization purpose 7

DPT HepB-Hib-I coverage rate and DPT HepB Hib I vs MR II dropout rate were taken into consideration. The coverage rate more than or equals to 90 percent was taken as high coverage and dropout rate more than or equals to 10 percent was taken as high dropout rate.

The 6 districts fell into category-II where there was still a problem of utilizing immunization services, utilization of immunization services could be considered poor as the dropout rate is higher than 10 percent. Either may not be sufficient sessions for the service or all sessions have not delivered their immunization services throughout the year. Three districts fall under category-IV.

Table 2.1.3: Immunization Categorization

Cat I Cat II Cat III Cat IV Coverage ≥ 90% Coverage ≥ 90% Coverage < 90% Coverage <90% Dropout < 10% Dropout ≥10% Dropout <10% Dropout ≥10% Rupandehi Nawalparsi west Dang Kapilbastu Gulmi Pyuthan Banke Bardiya Palpa Rukum East Arghakhanchi Rolpa

Immunization Coverage by Antigens Figure 2.1.1 presents the trend of antigens wise coverage at Province level during over the last three fiscal years (2073/74-075/76). Immunization coverage of all antigens except JE found increased in FY 2075/76 as compared to FY 2074/75. The highest coverage was 97.8 % for BCG, 97.9% for DPTHepBHIb1 and 94 % for PCV respectively. It perceptibly seems that there is not a consistency in the utilization of service in terms of the coverage of DPT-HepB-Hib-3 in compared to its first dose. However, most of the antigens’ coverage was slightly increased in the FY 075/76 compared to last year. The coverage for MR-2 reached around 84.3 % in this fiscal from 79.2 % of FY 074/075. Figure 2.1.1: Immunization Coverage by antigens in Province 5

Antigen-wise Provincial Coverage(%) for FY 073/74-75/76 120 97.8 97.8 97.9 94 94 93.5 93.5 92.4 92.4 91.8 91.8 91.4 91.4 90.7 90.7 90.4 90.4 90.3 90.3 90.1 90.1 100 89.4 87.8 87.8 87.3 87.3 87.1 87.1 87 87 86.1 86.1 85.5 85.5 84.7 84.7 84.6 84.3 84.3 79.2 79.2 72.4 72.4 72.5 70.7 70.7 80 70.6 67.3 67.3 60

0 BCG DPT3 PCV3 Measles/rubella 2 TD2 & TD2+ 2073/2074 2074/2075 2075/2076

Figure 2.1.2 provides information on status of coverage for DPT-HepB-Hib I at districts level across Province-5. The figure showed that the DPT-HepB-Hib I coverage was declined in Rolpa, Banke, Pyuthan while at provincial level it was slightly increased. Figure: 2.1.2 DPT-HepB-Hib I coverage by districts in 2073/74-2075/76

% of children under one year immunized with DPT-HepB-Hib1 111.2 111.2

120 109.2 105.1 105.1 103.7 103.7 103.6 102.9 102.9 101.8 101.8 99.3 99.3 99.1 99.1 98.7 98.7 98.3 98.3 98.2 98.2 97.6 97.6 97 97 94.1 94.1 93.1 93.1 92 92 90.7 90.7 90.5 90.5

100 89.2 88.2 88.2 88.1 88.1 84.7 84.7 84.3 84.3 83.9 83.9 83.8 83.8 83.6 83.6 81.8 81.8 80.6 80.6 80.4 80.4 79.4 79.4 79.1 79.1 78.9 78.9 78.7 78.7 78.4 78.4 80 76.9

0 DANG PALPA GULMI ROLPA BANKE HI BARDIYA PYUTHAN WEST RUPANDEHI KAPILBASTU RUKUM EAST RUKUM ARGHAKHANC NAWALPARASI 2073/74 2074/75 2075/76

Figure 2.1.3 provides information on status of coverage for DPT-HepB-Hib3 dose at district level of Province 5 as recorded in 2075/76. DPTHepBHib3 coverage during FY 2075/076 remained limited in between 74 percent to 109 percent but it was within 71% to 97 % in 2074/75. In the Province the coverage was highest in RukumEast (109%) whereas lowest in Arghakhanchi (74%). Figure 2.1.3: DPT-HepB-Hib3 Coverage by Districts

% of children under one year immunized with DPT-HepB-Hib3

120 109.2 109.2 101.2 101.2 101 101 97.8 97.8 96.8 96.8 96.7 96.7 96.6 96.6 94.6 94.6 94.6 94.3 94.3

100 93.5 92.6 92.6 92.4 92.4 91 91 90.2 90.2 89.8 89.8 89.4 89.4 88.2 88.2 87.8 87.8 86.7 86.7 85.1 85.1 84.6 84.6 84.2 84.2 82.4 82.4 82.1 82.1 80.9 80.9 79.5 79.5 77.8 77.8 77.5 77.5 75.8 75.8 75.7 75.7 74.8 74.8 74.7 74.7 74.4 74.4

80 73.2 71.4 71.4

0 DANG PALPA GULMI ROLPA BANKE BARDIYA PYUTHAN RUPANDEHI KAPILBASTU RUKUM EAST RUKUM ARGHAKHANCHI

NAWALPARASI NAWALPARASI WEST 2073/742 2074/753 2075/764 Drop Out Rates: Figure 2.1.4 comparison of drop-out status of Province

comparision of drop-out status 15 12.6 10.4 10 6.9 5.2 4 5 3.7

0 2073/742 2074/753 2075/764

Drop out BCG vs Measles Drop out DPT-HepB-Hib 1 vs 3

This graph shows the drop-out status of BCG Vs Measles, and DPT-HepB1Vs 3; during the period of last three fiscal years from 2073/74 to 2075/76. There is a decrease trend of drop-out in this fiscal year in comparison to last FY. Figure 2.1.5 Dropout rate of DPT-HepB-Hib 1 vs DPT-HepB-Hib 3

Status of Dropout rate ( DPT-HepB-Hib 1 vs DPT-HepB-Hib 3) 30 25.1 25

20 18.8

15 10.3 8.9 10 7.5 8.5 6.4 7.2 4.4 4 3.9 4.7 4 5 2.7 2.7 2 1.41.9 0 10.72 0.14 0.52 0 -0.89 -5 -3.5

-10 -7.9

Drop out BCG vs Measles Drop out DPT-HepB-Hib 1 vs 3

Figure 2.1.5 mentioned above shows the dropout rate for BCG vs Measles; and DPT-HepB-Hib1 Vs DPT-HepB-Hib3. The dropout rate must not increase than 10%. The highest dropout recorded in Rupandehi in this FY 2075/76 while there is just over 8.9 in Kapilvastu for DPT-Hep-Hib. Vaccine Wastage Rate Figure 2.1.6: Wastage rate by antigens at Province level for FY 2073/74- 2075/76

Vaccine wastage Rate by Antigen 90 82.5 82.5 81.1 81.1 80.6 80.6 80 70 60 46.6 46.6 44 44 50 43.4 40.8 40.8 40.3 40.3 39.7 39.7 40 30 14.7 14.7 14.7

20 13 7.8 7.7 10 6.2 0 BCG DPT-Hep B-Hib Measles/Rubella JE PCV

2073/074 2074 /075 2075/076

The figure 2.1.6 provides the information on vaccine wastage of this Province, based on antigens, in the last three fiscal years (2073/74 and 2075/76). The vaccine wastage of each antigen reported in this Province is higher than cut-off point set by WHO. Mainly, vaccine wastage rate of Multi-dose vaccines like DPT-Hep-Hib was still higher than accepted rate of 15%. In general, there was a steadily decreasing trend for DPT-HepB,Hib, MR and JE vaccine wastage rate. The wastage of BCG increased and reached 81 which was very high in the Province. Figure 2.1.7: Vaccine Wastage by District

Vaccine wastage rate by District 100 90.1 90.1 88.1 88.1 87.7 87.7 87.3 87.3 87.1 87.1 86.5 86.5 81.9 81.9

90 81.1 79 79 77.1 77.1 75.9 75.9

80 71.1 67.8 67.8 65.7 65.7 64.1 64.1 62 62

70 61 60 60 59.2 59.2 60 46.6 46.6 46.5 46.5 42 42 41.2 41.2 50 40.8

40 31

30 22.9 20 10 0

Wastage Rate BCG Wastage Rate Measles/Rubella

In general, the vaccine wastage rate of BCG and Measles/Rubella reported in the Province is still high. Both of the antigen BCG (60) and Measles (22) have minimum wastage in Rupandehi whereas Gulmi has the highest record of wastage BCG (90) and Measles (67). Fully immunized district declaration: Fully immunization VDC, district and then the country declaration is one of the new and innovative initiatives which started with the objective to reach every child and take ownership of immunization by local governments. The program targeted to declare the Province as fully immunized by 2075/76 and until 2075/76, 8 out of 12 districts were declared as fully immunized in this Province. This process is continuing and every month, some rural municipalities and districts are declaring as fully immunized.

Table 2.1.4: District wise status of full immunization declaration in Province 5

Full Immunization Declared District Districts yet to be declared as fully immunized  Nawalparasi West  Rukum East  Rupandehi  Kapilvastu  Palpa  Banke  Gulmi  Bardia  Arghakhanchi 12

 Pyuthan  Rolpa  Dang Vaccine Preventable Diseases The table 2.1.5 shows the district-wise reported non-measles and non-rubella cases from districts of this Province; in 2018. Out of reported cases, 51 measles were confirmed as measles positive and 3 were Rubella. Among the reported cases, 71, and 5 were detected as AES and JE cases respectively. In Kapilvastu there were 38 measles positive cases which is the highest number. Similarly, Rupandehi and Dang district reported 14 AES cases in this Province. Kapilvastu had 11 AFP cases found reporting which was the highest number in this Province among the total 56 cases.

Table 2.1.5: vaccine preventable diseases cases 2074/75

Measles AES S.N District AFP NNT Measles Rubella Measles AES JE Positive Positive 1 Arghakhanchi 2 3 0 0 1 0 0 2 Gulmi 2 10 1 0 7 0 0 3 Kapilvastu 8 42 11 0 10 1 0 4 Nawalparasi_W 2 8 0 0 6 1 0 5 Palpa 4 22 0 1 7 1 0 6 Rupandehi 7 57 1 1 6 1 0 7 Banke 3 8 1 0 12 1 0 8 Dang 4 76 52 0 14 4 0 9 Pyuthan 1 11 0 0 2 0 0 10 Rolpa 4 14 4 0 1 0 0 11 Bardiya 8 14 1 0 10 0 0 12 Rukum - E 0 2 0 0 0 0 0 Total 45 267 71 2 76 9 0

Problems/Constraints and Actions to be taken: Provincial review meeting in 2075/76 identified the following problems and constraints and recommended action to be taken at different level.

Table 2.1.6 Problems, Constraints and Actions to be taken at Provincial Level Problems/Constraints Actions to be taken Responsibility Inadequate human resources and lack of Provision of sufficient vaccinators for defined job description of sub-metropolitan and municipalities, Local and provincial government HF staffs MCH/institution Clinics

Joint supportive supervision and monitoring of immunization at all level. Health Facility Poor-Quality Quarterly review of performance of data Rural Health Municipality/Sub- Immunization Data different Level (HF level, municipality metropolitan Under and over reporting and health office and provincial level) Provincial HMIS section Conduct Routine data quality self- assessment for district/s -Update the inventory of cold-chain Health Facility equipment with the respective cold- Rural Health Municipality/Sub- Weak Inventory chain capacity, vaccine, syringe etc. metropolitan management System -Maintain maximum and minimum -Provincial Logistic procurement stock level. and distribution Section Utilize immunization months as an opportunity to ensure full immunization. Rural Health Municipality/Sub- Unplanned Immunization Report the immunization month’s metropolitan Celebration activities separately -District Health Office Increase the access and utilization in the category2,3 and 4, health facility, rural municipality, and sub-metropolitan Inadequate cold-chain equipment’s and supply Establish vaccine cold chain sub centers Building, infrastructure in all the municipalities for MOHP, MOSD, Local Levels For vaccine stores/ EPI uninterrupted immunization services clinics Set targets for immunization by census in local level Decreasing coverage and Conduct and proper implementation of increasing dropout rate Local governments, Health Offices microplanning in hilly districts Follow up and tracking of children under immunization Regular repair, Strengthen provincial vaccine store and maintenance and ware house. replacement of cold- Strength the exiting cold room at Provincial Logistic procurement chain equipment’s district level and distribution Section including spare parts Strengthen and establish new sub-store -Maintain EVM at Palika level as per requirement.

Problems/Constraints Actions to be taken Responsibility -Establish online HMIS reporting system at every R. Health Municipality/Sub- Provincial HMIS section Poor reporting metropolitan Health Division/MoSD. -Provide DHIS2 & HMIS training to respective human resource.

Nutrition Program Background Nutrition Section under the Family Welfare Division of Department of Health Services is responsible for National Nutrition Program for improving the nutritional status of children, pregnant and lactating women and adolescents. Its goal is to achieve nutritional well-being of all people to maintain a healthy life to contribute in the socio-economic development of the country, through effective implementation of nutrition program in collaboration with relevant government sectors and development partners. Nutrition interventions are cost effective investments for attaining many of the Sustainable Development Goals. The first three Sustainable Development Goals are directly related to nutrition and other are related indirectly. Hunger and under-nutrition often result in the vicious cycle of malnutrition and infections that leads to poor cognitive and intellectual development, less productivity and compromised socioeconomic development of a person. Nutrition now is not only the determinant of healthier life, but also of the overall national development through producing better human capital contributing to GDP of the country. With this realization, Nepal has signed up in the international and national declarations for making commitments for nutritional well-being its population. Aligning with those commitments and in accordance with the national health policies, the Government of Nepal is committed to ensure that its citizens have adequate food, health and nutrition. The Constitution of Nepal 2015 as well ensures the right to food, health and nutrition to all citizens. The major strategies for improving nutrition are i) promotion of a dietary diversification, ii) food fortification, iii) micronutrient supplementation and iv) public health measures. The first two being the Food-based Approach and other two are Non-Food Based Approach. Nepal, being a early riser of Scaling-up Nutrition (SUN) movement has initiated the multi-sector approach in nutrition interventions with formulation and effective implementation of Multi-sector Nutrition Plan (MSNP). It envisions the reduction of childhood stunting with scaling-up of nutrition-sensitive and nutrition- specific intervention. Under the MSNP framework Health sector is responsible for nutrition- specific interventions. Major achievements Growth Monitoring and Promotion Monitoring the growth of children less than two years of age helps prevent and control protein- energy malnutrition and provides the opportunity for taking preventive and curative actions. Health workers at all public health facilities monitor the growth of children once a month using the growth monitoring card that is based on WHO’s new growth standards. Growth monitoring is the platform, not only for assessing the growth of children, but also for providing necessary nutrition counseling to the mothers/caretaker of the children depending the growth status of the children

Figure 2.2.1: Percentage of new-borns with low birth weight (<2.5 kg)

25 21.3 18.8

20 18.4 17.6 17.4 17.1 16.9 14.3 13.5 13.3 15 13.2 12.5 12.5 12.4 11.8 11.4 11.2 10 9.4 9.4 9.3 9.3 8.3 8.3 8.3 10 8.2 8 8 7.9 7.9 7.8 7.8 5.8 5.8 5.1 5.1 4.8 4.8 4.4 4.4 4.4 3.5 3.5

5 3.1 3 3 2.9 2.9 2.9 2 2 2 1.5 1.5

2073/74 2074/75 2075/76

In FY 2075/76, the overall percentage of newborns with low birth weight (<2.5 kg) at Province level has decreased to 12.5% from 14.3% in FY 2073/74. Six districts have comparatively higher low birth ratet with the highest rate in Banke (17.6%). Rukum East has the lowest prevalence at 1.5%. Palpa, Rupandehi, Kapilvastu, and Banke have higher prevalence of low birth weight than provincial average (Figure 2.2.1). Figure 2.2.2: Percentage of Children aged 0-11 months registered for Growth Monitoring

160 144.2 144.2 149.1

140 136.1 120.7 120.7 120.5 120.5 116.6 116.6 115.5 115.5 115.3 115.3 113.8 113.8 113.5 113.5 113.5 120 113 110.2 110.2 109.6 109.6 106.6 106.6 106.5 106.5 105.8 105.8 104.4 104.4 103.2 103.2 102.9 102.9 101.1 101.1 100 100 99.7 99.6 98.3 98.1 97.9 97.8

100 93.2 93.3 86.9 82 80.8 80.6 77.3 80 74 68.4 65 60.9 60

2073/74 2074/75 2075/76

The progress on registering for growth monitoring among the children aged 0-11 months is highly impressive having all of them registered in FY 2075/76. There is an increasing trend across all districts for registering the target children for growth monitoring (figure 2.2.2). However, in Dang it has decreased gradually. The overall coverage for growth monitoring registration of the target children in Dang, Banke, Bardiya is lower than the provincial average. Figure 2.2.3: Percentage of children aged 12-23 months registered for growth monitoring

2073/74 2074/75 2075/76

120 107 107 98 93 92

100 90 89 88 87 85 84 81 81 79 73 73 71

80 70 67 67 67 65 64 60 59 59 58 53 52 60 52 44 43 39 39 38 33 40 33 22 20

20 10

Compared to the growth monitoring registration for the children aged 0-11 months, the same for the children aged 12-23 months is surprisingly low 64 % reflecting a serious concern (figure 2.2.3). The highest proportion of the children registered for growth monitoring among this age group is 107 in Palpa. This indicator seems a huge challenge for assessing the nutrition status during the Golden 1000 Days period of life, which is the Window of Opportunities for improving nutrition of children. Figure 2.2.4: Average number of visits for Growth Monitoring among children aged 0-23 months

7 5.8 6.1 6 5.5 4.54.5 4.6 4.6 5 3.9 4 3.8 3.8 3.53.7 3.5 3.7 3.23.4 3.33.2 3.33.4 3.43.3 3.4 4 3 2.9 2.8 2.82.8 2.42.7 2.52.4 2.4 2.5 2.4 2.4 3 2.1 2.1 2 1 0

2073/74 2074/75 2075/76

In regards to the average number of visits for growth monitoring, it as well alarming with the average visit of 3.4 times in FY 2075/76 out of total 24 recommended visits (figure 2.2.4). It is not very surprising since the registration of the children aged 12-23 months for growth monitoring is considerably low (figure 2.2.3). The findings in the figures 2.2.2-2.2.4 reveal that although the children are registered for growth monitoring, there is no continuity of assessing their growth every month as recommended. Figure 2.2.5: Percentage of Children aged 0-23 months, registered for Growth Monitoring (new) who were underweight.

14 12.7 12 8.5 8.2 8.3 10 7.6 5.9 8 5.3 5.3 5.6 5.3 4.4 4.6 6 4.1 3.9 3.7 3.8 4.2 3.4 3.5 3.1 2.5 2.5 2.3 4 1.7 1.9 1.8 2 1.7 1.8 1.7 2.1 2 1.3 1.1 1 0.9 1.3 1.3 0.8 1.2 0

2073/2074 2074/2075 2075-2076

The finding on underweight shown in figure 2.2.5 is among the children aged 0-23 months with new registration. The overall prevalence of underweight at province level has decreased from 4.4 percent o 3.9 percent from FY 073/074 to 075/076. However, inconsistency is observed in the progress during last three years except for Arghakhanchi, Palpa, Kapilvastu and Bardiya. In these four districts, the underweight prevalence among the target children has decreased in last three year period. In Rupandehi, Dang, and Banke the underweight prevalence has increased. For the rest of the districts, the progress is erratic in last three years. Kapilvastu has the highest prevalence, greater than the provincial average despite the drastic reduction. Dang, Banke and Bardiya as well have higher prevalence than the provincial average. Infant and Young Child Feeding Appropriate infant and young child feeding practices are essential to enhance the nutrition, survival, growth and development of infants and young children. The infant and young child feeding (IYCF) practices include exclusive breastfeeding for six months and timely initiation of appropriate complementary feeding at the age of six months with continued breastfeeding up to two years of age or beyond. Improving nutritional care and practices related to IYCF is a priority strategy of National Nutrition Program of Ministry of Health and Population. The IYCF programme was scaled- up in all 75 districts from FY 2072/73. Government has been putting enormous efforts in improving IYCF practices for uplifting nutrition of young children.

Figure 2.2.6: Percent of children aged 0-6 months registered for growth monitoring and were exclusively breast fed for the first 6 months.

120 93.5 100 109.5 71.3 69 65.3 80 63.1 60.4 60.5 54.8 54.1 54 53.2 51.7 49.7 49.3 47.8 47.4 45.3 44.7 43.8 42.3 41.9 60 41.3 40.2 39.8 38 37.3 36.8 36.2 34.8 27.6 22.8 40 22.3 20.5 18.5 18 16.7 20 10.1 0.06 0

2073/74 2074/75 2075/76

As shown in figure 2.2.6, around half (53.2%) of the children aged 0-6 months registered for growth monitoring had exclusive breastfeeding in FY 2075/76 with an improvement from the previous year (45.3%). There is large difference across the districts with highest at 109.9% in Nawalparasi West and lowest at 22.8% in Banke. The proportion of the infants receiving exclusive breastfeeding has increased across all districts except in Rolpa and Kapilvastu, where it has declined from the previous year. In fact, in Kapilvastu a significant decrease in the prevalence of exclusive breastfeeding among the children registered for growth monitoring from 98.5 percent in Fy 2073/74 to 60.5% in FY 2075/76 needs a programmatic attention. Integrated Management of Acute Malnutrition The Integrated Management of Acute Malnutrition (IMAM) Programme, previously termed as the Community based Management of Acute Malnutrition [CMAM] programme manages Severe Acute Malnutrition (SAM) in children aged 0-59 months through inpatient and outpatient services. Inpatient services are provide for the SAM with medical complications at Inpatient Treatment and Care Center (ITC) previously termed as Stabilization Center (SC) at the hospitals of the program districts. The outpatient services manages the SAM cases without medical complication in the OutpatientTreatment and Care Center (OTC), established in the selected Health Posts at community level. Along with management of SAM among children under five years of age with providing Ready-to-use-Therapeutic Food, this program also aims in providing effective nutrition counselling for better maternal, infant and young child nutrition (MIYCN). Through MIYCN promotion and support, IMAM aims to integrate nutrition support across the health, early childhood development, WASH and social protection sectors for the sustained rehabilitation of cases through supportive follow-up of the cases identified. Currently, eight out of twelve districts are implementing this program, the performance of which is given in table 2.2.1. Among those eight program districts, only two districts, Nawalparasi West and Kapilvastu are implementing the program effectively meeting the SPHERE standards for SAM Management (i.e. Recovery Rate >75%, Defaulter Rate <15% an Death Rate < 5%). To meet the minimum standards, all the three criteria need to be fulfilled. The death rate is satisfactory across all eight program districts, however, defaulter rate of more than 15 percent in Rupandehi, Dang, Banke, and Bardiya is a concern. It is as high as 67.5 percent in Banke, which is a very serious concern requiring immediate action in improving program implementation strengthening the community-outreach activities for identifying the defaulter cases and counselling for follow-up visits to OTCs.

Table 2.2.1: District-wise Performance on Integrated Management of Acute Malnutrition, FY 2075/76

Total number of % of Recovery % of death among % of defaulter District SAM case among SAM SAM discharged among SAM Name diagnosed discharged cases cases discharged cases

Rukum East 10 27.3 0 72.7 Nawalparasi 492 84.1 0.24 11.8 West

Rupandehi 444 49.3 0.19 39.4

Kapilvastu 519 82.7 0.28 10.1

Dang 321 57.8 0.35 36.2

Banke 309 28.9 0.26 67.5

Bardiya 396 68.4 0 20.2

Province 5 2406 66.3 0.22 26.1

Prevention and control of iron deficiency anaemia It is one of the major interventions of MOHP in prevention and control of maternal anemia. MOHP has been providing iron folic acid (IFA) supplementation to pregnant and post-partum women since 1998 to reduce maternal Anaemia. The protocol is to provide 60 mg elemental iron and 400 microgram folic acid to pregnant women for 225 days from their second trimester till 45 days postpartum. To improve access, in 2003, the Intensification of Maternal and Neonatal Micronutrient Programme (IMNMP) was initiated with modification of delivery mechanism with IFA supplementation through female community health volunteers (FCHVs). The intensification programme improved coverage, although compliance with taking 180 tablets during pregnancy and 45 tablets post-partum still remains an issue.

Figure 2.2.7: Coverage of 180 IFA distribution to the Pregnant Women by districts for last Three Years.

100 87.8 83.8 90 83.7 80 69.1 68.4 68.2 67.6 66 63.8 70 63.6 60.7 58.8 58.5 57.5 56.9 56.8 56.7 56.7 56.5 56.3 55.5 55.4 55 54.7 60 54.4 52.1 51.8 51.5 50.4 50.1 48.9 47.5 46.5 44.9 43.9 50 43.3 33.8 33.8 40 33.1 30 20 10 0

2073 - 2074 2074 - 2075 2075 - 2076

As shown in the figure 2.2.7, the distribution of iron folic acid for 180 days has slightly increased at overall in Province in last three years from 57.5 percent in FY 2073/74 to 60.7% in Fy 2075/76. However, around 40 percent of the pregnant women have not received the supplementation for recommended 180 days. The highest proportions of the pregnant women receiving recommended dose is observed in Palpa (83.7%) although it has decreased from 87.5% in FY 2074/75. Eight out of 12 districts (Rukum East, Rolpa, Pyuthan, Gulmi, Arghakhanchi, Kapilvastu, Dang, and Bardiya) having the coverage lower than provincial average is a concern. The coverage in those district is around or less than 50 percent. Biannual Deworming Tablet Distribution to the Children aged 12-59 months Aiming to reduce childhood anemia with control of parasitic infestation through public health measures, this activity is integrated with biannual Vitamin A supplementation to the children aged 6-59 months considering the high coverage of vitamin A supplementation reaching around 90 percent of the target children. Deworming to the target children was initiated in few districts in the year 2000 successfully nationwide scale-up by the year 2010. As shown in figure 2.2.8, the overall provincial coverage of deworming tablet distribution is 93 percent in Kartik round and 85 percent in Baisakh round. Alike the vitamin A supplementation the coverage of Baisakh was round found decreased in all the districts except Rupandehi and Pyuthan. Relatively lowest coverage in second round was seen in Dang at 68 percent, although coverage of vitamin A supplementation was 83 percent for the same round in the district. The reason behind this needs to be discussed to improve the implementation in coming years.

Figure 2.2.8: Coverage of Deworming Tablets Distribution to the Children aged 12-59 months

140 120 120 120 108 108 108 107 107 100 100 98 97 97 96 95 95 94 93 92 92

100 90 89 88 85 84 83 82 79 79 80 78 68

1st round 2nd round

Home Fortification of Complementary Food with Multiple Micronutrient Powder (MNP)/Baal-Vita MOHP has introduced home fortification of complementary food with Multiple Micronutrient Powder (MNP) in 2012 aiming to reduced very high prevalence of anemia (69 percent) among the children aged 6-23 months as reported by Nepal Demographic Health Survey 2011. MNP, termed as Baal-Vita in Nepali is a sprinkle powder mix of 16 micronutrients including iron, vitamin A and zinc. This intervention is linked with IYCF program with counseling on timely initiation of appropriate complementary feeding enriching it with multiple micronutrients of MNP. The recommended dose of fortification is a total of 180 sachets for a child during the age of 6-23 months in 3 cycles with a gap of 4 months in between each cycle, i.e. a child receives Baal-Vita for 2 consecutive months, then will have 4 months gap and then have it for 2 months, and so on. In each cycle, a child is recommended to have 60 sachets of Baal-Vita for 2 months with a dose of one sachet per day. The Baal-Vita is to be mixed with complementary food of the children for enriching the micronutrient contents of the child's diet. As of FY 2075/76, eight districts have implemented this intervention with Rolpa having it initiated only in few rural municipalities. As shown in the figures 2.2.9 and 2.2.10, the coverage of this home-fortification is not that satisfactory with provincial average coverage of any MNP at 54.5 percent. The compliance is even worrisome with only nearly 10 percent of the target children having all 3 cycles of Baal-Vita. Palpa has observed relatively better coverage in terms of any MNP (88.8%, second highest) and compliance (28.3%, the highest) in FY 2075/76. A quite surprising result was seen in Nawalparasi West with around 100 percent coverage of any MNP, but only 3.4 percent of compliance.

Figure 2.2.9: Percentage of Children aged 0-23 months receiving Recommended 3 Cycles of MNP 31.3 35 28.3 30 25 22.1 19.1 17.3 16.8 20 13.8 16.3 15.9 10.9 12.4 12.3 15 9.58.3 9.7 8.7 9 8.6 10 3.4 5 4 4.8 5 0 0 0 0 0 0

2073/74 2074/75 2075/76

Figure 2.2.10: Percentage of Children aged 0-23 months receiving any MNP

140 118.2 120 88.8 93.8 100 81.3 80 80.7 70.7 75.9 80 63.165 54.5 54.158.6 53.5 60 50.145.5 49.9 51 51 40.137.4 39.2 40 13.6 11.2 20 0 0 0 0

2073/74 2074/75 2075/76

Iron Folic Supplementation to the Adolescent Girls This is a new initiative introduced by MOHP in FY 2072/73 in collaboration with Ministry of Education under the School Health and Nutrition Program (SHN) with an objective of preventing and controlling of anemia among adolescent girls aged 10-19 years. In the first year of the implementation, the intervention was rolled-out in Kathmandu, Khotang, Panchthar, Bhojpur, Saptari, Pyuthan and Kapilvastu with scaling up in 42 district by FY 2075/76. In Province 5, nine districts (Nawalparasi West, Kapilvastu, Rupandehi, Dang, Banke, Bardiya, Rolpa, Rukum East, and Pyuthan have rolled-out this intervention. Under this intervention, the adolescent girls aged 10-19 years are supplemented with weekly iron folic acid in two rounds (Shrawan-Asoj and Magh-Chaitra). The recommended dose of the supplementation for each round is 13 iron folic acid (60 mg elemental iron and 400 microgram folic acid) tablet in a weekly basis, i.e. one tablet per week. So, each adolescent girl is entitled to have 26 iron folic acid tablet in a year. Although the indicator for this intervention is in the HMIS indicator list under Nutrition Program, the recording and reporting of the progress has yet not been mainstreamed in routine online reporting system. Hence, progress till date is not available except for Pyuthan. As shown in table 2.1, total 32,463 adolescent girls received any weekly iron folic supplementation, of which 54.3 percent (17,633) has received the full compliance of 26 tablets. Looking at the coverage by age groups, the relatively higher percentage (55.3%) of girls aged 10-14 years received any iron folic supplements compared to those aged 15-19 years (44.7%). Table 2.2.2: Coverage of Adolescent Girls Iron Folic Acid Supplementation in Pyuthan District

SN Age Group (Adolescent Iron Folic Acid Consumption Period girl) Within first 13 weeks Within 26 weeks Grand Total 1 10-14 years 8459 9494 17953 2 15-19 years 6371 8139 14510 Total 14830 17633 32463

Prevention and Control of Vitamin A Deficiency Disorders The government initiated the National Vitamin A Programme in 1993 to improve the vitamin A status of children aged 6-59 months with an objective to reduce child mortality. This programme has been recognized as a global public health success story. It initially covered 8 districts and was scaled up nationwide by 2002. FCHVs dose the vitamin A supplementation to the target children twice a year through a campaign-style activity in Baisakh and Kartik of every year.

The progress on biannual Vitamin A supplementation is presented by 1st Round (Kartik) and 2nd Round (Baisakh) in figure 2.2.11. The overall provincial achievement is more than 85 percent among with highest coverage at around 100 percent in Rukum East for both round. The interesting fact observed across all districts was that the coverage in 2nd round was lower than that in 1st round of supplementation except in Rupandehi. Bardiya observed lowest (77%) among all requiring improving the coverage.

Figure 2.2.11: Coverage of vitamin A supplementation to children aged 6-59 months by Distribution Round

140 128 128

120 110 110 106 106 106 106 105 105 100 100 97 97 96 96 95 95 95 94 94 92 92 100 92 91 91 90 88 88 87 87 86 86 86 84 84 84 84 84 83 80 77

1st round 2nd round

Nutrition Rehabilitation Homes Nutrition Rehabilitation Home (NRH) is also a component of IMAM program. The way it differs from other IMAM components is that it not only treats and manages SAM cases among the children under five-years of age, but also provide intensive nutrition education and counseling to the mothers/caretakers of the children admitted in NRH with lodging and fooding facilities to them. The first NRH was established in Kathmandu in the year 1998 with expansion in 19 districts as of now. In province 5, there are three of them: in Lumbini Provincial Hospital, Butwal; Bheri Hospital, Nepalgunj; and Rapti Health Science Academy, Ghorahi. As shown in the table 2.2.3. total 293 cases of SAM were admitted during FY 2075/076 in two NRHs, in Bheri Hospital and Lumbini Provincial Hospital. Out of them, 147 were boys and 146 were girl children. A total of 291 cases were discharged, out of which 234 cases were recovered. As teh data reflected, the NRH in Bheri Hospital has met the SPHERE standards (Recovery Rate >75 percent, Defaulter Rate <15 percent, and Death Rate < 5 percent) in management of SAM cases. Table 2.2.3 : Status on Treatment of Severe Acute Malnutrition among Children in NRH of Province 5 during FY 2075/076.

Total # Total # of Total # Total # of Recovery Defaulter Death # of Admissions of SN NRH Location Dafaulter of Discharged rate Rate Rate Recover Cases Deaths Cases ed Cases Boys Girls Total 1 Bheri Hospital, Nepalgunj, Banke 94 84 178 146 22 0 173 84% 11% 0% Lumbini Provincial Hospital, Butwal, 2 Rupandehi 53 62 115 88 19 1 118 75% 19% 1% Rapti Health Science Academay, 3 Ghorahi, Dang No data available

TOTAL 147 146 293 234 41 1 291 80% 14% 0% Source: National Review of Nutrtion Rehabilitation Homes, Pokhara, 29 Kartik, FY 2076/077.

Integrated Management of Newborn and Child Health Program Background Integrated Management of Neonatal and Childhood Illness (CBIMNCI) is integrated program of Integrated Management of Childhood Illness (CB-IMCI) and New-born Care Practices (CBNCP) Program which is being implemented in phase wise model. The goal of this program is to improve neonatal and child health as well as contribute in their health improvement and reduce illness and mortality among under five children. IMNCI Program is the integration package of child-survival addressing five major killer diseases namely diarrhea, pneumonia, malnutrition, measles, and malaria at community and health facility level focusing on under-five children throughout the country which is focused to reduce mortality and morbidity of new born, addresses the main causes of neonatal mortality - infection, low birth weight, prematurity, hypothermia, and asphyxia. Major Achievements

Table 2.3. 1 District wise classification of CBIMNCI cases Malaria Very Measle Ear Severe Anemia Falciparu Non- severe s Infection Mal- Districts m Falciparum febrile Nutrition disease Rukum East 0 0 8 0 242 7 9 Rolpa 0 0 3 20 1797 79 42 Pyuthan 0 0 0 0 1297 58 23 Gulmi 4 3 9 16 1422 10 38 Arghakhanchi 0 1 3 8 649 16 4 Palpa 0 6 124 23 1599 26 318 Nawalparasi 0 0 0 6 822 304 117 West Rupandehi 0 213 3 5 2253 290 267 Kapilbastu 15 9 3 20 2701 434 134 Dang 2 0 9 13 1805 263 29 Banke 3 2 2 19 2102 316 164 Bardiya 1 0 11 20 1180 485 183 Province 5 25 234 175 150 17869 2288 1328 Under the CB-IMCI programme, health workers identified 25 falciparum malaria cases, 234 non- falciparum malaria cases, 150 measles cases,175 very sever febrile disease, 16233 ear infection cases, 17869 severe malnutrition cases and 1328 anaemia cases in children.

Table 2.3.2: CB-IMNCI major indicators by District FY 2075/76

% of PSBI cases received % of diarrheal % of newborns applied Districtss complete dose of inj. disease treated by chlorhexidine (CHX) gel Gentamicin ORS and Zinc

Rukum East 94.4 0 93.5 Rolpa 94.1 62.9 95.4 Pyuthan 95.1 40 100 Gulmi 93.2 47.1 95.9

% of PSBI cases received % of diarrheal % of newborns applied Districtss complete dose of inj. disease treated by chlorhexidine (CHX) gel Gentamicin ORS and Zinc

Arghakhanchi 69.5 50 91.1 Palpa 96.8 0 100 Nawalparasi West 93.7 0 90.3 Rupandehi 67 29.1 85.3 Kapilbastu 86.7 2.1 89.5 Dang 93 51.7 96.4 Banke 84.2 14.8 97.3 Bardiya 96.9 87.9 95.7 Province 5 85.2 50.8 94.4 The average use of CHX was highest (96.8%) in Bardiya and Palpa lowest (67%) in Rupandehi . Acute Respiratory Tract Infection In F/Y 2075/76, a total of 294668 ARI cases were registered, out of which 18 percent were classified as pneumonia cases and 0.19 were classified as sever pneumonia among ARI cases. The highest ARI incidence was seen in Rolpa district (1065 under 5 children). Similarly, Gulmi had 1048 ARI incidence per 1000 under 5 years’ age children. The Dang where the ARI reported cases were 343/1000 under-five children which was the lowest as comparison to other district’s figure in this Province. The total ARI-related death at health facilities ARI reported to be 15 in this Province. If we compare the district wise death, there was 5 fatalities in Argakhanchi , 4 death in Banke and Rolpa 3 cases due to ARI.

Tabe 2.3.3: Acute Respiratory Infection (ARI) and Pneumonia cases by Districts (FY 2075/76) West West Dang Palpa Rolpa Gulmi Banke Banke Bardiya Pyuthan Province 5 Province Kapilbastu Rupandehi Rukum Rukum East Nawalparasi Nawalparasi Arghakhanchi Arghakhanchi Indicators Indicators Under 5 years 5481 23936 24314 26343 20422 25393 38093 105753 66737 64403 60045 48006 508926 Children Incidence 707 1065 985 1048 879 633 353 363 347 543 585 722 579 rate of ARI Incidence rate of 160 147 112 47 48 85 22 17 18 52 52 38 46 Pneumonia % of Pneumonia among U5 years New ARI 31 31 23 10 17 23 13 12 10 21 23 14 18 registered children (HF & ORC) % of severe Pneumonia 0.98 0.18 0.17 0.10 0.15 0.53 0.07 0.16 0.28 0.11 0.25 0.13 0.19 among new cases

West West Dang Palpa Rolpa Gulmi Banke Banke Bardiya Pyuthan Province 5 Province Kapilbastu Rupandehi Rukum Rukum East Nawalparasi Nawalparasi Arghakhanchi Arghakhanchi Indicators Indicators

Death due 0 3 0 0 5 1 0 0 0 0 4 2 15 to ARI ARI mortality rate among children 0 0.13 0 0 0.24 0.04 0 0 0 0 0.07 0.04 0.03 under five years (per 1000) Classification of Diarrheal cases

Table 2.3.4: Classification of Diarrheal Cases by Districts (FY 2075/76) WEST DANG GULMI GULMI PALPA ROLPA BANKE BARDIYA PYUTHAN Indicators Province 5Province RUPANDEHI KAPILBASTU RUKUM EAST NAWALPARASI ARGHAKHANCHI

Diarrhoea incidence rate among 554.3 832.7 591.3 390.2 353 355.1 299.4 314.9 382.9 404.8 488.4 338.4 404.3 children under five years

Percentage of children under five years with 23.2 14 12.2 10 8.7 18.7 7.6 7.7 12 7 16.6 13 12 diarrhea suffering from Some dehydration

Percentage of children under five years with 0.39 0.17 0.1 0.55 0.05 6.1 0.48 0 0.19 0.03 0.06 0.21 0.51 diarrhea suffering from Severe dehydration

Percentage of children under five years with 93.5 95.4 101.4 95.9 91.1 118.4 90.3 85.3 89.5 96.4 97.3 95.7 94.4 diarrhea treated with zinc and ORS

CBIMCI-(2- 59Months)- 0 0 1 0 0 0 0 0 0 0 0 0 1 Death- Diarrhoea

WEST DANG GULMI GULMI PALPA ROLPA BANKE BARDIYA PYUTHAN Indicators Province 5Province RUPANDEHI KAPILBASTU RUKUM EAST NAWALPARASI ARGHAKHANCHI

Diarrhoea case fatality rate among children 0 0 0.17 0 0 0 0 0 0 0 0 0 0.01 under five years (per 1000)

In FY 2075/76, a total of 205606 diarrheal cases were reported. Among registered cases (0.51 %) were classified as having severe dehydration. Treatment of Diarrhoeal Cases In FY 2075/76, the proportion of diarrheal cases treated with ORS and Zinc as per IMNCI national protocol at Province level was 94.4% and was highest in Palpa (118.4%) and lowest in Rupandehi (85.3%). Problems/Constraints of IMNCI Program

Table 2.3.5 Problems, constraints and actions to be taken in IMNCI Program Problems/Constraints Actions to be taken Responsibility Frequent stock-out of essential Timely supply of commodities Health Directorate, Local commodities in R. level Municipality/Municipality and health facility. Inadequate equipment to deliver -Need to timely procurement and Health Directorate, Local new-born and child health supply form provincial and R. level services at service delivery point Municipality. Poor service data quality Strengthen regular supervision, Health Directorate, Local monitoring and feedback level mechanism Poor quality of care Onsite coaching for service Province level providers Supportive supervision Enhanced for quality improvement tools Poor refer mechanism Strengthen of referral mechanism MOSD, Local Level

Family Planning and Reproductive Health Programs Background Family planning (FP) refers to a conscious effort by a couple to limit or space the number of children through the use of contraceptive methods. Classically, contraceptive methods are classified as modern or traditional. Modern methods include female sterilization (e.g. minilap), male sterilization (e.g. non-scalpel vasectomy), intrauterine contraceptive device (IUCD), implants (e.g. Jadelle), injectable (e.g. Depo Provera), the pill (combined oral pills), condoms (male condom), lacational amenorrhea method (LAM) and standard day’s method (SDM). Methods such as rhythm including abstinence, withdrawal, and folk methods are grouped as traditional. The main aim of the National Family Planning Programme is to ensure that individuals and couples can fulfill their reproductive needs by using appropriate FP methods voluntarily based on informed choices. To achieve this, the Government of Nepal (GoN) is committed to equitable and right based access to voluntary, quality FP services based on informed choice for all individuals and couples, including adolescents and youth, those living in rural areas, migrants and other vulnerable or marginalized groups ensuring no one is left behind. Province 5 also commits to strengthen policies and strategies related to FP within the new federal context as reflected through its first five-year approach paper, and its commitment to FP 2020 movement at the subnational level. Province 5 aims to mobilize resources, improve enabling environment to engage effectively with external development partners and supporting partners, promote public-private partnerships, and involve non-health sectors. National and international commitments will be respected and implemented (such as NHSSIP 2015-2020, Costed Implementation Plan 2015-2020 etc.). From program perspective, Province 5 through its subsidiary will ensure access to and utilization of quality FP services especially among hard to reach, marginalized, disadvantaged and vulnerable groups and areas, broaden the access to range of modern contraceptives method mix including long acting reversible contraceptives (LARCs) such as IUCD and implant from service delivery points, reduce contraceptive discontinuation, scale up successful innovations, informed FP service delivery and demand generation interventions. FP services are part of basic health care services and are provided free of cost in all public health facilities in Province 5. FP Services are also provided through private and commercial outlets such as NGO run clinic/center, private clinics, pharmacies, drug stores, hospitals including academic hospitals. Policies and strategic areas for FP 1. Enabling environment: Strengthen the enabling environment for FP 2. Demand generation: Increase health care seeking behavior among populations with high unmet need for modern contraception 3. Service delivery: Enhance FP service delivery including commodities to respond to the needs of marginalized people, rural people, migrants, adolescents and other special groups 4. Capacity building: Strengthen the capacity of service providers to expand FP service delivery 5. Research and innovation: Strengthen the evidence base for programme implementation through research and innovation

Major Activities accomplished in 2075/76 Key FP activities carried out in 2075/76 are as follows:  Provision of regular comprehensive FP service  Provision of long acting reversible services (LARCs)  Provision of VSP and RANM initiative to increase accessibility to FP services, mainly LARCs  Provision of permanent FP Methods or Voluntary Surgical Contraception (VSC)  Accreditation of a Family Planning training site in Chandrauta, Kapilvastu District  Satellite clinic services for long acting reversible contraceptives  Micro planning to address unmet need of FP in targeted communities with low CPR  Targeted innovative intervention- “Khushal Priwar Swastha Karyakram” in Muslim community of Kapilvastu district  Skill based training for health workers on NSV, Mini-lap, IUCD and Implant.  Community awareness and demand generation initiatives via, orientation to men’s group, women group, adolescent groups and other marginalized population. Family Planning users by methods 2075/76 Sterilization (37%) occupies the greatest part of the contraceptive method mix among all current user, followed by Depo (19%), implant (16%), condom (11%), pills (10%), and lastly IUCD (7%) in 2074/75 (Figure 2.3.1). Figure 2.4.1: Proportion of FP current user-method mix, 2075/76

Proportion of FP current user-method mix, 2075/76

Depo 19%

Sterlization 37% Pills 10%

Implant 16% Condom 11% IUCD 7%

Figure 2.4.2: Modern contraceptive prevalence rate (mCPR), 2075/76

mCPR by districts of 2075/76 60 55 48 50 47 46 43 39 38 43 40 36 35 35 29 30 26

0 DANG PALPA GULMI ROLPA BANKE Province BARDIYA PYUTHAN RUPANDEHI KAPILBASTU RUKUM EAST ARGHAKHANCHI

NAWALPARASI WEST The modern contraceptive prevalence rate (mCPR) for modern FP methods at Province 5 has slightly increased from 40.9 to 43 percent from FY 2074/75-2075/76 (Figure 2.4.2). Rupendehi has the highest mCPR (55%) and is only district having mCPR more than 50 percent while Arghakhanchi has the lowest (26%). The mCPR of Rukum East has increased from 21.9 percent to 35 percent in this year. 8 districts have mCPR below the Province Average, 9 districts have mCPR between 35-50 percent and 2 districts (Arghakhanchi and Gulmi) have mCPR less than 30 percent indicating below par performance among the low mCPR districts. mCPR is computed based on service data available in HMIS thus, does not capture service data from all the private and non-government sites.

Figure 2.4.3: Percentage of contraceptive method defaulters by methods, 2074/75 to 2075/76 Percentage of contraceptive method defaulters by methods, 2074/75 to 2075/76 100% 84% 74% 79% 80% 63% 50% 60% 43% 40% 20% 11% 11% 12% 14% 0% Pills Depo IUCD Implant Total 2074/75 2075/76

Contraceptive defaulters (for all temporary methods excluding condom), a proxy indicator for Contraceptive discontinuation is high in province 5. About 43% of contraceptive users have discontinued using the method or switched to another contraceptive method (Figure 2.4.3). These women may choose (switch to) less effective methods or remain method unused (discontinued while still in need) leading to risk of unintended pregnancy and its consequences. Compared to SARCs (short acting reversible contraceptives—Pills and Depo), LARCs (Long acting reversible contraceptives-IUCD and Implant has low defaulter rate. LARCs are the most effective as well as most cost-effective contraceptives. Trends of contraceptive discontinuation have decreased in 2075/76 compared to. Globally, LARCs are promoted as first line contraceptives for all prospective clients. The high discontinuation of SARCs and low uptake of LARCs in Nepal indicates concerns over and the need of programmatic focus on both supply and demand aspect sustaining the past gains and focusing more on LARCs. New acceptors of Family Planning for spacing Figure 2.4.4: Method mix for FP Spacing among new acceptors

Pills 22% Depo 36% Implant 11% Condom IUCD 28% 3%

Among new acceptors of contraceptive methods for spacing, one third (36%) was contributed by Depo, followed by Condom (28%) and Pills (22%) IUCD was least (3%) accepted method among all the new acceptors for spacing.

Table 2.4.1: New Acceptors (temporary modern methods) by districts, 2075/76 Total new Share of total new Temporary Districts IUCD Implant Depo Pills Condom acceptors as % of methods total users acceptors Rukum East 6 506 1034 516 520 2582 1.27

Rolpa 80 1673 4542 1152 3533 10980 5.39

Pyuthan 176 2202 3401 2515 4852 13146 6.45

Gulmi 295 1143 2650 2192 3837 10117 4.96

Arghakhanchi 248 1028 1376 1049 2074 5775 2.83

Palpa 505 981 2210 1275 3483 8454 4.15

Nawalparasi West 255 1749 2109 1204 2255 7572 3.72

Rupandehi 1699 3385 37114 22029 15079 79306 38.92

Kapilbastu 958 4362 4283 3768 5926 19297 9.47

Dang 564 2438 4910 3433 6071 17416 8.55

Banke 331 2486 6284 3553 5177 17831 8.75

Bardiya 786 1292 4348 1614 3261 11301 5.55

Total 5903 23245 74261 44300 56068 203777 100 New acceptors of all temporary methods (absolute numbers) have increased from 173849 (2074/75) to 203777 in 2075/76. Rupendehi district has the highest proportion (38.92%) of new acceptors of temporary methods while Rukum East has the (1.27%) lowest proportion of new acceptors of temporary family planning methods. New acceptors of voluntary surgical contraception Figure 2.4.5: Share of VSC as of total new acceptors by Province, 2074/75

% of VSC share of total new acceptor by district, 2075/76 10.00 8.39 8.00 6.00 4.11 4.00 2.06 0.83 1.23 1.17 1.14 1.23 2.00 0.43 0.03 0.17 0.13 0.50 0.00

Percentage of share of VSC among total new acceptors in provincial level has decreased from 2.3 percent (2074/75) to 1.23 percent (2075/76). Among the total new acceptors, Nawalparasi West comprised the highest (8.39%) followed by Bardiya (4.11%) and Kapilbastu (2.06%).

New acceptors of spacing methods among under 20 year women

Figure 2.4.6: Temporary method mix among under 20 total new acceptors, 2075/76

Temporary method mix among under 20 total new acceptors, 2075/76

Pills 26%

Implant Depo 11% 61%

IUCD 2%

Out of total new acceptors, 4.29 percent are from below 20 years of age. More than half of the method mix among under 20 years of age population is contributed by Depo (61%). One fourth of the population under 20 years of age accepted pills as a contraceptive method while less than a quarter population under 20 years age accepted LARC in 2075/76 (Figure 2.4.6) Issues, constraints and recommendations in Family Planning program

Table 2.4.2: Issues and constraints- family planning Issues and Recommendations Responsibility constraints Disparity of access Implementation of FP micro-planning in low mCPR MoHD, PHD, to and use of FP districts. PHTC, PPSC services Extend the visiting providers approaches to narrow down High unmet need the unmet need of the FP in low CPR districts. and unintended pregnancies Conduct targeted mobile outreach and satellite clinics focusing on LARCs Limited health facilities providing Strengthen and revitalize hospital based MCH/FP clinics all 5 temporary FP Strengthen FP services in urban health clinics, community methods clinics and private hospitals High contraceptive Ensure regular availability and smooth supply system of FP discontinuation commodities

Issues and Recommendations Responsibility constraints Underutilized Strengthen and expand the capacity of FP training sites LARCs Capacity development of health service providers through Underutilization of training/onsite mentoring/coaching for quality FP services, Postpartum Family mainly LARCs planning Ensuring proper counselling for reducing discontinuation rates Increased demand generation activities/information sessions and orientations at the community levels Scale up integrated FP/EPI clinics and postpartum and post-abortion services

Safe motherhood Program Background The goal of the National Safe Motherhood Programme is to reduce maternal and neonatal morbidity and mortality and improve maternal and neonatal health through preventive and promotive activities and by addressing avoidable factors that cause death during pregnancy, childbirth and the postpartum period. Evidence suggests that three delays are important factors for maternal and newborn morbidity and mortality in Nepal (delays in seeking care, reaching care and receiving care). The following major strategies have been adopted to reduce risks during pregnancy and childbirth and address factors associated with mortality and morbidity:  Promoting birth preparedness and complication readiness including awareness raising and improving preparedness for funds, transport and blood supplies.  Expansion of 24 hours birthing facilities alongside Aama Suraksha Programme promotes antenatal check-ups and institutional delivery.  The expansion of 24-hour emergency obstetric care services (basic and comprehensive) at selected public health facilities in all districts. The Safe Motherhood Programme has made significant progress since it began in 1997 and with formulation of safe motherhood policy in 1998. Service coverage has grown along with the development of policies, programmes and protocols. The policy on skilled birth attendants (2006) highlights the importance of skilled birth attendance (SBA) at all births and embodies the government’s commitment to train and deploy doctors, nurses and ANMs with the required skills across the country. Introduction of Aama programme to ensure free service and encourage women for institutional delivery has improved access to institutional deliveries and emergency obstetric care services. The endorsement of the revised National Blood Transfusion Policy (2006) was another significant step for ensuring the availability of safe blood supplies for emergency cases. The main programme strategies are listed in Box 3.2.1. The Nepal Health Sector Strategy (NHSS) identifies equity and quality of care gaps as areas of concern for achieving the maternal health sustainable development goal (SDG) target, and gives guidance for improving quality of care, equitable distribution of health services and utilisation and universal health coverage with better financing mechanism to reduce financial hardship and out of pocket expenditure for ill health.

Main strategies of the Safe Motherhood Programme . Promoting inter-sectoral coordination and collaboration at central, regional, districts and community levels to ensure commitment and action for promoting safe motherhood with a focus on poor and excluded groups. . Strengthening and expanding delivery by skilled birth attendants and providing basic and comprehensive obstetric care services at all levels. Interventions include: . developing the infrastructure for delivery and emergency obstetric care; . standardizing basic maternity care and emergency obstetric care at appropriate levels of the health care system; . strengthening human resource management —training and deployment of advanced skilled birth attendant (ASBA), SBA, anesthesia assistant and contracting short-term human resources for expansion of services sites; . establishing a functional referral system with airlifting for emergency referrals from remote areas, the provision of stretchers in wards and emergency referral funds in remote districts; and 38

. Strengthening community-based awareness on birth preparedness and complication readiness through FCHVs and increasing access to maternal health information and services. . Supporting activities that raise the status of women in society. . Promoting research on safe motherhood to contribute to improved planning, higher quality services and more cost-effective interventions.

Major Achievements: Antenatal care WHO recommends a minimum of four antenatal check-ups at regular intervals to all pregnant women (at the fourth, sixth, eighth and ninth months of pregnancy). During these visits women should receive the following services and general health check-ups:  Blood pressure, weight and foetal heart rate monitoring.  IEC and BCC on pregnancy, childbirth and early newborn care and family planning.  Information on danger signs during pregnancy, childbirth and in the postpartum period, and timely referral to appropriate health facilities.  Early detection and management of complications during pregnancy.

Provision of tetanus toxoid and diphtheria (Td) immunization, iron folic acid tablets and deworming tablets to all pregnant women, and malaria prophylaxis where necessary. Figure 2.5.1: District and Provincial trends of percentage pregnant women with first ANC visits (as per protocol) among expected live birth.

120 97 97 97 97 91 91 100 91 89 89 86 86 86 86 84 84 83 83 82 82 80 80 80 80 80 80 79 79 78 78 77 77 77 77 76 76 75 75 75 75 75 74 74 74 74 74 74 71 71 71 71 70 70 80 70 69 69 68 68 65 65 64 64 63 63 63 63 60 60 56 56 54 54 53 53 60 51

2073/74 2074/75 2075/76

Pregnant women are encouraged to receive at least four antenatal check-ups, give birth at a health institution and receive three post-natal check-ups, according to the national protocols. The first ANC visit as per protocol has been increased in 8 districts of Province no. 5. The provincial average of first ANC visit (as per protocol) as of expected live birth increased from 79 percent in FY 2074/75 to 80 percent in FY 2075/76 (Figure 2.5.1)

Figure 2.5.2: District and Provincial trends of percentage pregnant women with four ANC visits(as per protocol) among expected live birth

100

90 88 82 82 77 77

80 74 69 69 69 69 67 67 65 65 65 70 65 63 63 62 62 62 62 61 61 61 61 61 61 61 61 59 59 59 59 59 59 58 58 58 58 58 58 57 57 56 56 54 54

60 54 51 51 50 50 50 48 48 48 48 46 46 45 45 50 44 44 41 41 39 39

40 35 30 20 10 0

2073/74 2074/75 2075/76

The provincial average of fourth ANC visits (as per protocol) as a percentage of expected live births increased from 61 percent in 2074/75 to 65 percent in 2075/76. Out of twelve districts, eight districts had fourth ANC visit as a percentage of expected live birth had below the provincial level. Figure 2.5.3: Percentage of ANC visit under 20 yrs by districts in FY 2075/76

% of ANC visit under 20 yrs 35 32.59 30 27.81 24.01 23.44 25 19.37 19.37 17.44 16.35 20 13.75 15 10.77 12.8 10 7.1 5.28 5 0

In this province, among total ANC 1st visit, 13.75 percent ANC visit was done by adolescents. Out of twelve districts, Rukum east had highest, i.e. 32.59 percent adolescents received ANC care whereas Kapilbastu had lowest i.e. 5.28 percent adolescents who received antenatal care.

Delivery care

Figure 2.5.4: Trend of deliveries attended by SBAs as percentage expected live births

160 135 135

140 125 114 114 106 106 104 104

120 101 97 91 100 89 73 70 68 66 65 62 80 60 58 54 51 50 47 48 43 39

60 38 38 37 37 36 36 36 34 34 32 29 28 27 24 40 23 20 0

2073/74 2074/75 2075/76

As a percent of expected live birth, deliveries attended by SBA had increased from 70 percent in 2074/75 to 73 percent in 2075/76. Out of twelve districts, ten districts had increased in deliveries attended by SBA than the previous year.

Figure 2.5.5: Trend of institutional deliveries as percentage of expected live births 180 160 160 135 135 128 128 140 127 117 117

120 109 97 97 91 91 100 89 79 79 75 75 69 69 69 69 66 66 64 64

80 62 61 61 61 61 55 55 54 54 51 51 51 51 50 50 50 50 48 48 60 47 40 40 38 38 38 38 38 38 38 37 37 34 34 31 31 30 30 28 28 28 28 27 27

40 24 20 0

2073/74 2074/75 2075/76

The proportion of institutional deliveries increased from 75 percent in 2074/75 to 79 percent in 2075/76 in the provincial level. Out of twelve, nine districts had increased the institutional deliveries than the last years.

Postnatal care Postnatal care services include the following:  Three postnatal check-ups, the first within 24 hours of delivery, the second on the third day and the third on the seventh day after delivery.  The identification and management of complications of mothers and newborns and referrals to appropriate health facilities.  The promotion of exclusive breastfeeding.  Personal hygiene and nutrition education, and postnatal vitamin A and iron supplementation for mothers.  The immunization of newborns.  Postnatal family planning counseling and services.

Figure 2.5.6: Trend of three PNC as per protocols percentage of live births

60 51 51

50 48 43 43 40 30 30 30 29 29 28 28 30 27 25 25 24 24 24 24 23 23 23 23 23 23 22 22 20 20 19 19 18 18 17 17 20 17 15 15 15 15 14 14 14 14 13 13 13 12 12 11 11 11 11 11 11 11 11 9 7 7 6 6 10 6 5 3 0

2073/74 2074/75 2075/76

The number of mothers who received their first postnatal care at a health facility within 24 hours of delivery is similar to the number of institutional deliveries in almost all health facilities as most health workers reported to have provided post-natal care to both mothers and babies on discharge. The proportion of mothers attending three PNC visits as per the protocol is declined from 22 percent in 2074/75 to 19 percent in 2075/76 (Figure 2.5.5). Safe abortions The use of safe abortion services has decreased from 18463 in 2074/75 to 17313 women in 2074/75. In Rukum East, there was no safe abortion services due to lack of trained CAC service provider. Besides that, Rolpa and Arghakhanchi had low safe abortion services. In comparison to fiscal year 2074/75, out of total safe abortion service users, adolescent users slightly increased from 6 percent to 8 percent in 2075/76.

Table 2.5.1: Safe Abortion Service by districts. District 2073/74 2074/75 2075/76 Rukum East 0 0 0 Rolpa 100 312 639 Pyuthan 847 1018 1006 Gulmi 178 667 815 Arghakhanchi 75 616 768 Palpa 1363 1450 1818 Nawalparasi West 1600 1744 1225 Rupandehi 3835 4553 1296 Kapilbastu 2713 2994 3280 Dang 4003 1877 2786 Banke 2329 2632 2812 Bardiya 550 600 868 Province 5 17593 18463 17313

Figure 2.5.7: Percentage of adolescents who used Safe Abortion Service in FY 2075/76.

% of adolescents using safe abortion services 16 14.82 14 10.8 12 9.94 8.72 10 8.05 8.03 7.79 8.35 6.68 8 5.8 5.58 6.22 6 4 2 0 0

In this province, 8.35% adolescents had taken abortion services. Out of twelve district, Dang had the highest percentage (14.82) of adolescents who used abortion services whereas Nawalparasi west had the lowest i.e. 5.8. Rukum east had no service users because of lack of service.

Trend of post abortion contraceptive use (%) Figure 2.5.8: Percent of women who received FP methods after safe abortion service by districts.

120 105 105 100 100 99 99

100 94 91 91 90 90 90 90 89 89 88 88 88 88 87 87 87 87 86 86 84 84 84 84 83 83 83 83 83 82 82 82 81 81 77 77 77 77 76 76 76 76 75 75 74 74 80 73 71 71 69 69 66 66 65 65

60 52

40 37 31 31

20 0 0 0

2073/74 2074/75 2074/752

Use of post abortion contraceptives had slightly declined from 84 in 2074/75 to 82 in 2075/76 in provincial average. However, six districts had increased the use contraceptives after safe abortion.

Figure 2.5.9: Proportion of LARC among post abortion contraception used

40 35 35 35 31 31 30 30

30 28 26 26 26 26 26 25 25 24 24 24 24 23 23 23 23 23

25 22 22 22 22 22 22 22 20 20 20 20 18 18

20 17 16 16 16 16 14 14 15 14 12 12 11 11 11 11 11 10 7 7 6 6

5 3 0 0 0

2073/74 2074/75 2075/76

Out of twelve, five districts had increased the use of LARC among post abortion contraceptive users. Among them, Dang district had highest use of LARC from 17 percent in 2075 to 30 percent in 2076. Issues, constraints and recommendations

Table 2.5.2: Issues, constraints and recommendations— safe motherhood and newborn health Issues and constraints Recommendations Responsibilities

Inconsistency in recording & reporting Adequate follow up & Feedback MoSD/HD from Health Facilities Conduct HMIS training Construction of family folder/ line Local level/ listing of pregnant women MoSD/HD

First ANC before 4th month (for pregnancy confirmation and advice about pregnancy) ANC 5 ANC visits schedule

Low ANC visit Before 4, 4, 6, 8, 9th months of pregnancy Nutrition advice Facility or home-based ANC visit Identification of fetal wellbeing and by nursing staffs abnormalities Locally available and home-based

protein and vitamin rich food must be prioritized Capacity building of nursing staff birthing center Expansion of rural ultrasound to all birthing center Adequate equipment supplies 24 hour functional birthing center MoSD/HD Low institutional delivery with appropriate HR, equipment's and local support. Refer of complicated cases to and from district level hospitals 24 hour functional CEONC at district level hospitals High load of maternity cases in referral hospitals 24 hours free ambulance service availability Zero Home delivery initiative Separate maternity building with

sufficient HR and equipment

Guideline of zero home delivery declaration need to be developed Infrastructure for establishing lab 45

Issues and constraints Recommendations Responsibilities facilities & Birthing center Three PNC visits are rarely made Home based PNC visit by nursing MoSD/HD staff should be promoted Local level Less priority of ASRH Program ASRH information should be MOHP, MOSD, streamlined in DHIS-2 Local Level

Adolescent Sexual and Reproductive Health Program Background National Adolescent Sexual and Reproductive Health is one of the priority program of Family Welfare Division (FWD), Department of Health Services. Nepal is one of the country in South Asia developed and endorsed the first National Adolescent Health and Development (NAHD) Strategy in 2000. To address the needs of emerging issues of adolescents in the changing context, the NAHD strategy is revised and endorsed in 2018.The goal of National ASRH programme is to promote the sexual and reproductive health of adolescents. Objectives:  To increase the availability of and access to quality information on adolescent health and development, and provide opportunities to build the knowledge and skills of adolescents, service providers and educators.  To increase the accessibility and use of adolescent health and counselling services.  To create safe and supportive environments for adolescents to improve their legal, social and economic status.  To create awareness on adolescence issues through BCC campaigns and at national, provincial and community levels through FCHVs and mother groups Targets: To make all health facilities as adolescent friendly as per the envision of National Health policy (2014) and NHSS (2016-2021) To ensure universal access to ASRH services, the Nepal Health Sector Strategy Implementation Plan (2016-2021) aims to:  scale up Adolescent Friendly Service (AFS) to all health facilities;  behavioral skill focused ASRH training to 5,000 Health Service Providers and  more than 100 health facilities to be certified with quality AFS by 2021 The programme aims to reduce the adolescent fertility rate (AFR) by improving access to family planning services and information. Implementation status of ASRH Programme in Province 5

Table 2.6.1: Cumulative implementation status of ASRH Programme in Province 5 Scale up of ASRH programme ASRH programme districts in Province 5 2065/2066 Bardiya (Piloting) 2066/2067 Gulmi 2067/2068 Nawalparasi 2068/2069 Rolpa, Rukum, Banke, Dang, Pyuthan, Kapilvastu, Arghakhanchi, Rupandehi 2069/2070 No expansion in Province 5 2070/2071 No expansion in Province 5 2071/2072 Palpa

ASRH Certified Health Facilities in Province 5

Table: 2.6.2 Summary of ASRH Certified Health Facilities in Province 5 District Health Facilities Arghakhanchi Thada PHC, Hansapur HP, Dang Gadawa HP, Satbariya HP, Sisahaniya HP Kapilvastu Gauri HP, Tillaurakot HP, Shivpur HP, Jayanagar HP Pyuthan Puranthanti HP, Okharkot HP, Khaira HP, Sotre HP, Bhingri PHC, Gothiwang HP Rolpa Khumel HP, Libang HP, Kotgaun HP, Korchawang HF, Gairegaun HF Rukum Sylakapha HP, Bafikot HP, Smiruti HP

Key Interventions Area for National ASRH program  Capacity building of health workers  Scale up and strengthen health facilities for Adolescent Friendly Services (AFS)  Establishment of Adolescent Friendly Information Corners (AFICs) in schools  Menstrual Hygiene management (MHM)  Comprehensive Sexuality Education (CSE) in School  Advocacy  ASRH service utilization by adolescents

Issues, constraints and recommendations

Table: 2.6.3 Issues, constraints and recommendations— Adolescent sexual reproductive health Issues / constraints Recommendation Responsibility High prevalence of early marriage Intensify community awareness activities MoSD, Local and teenage pregnancy and comprehensive sexuality education in Level schools Less priority and inadequate Organize sensitization/advocacy events to MOHP, MOSD, resource allocation for ASRH decision makers at Province level and local Local Level program. level for increased investment in adolescents and youths Low CPR and high unmet need for Intensify information and awareness MOHP, MOSD, contraception among vulnerable programs targeted to adolescents. Local Level populations including Strengthen Adolescent Friendly Service adolescents Sites and information corners. Capacitate health workers regarding adolescent responsive service provision. Inadequate trained human Strengthen ASRH clinical training sites and MOHP, MOSD, resources on ASRH in health develop the capacity of service providers Local Level facilities with “behavioural and skill focused competency based 5 days ASRH training”

at all health facilities and specially AFS sites Vertical reporting of ASRH Revise the monthly/annual reporting MD, MOHP, program format (Annex 5: ASRH Program MOSD, Local Implementation Guidelines, 2011) and Level advocate to incorporate in HMIS.

Inadequate IEC/BCC Ensure the supply of ASRH related IEC/BCC MOHP, MOSD, materials to health facilities Local Level and Materials ASRH partners

Primary Health Care Outreach Clinic Background Health facilities were extended to the village level under the National Health Policy (1991). However, the use of services provided by these facilities, especially preventive and promotive services, was limited due to accessibility factors. Primary health care outreach clinics (PHC-ORC) were therefore initiated in 1994 (2051 BS) to bring health services closer to communities. The aim of these clinics is to improve access to basic health services including family planning, child health and safe motherhood. These clinics are service extension sites of PHCCs and health posts. The primary responsibility for conducting them lies with maternal and child health workers (MCHWs) and village health workers (VHWs) at sub-health posts and ANMs, AHWs and VHWs at PHCCs and health posts. With the upgrading of MCHWs and VHWs and the upgrading of all sub-health posts the responsibility is being shared with all ANMs and AHWs. FCHVs and local NGOs and community based organisations (CBOs) support health workers to conduct clinics including recording and reporting. ANMs/AHWs provide the basic primary health care services listed in 3.4.1

Services to be provided by PHC-ORCs according to PHC-ORC strategy Safe motherhood and newborn care: Child health:  Antenatal, postnatal, and newborn care  Growth monitoring of under 3 years  Iron supplement distribution children  Referral if danger signs identified.  Treatment of pneumonia and diarrhoea. Family planning: Health education and counselling:  DMPA (Depo-Provera) pills and  Family planning condoms  Maternal and newborn care  Monitoring of continuous use  Child health  Education and counselling on family  STI, HIV/AIDS planning methods and emergency  Adolescent sexual and reproductive contraception health.  Counselling and referral for IUCDs, implants and VSC services First aid:  Tracing defaulters.  Minor treatment and referral of complicated cases.

Service coverage

Across twelve districts of Province no. 529086 people were served from 22008 outreach sessions (Table 2.7.1) in 2075/76.

Table 2.7.1:PHC-ORCs conducted and people served in 2075/76 by districts Disttricts Total number of ORC Sessions Service provided to clients (New+Old) Rukum East 444 8522 Rolpa 1904 33120 Pyuthan 1765 38770

Disttricts Total number of ORC Sessions Service provided to clients (New+Old) Gulmi 2549 45169 Arghakhanchi 971 21983 Palpa 2180 49552 Nawalparasi West 1246 29903 Rupandehi 2865 72451 Kapilbastu 3071 71408 Dang 1443 42449 Banke 1645 52140 Bardiya 1925 63619 Province 5 22008 529086

An average of 24 clients were served per day per outreach clinic in Province no.5 with the highest average number being in Bardiya (33 clients per clinic) and lowest in Rolpa (17 clients per clinic). The average number of daily clients served by PHC-ORC is higher than the number of served in Health posts (Table 2.7.2).

Table 2.7.2: Average number of people served per ORC clinic per day by districts in FY 2075/76 Districts 2073/74 2074/75 2075/76 Rukum East 22 23 19 Rolpa 15 27 17 Pyuthan 21 20 22 Gulmi 15 17 18 Arghakhanchi 21 18 23 Palpa 19 21 23 Nawalparasi West 22 23 24 Rupandehi 23 23 25 Kapilbastu 25 22 23 Dang 26 30 29 Banke 29 30 32 Bardiya 28 30 33 Province 5 22 22 24

Services provision The average number of people served by PHC-ORCs in the Province was stagnant in the past two years (Table 3.4.2). In FY 2075/76 primary treatment, ANC services (Persons) and growth monitoring from PHCORCs has been increased in comparison to FY 2074/75 while PNC service (Persons) has slightly declined in the same time period (Table 3.4.3).

Table 2.7.3: Trend of services provided by PHC-ORCs Services 2073/74 2074/75 2075/76 Primary treatment (person) 123462 133102 154948 ANC(Person) 53764 55633 59096 PNC (Person) 5680 4330 4216 Depo (Person) 25445 25251 24789 Growth Monitoring 190392 210981 238038 Issues, constraints and recommendations

Table 2.7.4: Issues, constraints and recommendations— primary health care outreach Issues / constraints Recommendation Responsibility All the PHC-ORCs are not Functionalize all PHC-ORCs by resolving all MOSD, HD/ Local functional issues at every levels Level

Female Community Health Volunteers Program Background The government initiated the Female Community Health Volunteer (FCHV) Programme in 2045/46 (1988/1989) in 27 districts and expanded it to all 75 districts thereafter. Initially one FCHVs were appointed per ward following which in 2050 (1993/94) a population-based approach was introduced in 28 districts. There are 8994 FCHVs working across 12 districts of Province no. 5. The goal and objectives of the programme are listed in Box 3.3.1. FCHVs are selected by health mothers' groups. FCHVs are provided with 18 days basic training following which they receive medicine kit boxes, manuals, flipcharts, ward registers, IEC materials, and an FCHV bag, signboard and identity card. Family planning devices (pills and condoms only), iron tablets, vitamin A capsules, and ORS are supplied to them through health facilities. Province 5 has started 3 months advanced FCHV training course to upgrade the capabilities of FCHVs. The major role of FCHVs is to advocate healthy behaviour by mothers and community people to promote safe motherhood, child health, and family planning and other community based health issues and service delivery. FCHVs distribute condoms and pills, ORS packets and vitamin A capsules, treat pneumonia cases, refer serious cases to health institution and motivate and educate local people on healthy behaviour. They also distribute iron tablets to pregnant women. FCHVs are recognised for having played a major role in reducing maternal and child mortality and general fertility through community-based health programmes. The Province government is committed to increase the morale and participation of FCHVs for community health. In fiscal year 2064/65 MOHP established FCHV funds of NPR 50,000 in each health facility level mainly to promote income generation activities.

Goal and objectives of the FCHV Programme Goal — Improve the health of local communities by promoting public health. This includes imparting knowledge and skills for empowering women, increasing awareness on health related issues and involving local institutions in promoting health care. Objectives — i) Mobilise a pool of motivated volunteers to connect health programmes with communities and to provide community-based health services, ii) activate women to tackle common health problems by imparting relevant knowledge and skills; iii) increase community participation in improving health, iv) Develop FCHVs as health motivators and v) increase the use of health care services.

Major achievements in 2075/76 Progress reports, which provide the basis for the following analysis, were only received from 8994 FCHVs for 2075/76. In 2075/76 FCHVs in Province 5 distributed fewer condoms in comparison to 2074/75. (Table 2.8.1 and Figure 2.8.1). The number of mothers participating in health mother's group meetings and pills cycle distribution in 2075/76 has increased slightly.

Table 2.8.1: Trend of services provided by FCHVs Services 2073/74 2074/75 2075/76 Pills distribution (no. cycles) 164771 157663 158067 Condom distribution (pieces) 2259774 2137000 2026684 Iron tablet distribution 147286 147500 187123 Health mother's group meeting 89709 96597 96631

Figure 2.8.1:FCHV contribution on selected health services in FY 2074/75–2075/76

2073/74 2074/75 2075/76 2500000 2259774 2259774 2137000 2137000 2026684 2026684 2000000

1500000

1000000

500000 187123 187123 164771 164771 157663 157663 158067 147286 147286 147500 96597 96597 96631 89709 89709 0 Pills distribution Iron distribution Health mother group Condom distribution meeting

Support for home deliveries

FCHVs support home deliveries. In 2075/76 they initiated baby to mother’s skin-to-skin contact after delivery in 10823 cases, applied chlorhexidine to the umbilicus after delivery for 9199 cases and ensured the taking of misoprostol for preventing PPH in 2243 cases (Table 2.8.2) across 12 districts in Province 5.

Table 2.8.2: Support provided by FCHVs for home deliveries, 2075/76 Initiating skin to skin Chlorhexidine applied Ensured misoprostal Districts contact after birth on umbilicus tablets taken Rukum East 153 124 5 Rolpa 992 933 344 Pyuthan 609 641 60 Gulmi 681 573 118 Arghakhanchi 570 632 193 Palpa 312 338 2 54

Initiating skin to skin Chlorhexidine applied Ensured misoprostal Districts contact after birth on umbilicus tablets taken Nawalparasi West 289 320 8 Rupandehi 829 847 28 Kapilbastu 3435 3163 707 Dang 473 457 226 Banke 2250 941 339 Bardiya 230 230 213 Province 5 10823 9199 2243

CB-IMNCI service provided by FCHVs at the community level FCHVs reported 164813 cases of ARI . Similarly, 134482 diarrhoea cases were reported by FCHVs whereas 124518 cases of diarrhoea were treated with ORS and Zinc by FCHVs. Also, FCHVs assisted the immunization against polio of children below 5 years on National Immunisation Day, the community-based management and treatment of acute respiratory infections and control of diarrheal diseases, community nutrition programmes and other public health activities.

Table 2.8.3: CB-IMNCI service provided by FCHVs at the community level Services 2073/74 2074/75 2075/76 Total ARI cases reported by FCHV 171864 165463 164813 Total diarrhoea cases reported by 134482 140718 135890 FCHVS Treated with ORS and Zinc 120087 125726 124518

Issues and constraints

Table 2.8.4: Issues and constraints of FCHV program Issues and constraints Recommendations Responsibility Low utilization of FCHV Fund Strictly implement guidelines and audit MOSD,HD,Local Level FCHV fund every year Decreasing work performance Motivate FCHV through FCHV Review MOSD,HD Local Level of FCHV meeting and program related orientation Workload created by multiple Awareness focused program should be Central/ community based programs prioritized Provincial/Local level Poor and irregular reporting Monthly Health mother group and FCHV Central level by FCHV meeting at Health Facility should make Provincial level attractive Motivational issues Focus on motivational factors Central level Provincial level

Malaria Control Program Background Nepal’s malaria control programme began in 1954, mainly in the Tarai belt of central Nepalwith support from the United States. In 1958, the National Malaria Eradication Programme was initiated and in 1978 the concept reverted to a control programme. In 1998, the Roll Back Malaria (RBM) initiative was launched for control in hard-core forests, foothills, the inner Tarai and hill river valleys, which accounted for more than 70 percent of malaria cases in Nepal. Malaria is a greater risk in areas with an abundance of vector mosquitoes, amongst mobile and vulnerable populations, in relatively inaccessible areas, and during times of certain temperatures. National Malaria Strategic Plan (2014–2025) Current National Malaria Strategic Plan (NMSP) 2014-2025 was developed based on the epidemiology of malaria derived from 2012 micro-stratification, 2013 Mid –Term Malaria Program Review, and the updated WHO guidelines, particularly for elimination in low endemic country. This plan has inherent Government of Nepal’s commitment and seeks appraisal of external development partners, including the Global Fund, for possible external funding and technical assistance. The aim of NMSP is to attain “Malaria Free Nepal by 2026”. The strategic plan was divided into two phases: achieve Malaria Pre - Elimination by 2018 and attain Malaria Elimination by 2026. Malaria pre-elimination targets were set to achieve and sustain zero deaths due to malaria by 2015, reduce the incidence of indigenous malaria cases by 90%, and reduce the number of local levels having indigenous malaria cases by 70% of current levels by 2018. The baseline year was taken as 2012.

Strategy The strategy to achieve the targets was identified as follows:

 to strengthen strategic information for decision making towards malaria elimination  to further reduce malaria transmission and eliminate the foci wherever feasible  to improve quality of and access to early diagnosis and effective treatment of malaria  to develop and sustain support through advocacy and communication, from the political leadership and the communities towards malaria elimination and  To strengthen programmatic technical and managerial capacities towards malaria elimination. Achievements in FY 2075/76 Though the number of total slides examined for malaria had increased in the provincial level by 46187 in 2075/76 malaria positive cased had slightly declined. Imported malaria cases are higher in numbers than the indigenous for both PF and PV cases in the Province. Epidemiology of Malaria

Table 2.9.1: Malaria epidemiological information (2073/74-2075/76) Data / Period 2073/74 2074/75 2075/76 Population of Malaria endemic area 3381205 3436831 3483018

Data / Period 2073/74 2074/75 2075/76 Total Slide examined 38609 57451 56236 Total Malaria positive Cases 268 233 219 Total Malaria PF cases 39 27 9 % of PF cases 14.55 11.59 4.11 Total Malaria PF indigenous 8 1 1 Total Malaria PF imported 31 26 8 Total Malaria Indigenous Cases 74 75 45 Total P. Vivax(PV) cases 229 206 210 Annual blood examination rate (ABER) of malaria in 1.14 1.67 1.61 high risk districts Annual parasite incidence rate 0.079 0.068 0.063 Annual PF incidence rate 0.012 0.008 0.003 Slide positivity rate (SPR) of malaria in high risk 0.69 0.41 0.39 districts Slide positivity rate (SPR) of PF malaria in high risk 0.10 0.05 0.02 districts

Among the positive cases of malaria PF accounts for 9 percent. Overall indicators of malaria control program across the districts in Province are in progressive trend. This shows substantial progress towards elimination targets (bearing in mind that data are only generated by public health care facilities and require continuous attention for improvement). (Table 2.9.1 and 2.9.2)

Table 2.9.2: District wise malaria epidemiological information

No imported cases % of imported cases Malaria API per Slide positivity Data ABER % of PF cases among positive cases of among positive cases 1000 population rate malaria of malaria

Organization unit / Period 2074/75 2074/75 2074/75 2074/75 2074/75 2074/75 2074/75 2073 /74 2073 /74 2075 /76 2073 /74 2075 /76 2073 /74 2075 /76 2073 /74 2075 /76 2073 /74 2075 /76 2073 /74 2075 /76

Rukum East 0 0 0 0.00 0.00 0.00 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Rolpa 0 0 0 0.00 0.00 0.00 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Pyuthan 5.92 7.33 4.35 0.84 0.28 0.00 33.3 0.0 0.0 6.0 1.0 0.0 0.0 50.0 0.0 1.4 0.4 0.0 Gulmi 1.05 1.17 0.12 0.00 0.00 0.00 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Arghakhanchi 0.97 1.00 1.27 0.26 0.20 0.42 50.0 33.3 0.0 8.0 5.0 13.0 100.0 83.3 100.0 2.7 1.9 3.3 Palpa 1.52 1.41 2.89 0.06 0.08 0.04 33.3 0.0 0.0 2.0 2.0 1.0 66.7 50.0 50.0 0.4 0.5 0.1 Nawalparasi West 1.53 1.67 1.65 0.03 0.03 0.02 0.0 25.0 0.0 5.0 6.0 4.0 55.6 75.0 80.0 0.2 0.2 0.1 Rupandehi 1.43 1.59 1.63 0.07 0.02 0.04 24.2 28.6 5.9 34.0 20.0 29.0 51.5 95.2 85.3 0.5 0.1 0.2 Kapilbastu 0.90 1.76 1.37 0.14 0.10 0.12 12.5 11.8 8.2 58.0 39.0 56.0 80.6 76.5 91.8 1.6 0.6 0.9 Dang 0.99 0.95 0.81 0.06 0.04 0.02 2.9 11.1 9.1 31.0 22.0 9.0 91.2 81.5 81.8 0.6 0.5 0.2 Banke 0.66 1.64 3.05 0.06 0.15 0.12 3.4 8.2 0.0 20.0 50.0 46.0 69.0 68.5 75.4 0.9 0.9 0.4 Bardiya 1.19 2.81 1.31 0.09 0.10 0.07 12.5 4.3 3.1 29.0 19.0 16.0 72.5 40.4 50.0 0.8 0.4 0.5 Province 5 1.14 1.67 1.61 0.08 0.07 0.06 14.6 11.3 4.1 193.0 164.0 174.0 72.3 68.6 79.5 0.7 0.4 0.4

Issues, constraints and recommendations

Table 2.9.3: Issues and actions to be taken in Malaria Control program

Problems and constraints Action to be taken Responsibility

Malaria microscopy trainings of all untrained lab personnel

Availability of RDT at non microscopic Confirmation of suspected and sites MOHP, MOSD, probable malaria cases Local Level Orientation of service providers, clinicians, health workers and private practitioners Validation of probable malaria case through cases investigation Low blood slide examination rates Train health workers on RDT and MOHP, MOSD, for malaria elimination programme microscopy in malaria reported districts Local Level Orientation on malaria programme Run training programmes with GFATM MOHP, MOSD, to health workers support Local Level Malaria case reporting and case Orient district and peripheral staff on MOHP, MOSD, investigation case investigation and reporting Local Level Insufficient variables in HMIS tool EDCD to address the insufficient MOHP, MOSD, (for e.g. slide and RDT classification) variables during HMIS tools revision Local Level Malaria cases increasing in non- Programme should address non-endemic MOHP, MOSD, endemic district districts Local Level

Kala-azar Background Kala-azar is a vector-borne disease caused by the parasite Leishmania donovani, which is transmitted by the sand fly Phlebotomus argentipes. The disease is characterized by fever for more than two weeks with spleenomegaly, anaemia, and progressive weight loss and sometimes darkening of the skin. In endemic areas, children and young adults are the principal victims. The disease is fatal if not treated on time. Kala-azar and HIV/TB co-infections have emerged in recent years.

Table 2.10.1: Reported case of Kala-Azar by districts in OPD morbidity for FY 2073/74- 2075/76 District 2073/74 2074/75 2075/76 Rukum East 0 0 0 Rolpa 0 0 0 Pyuthan 0 1 0 Gulmi 0 0 0 Arghakhanchi 0 0 0 Palpa 17 22 4 Nawalparasi West 0 0 0 Rupandehi 14 12 15 Kapilbastu 1 0 0 Dang 0 0 0 Banke 6 30 40 Bardiya 0 0 0 Province 5 38 65 59

In 2075/076, 61 kala-azar cases were reported, decreased from the previous year (table 2.10.1). The most cases were reported from Banke (40), Rupandehi (15) and Palpa (4) while the programme of remaining districts reported no cases. Issues, Constraints and Actions to be taken

Table 2.10.2: Issues and recommendations to be taken in Kala-Azar control Issues Recommendations Responsibility Early case detection and complete Orientation and training of health treatment of kala-azar workers Regular supply of kala-azar test kits MOHP, MOSD, Local and drugs Level Active case detection in endemic districts Early detection and case Case based surveillance MOHP, MOSD, Local investigation Reporting with line listing of cases Level Cases increasing in non-endemic Extend programme to other non- MOHP, MOSD, Local districts endemic districts Level

Dengue Background Dengue is a mosquito-borne disease that occurs in Nepal as dengue fever, dengue haemorrhagic fever (DHF) and dengue shock syndrome (DSS). The earliest cases were detected in 2005. Sporadic cases and outbreaks occurred in 2006 and 2010. Initially most cases had travelled to the neighbouring country (India), although lately indigenous cases are also being reported. The affected districts in the province are Banke, Bardiya, Dang, Kapilvastu and Rupandehi reflecting the spread of the disease throughout the Tarai plains from west to east. Cases of Dengue in EWARS The EWARS was established in 1997 to strengthen the flow of information on vector-borne and other outbreak prone infectious diseases from the district to Epidemiology and Disease Control Division (EDCD) and Vector-Borne Disease Research and Training Center (VBDRTC), Hetauda. Rapid Response Teams (RRTs) can be mobilized at short notice to facilitate prompt outbreak response at Central, Regional and District level. RRTs can also support local level health institutions for investigation and outbreak control activities. This information system is hospital-based. So far, the EWARS mainly focuses on the weekly reporting of number of cases and deaths (including "zero" reports) of six priority diseases/syndromes—Malaria, Kala-azar, Dengue, Acute Gastroenteritis (AGE), Cholera and Severe Acute Respiratory Infection (SARI), and other epidemic potential diseases/syndromes (like enteric fever). It equally focuses on immediate reporting (to be reported within 24 hours of diagnosis) of one confirmed case of Cholera, Kala-azar severe and complicated Malaria and one suspect/clinical case of Dengue as well as 5 or more cases of AGE and SARI from the same geographical locality in one-week period. A total of 114 dengue cases were reported in province 5 in 2018. The reported cases from sentinel site in Province 5 are as follows: Table 2.11.1: Dengue case reported in 2018:

Sentinel Site Number of dengue cases Bheri Hospital, Banke 10 Lumbini Provincial Hospital, Rupandehi 92 Prithvi Bir Hospital, Kapilvastu 1 United Mission Hospital, Palpa 11 Grand Total 114

A total of 114 dengue cases were reported from 4 districts of this province in 2075/76 (see above table 2.11.1). The most were from Rupandehi (92) followed by Palpa (11), Banke(10) and Kapilbatu (1). There were no cases other 8 district. Issues constraints and recommendations

Table 2.11.2: issues constraints and recommendations of Dengue control Program Issues Recommendations Responsibility Re-emerging disease with Conduct awareness campaign on dengue; Prepare MOSD, epidemic potential plan for emergency response Local Government

Lymphatic Filariasis Background Lymphatic filariasis is a public health problem in Nepal.The disease has been detected from 300 feet above sea level in the Terai to 5,800 feet above sea level in the Mid hills. Comparatively more cases are seen in the Terai than the hills, but hill valleys and river basins also have high disease burdens. The disease is more prevalent in rural areas, predominantly affecting poorer people. Wuchereriabancrofti is the only recorded parasite in Nepal, The mosquito Culexquinquefasciatus, an efficient vector of the disease, has been recorded in all endemic areas of the country. Reported cases of Lymphatic Filariasis The number of reported Filariasis cases has increased significantly in 2075/76 with higher number Out of total, many of the cases have been reported from Palpa, Bardiya, Rolpa, Kapilbastu, Nawalparasi West, Dang and Banke on HMIS OPD morbidity reporting.

Table 2.12.1 Reported case of Filariasis by districts in OPD morbidity for FY 2073/74-2075/76

District 2073/74 2074/75 2074/75 Pyuthan 0 0 0 Gulmi 0 8 0 Rukum East 0 0 1 Banke 6 27 5 Dang 0 2 6 Nawalparasi West 6 59 7 Kapilbastu 32 9 16 Bardiya 2 16 24 Rolpa 0 0 16 Palpa 15 0 79 Arghakhanchi 7 9 0 Rupandehi 20 55 0 Province 5 88 185 154 Issues constraints and recommendations

Table 2.12.2: issues constraints and recommendations of Lymphatic Filariasis control Program Issues Recommendations Responsibility Poor compliance of MDA Spread Awareness on MDA to overcome rumours MOSD, Appoint brand ambassador for better Local Government compliance Assign health workers for MDA campaign and drug dispensing

Tuberculosis Background Tuberculosis (TB) is a public health problem in Nepal that affects thousands of people each year and is the sixth leading cause of death in the country. WHO estimates that 44,000 people develop active TB every year and out of them 20,500 have infectious pulmonary disease and can spread the disease to others. Case notification The Provincial Case Notification Rate (all forms) in 2075/76 was 118/100,000 population which was Decreased from 136/100,000 in 2074/75. Based on the figure 4.5.1, there only 2 districts (Rukum East, Gulmi and Kapilbastu) having CNR less than 100/100,000 population with highest (149/100000) CNR reporting from Pyuthan. In comparison to relapse cases, provincial CNR of PBC new cases had increased sharply over the last year (Table 4.5.1)

Figure 2.13.1: Case notification rate of all forms of TB, 2075/76

200 185 185 180 164 164 159 159 155 155 151 151 149 149 160 149 143 143 139 139 138 138 136 136 136 136 136 136 132 132 131 131 130 130 140 129 125 125 125 125 125 125 125 125 125 124 124 124 124 123 123 119 119 118 118 114 114 113 113 111 111 120 109 102 102 97 97

100 91 91 77 77 68 68

80 66 63 63 60 40 20 0

2073 /2074 2074 / 2075 2075 /2076

Table 2.13.1: Case Notification rate new cases vs relapse cases CNR PBC New cases CNR PBC Relapse cases Districts 2073/74 2074/75 2075/76 2073/74 2074/75 2075/76 Province 5 64 69.9 61.2 10 10.9 8.2 Rukum East 26.2 42.1 38.2 1.7 0 3.5 Rolpa 67.4 64.4 60.6 9.9 13.2 7.6 Pyuthan 55.2 85.8 85.3 11.8 15.5 7.9 Gulmi 47.6 37.6 38 6 11 10.4 Arghakhanchi 36.3 49.6 48 9.9 14.9 6.4 Palpa 68.8 72.9 58.6 9.8 11.5 11.6 Nawalparasi West 69.8 69.3 71.9 9.7 13.5 10.9 Rupandehi 51.7 71.1 61.7 9.2 10.8 8.3

CNR PBC New cases CNR PBC Relapse cases Districts 2073/74 2074/75 2075/76 2073/74 2074/75 2075/76 Kapilbastu 58.2 71.1 48.7 8.6 7.2 4.3 Dang 79.7 77.9 69.9 14.7 10.9 10.6 Banke 85.5 77.2 68.8 11.8 10.3 7.8 Bardiya 73.1 70 58.9 8.1 11.2 7.6 Among all TB cases notified around 59 percent of all TB cases reported accounts for pulmonary (new and relapse) smear positive cases in 2075/76. During the same time period 25 percent of TB cases were extra pulmonary TB, 14 percent of pulmonary clinically diagnosed cases and 2 percent smear positive retreatment cases were reported across all the districts in Province 5.

Figure 2.13.2: TB cases registered in 2075/76

122, 2%

795, 14% New and relapse PBC

Extra Pulmonary TB cases

1487, 25% Pulmonary Clinical Diagnosed 3473, 59% Smear Positive Retreatment cases

Treatment outcomes Provincial treatment success rate of TB in 2075/76 was 91 percent which is decreased from 91.5 percent. Treatment success rate in Palpa was lowest (84.6%) whereas Pyuthan had the highest treatment success rate (92.1%) among the districts in Province 5.

Table 2.13.2: TB treatment success rate 2073/74- 2075/76 Districts 2073/74 2074/75 2075/76 89.7 87.1 89.1 Rukum East 133.3 94.4 88.9 Rolpa 93.4 92 92.1 Pyuthan 85.7 93.3 87.5 Gulmi 91.6 100 91.2 Arghakhanchi

Districts 2073/74 2074/75 2075/76 103.4 75 84.6 Palpa 88.3 92 91.5 Nawalparasi West 84.9 80.2 87.2 Rupandehi 89.9 87.1 87.3 Kapilvastu 89.7 85.4 85.3 Dang 88.8 87.8 90.5 Banke 90 83.7 92 Bardiya 88.5 91 91.5 Province 5 Drug resistant tuberculosis Drug-resistant TB has become a great challenge for the NTP and a major public health concern in in the Province. Innovative approaches and more funding are urgently needed for the programmatic management of drug resistance-TB nationally to detect and enrol more patients on multi-drug resistant (MDR) TB treatment, and to improve outcomes. The national policy defines six types of MDR-TB cases. Drug resistant TB is detected early by the investigation of all new TB cases. Most MDR-TB cases are diagnosed as failure after category 2 and retreatment.

Figure 2.13.3: Number of MDR-TB cases notified (2073/74-2075/76)

2073/74 2074/75 2075/76

60 53 50 35 40 34 32 29 31 29 30 15 20 12 12 13 10 9 10 5 5 3 3 4 3 2 0 0 new Other relapse Transfer in Transfer up RX after failure cat-1 failure after RX RX after lost to follow to lost after RX

RX After Failure (Cat II) (Cat Failure After RX MDR TB cases were notified in Banke and Rupandehi districts in the Province. MDR cases notified in Province 5 have an increasing trend. (Figure.2.13.3).

Figure 2.13.4: MDR TB cases notified by districts (2073/74-2075/76)

700

600 574

500 470

400

300

200 138 101 86 83 100

0 Banke Rupandehi

2073/74 2074/75 2075/76

Issues constraints and recommendations

Table 2.13.2: issues constraints and recommendations of TB control Program Issues Recommendations Responsibility

Case notification not reaching to Strengthen the awareness program with target new innovative approach MOSD, Local Expand xene-expert and microscopic Government centers Increase the number of microscopic camps Increasing number of DR Training to newly appointed HWs MOSD, Local Tuberculosis Strictly folloe the DOTS protocol Government Expansion of DOTS program in Orientation to Private sectors inTB Private Hospitals treatment protocols Regulate and enforce private sectors in TB identification and treatment

Leprosy Prevalence of Leprosy The cut-off point for leprosy elimination set by WHO is less than 1 case per ten thousand population. The overall prevalence of leprosy in the Province was found 0.97/10,000 which showed that the Province is near to leprosy elimination. Total Cases of leprosy in the Province has slightly declined from 669 in 2075 to 486 in 2076.The highest number of leprosy cases under treatment was reported from Rupandehi (130 cases) followed by Banke (125 cases) in 2075/76(Table 2.14.1).

Table 2.14.1: Distribution of registered cases and prevalence rate in 2075/76 Districts Total cases at the end of the year Reg. prevalence Rate/10,000 population 2073/74 2074/75 2075/76

Rukum East 0.0 0.0 0.0

Rolpa 13 10 8

Pyuthan 9 0 10

Gulmi 2 3 1

Arghakhanchi 4 1 4

Palpa 20 18 13

Nawalparasi West 44 109 53

Rupandehi 87 170 130

Kapilbastu 58 137 58

Dang 30 17 19

Banke 264 153 125

Bardiya 200 51 65

731 669 486 Province 5

Figure: 2.14.1: Trend of prevalence rate of Leprosy by District.

2073/74 2074/75 2075/76

5.0 4.7 4.5 4.4 4.0 3.5 3.0

3.0 2.7 2.1 2.5 2.1

2.0 1.7 1.5 1.4 1.4 1.4 1.3 1.2

1.5 1.1 0.97 0.9 0.9 0.9 0.8 1.0 0.7 0.6 0.5 0.5 0.4 0.4 0.4 0.3 0.3 0.3 0.2 0.2 0.1

0.5 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Prevalence rate of Leprosy has slightly declined from 1.4/10,000 in 2075 to 0.97/10,000 in 2076. Out of total, prevalence rate was highest in Banke (2.1 case per 10,000 population) followed by Bardiya and Nawalparasi West in 2076. There was no any cases reported from Rukum-East.

District-wise New Case Detection The detection of new cases signifies ongoing transmission with the rate measured per 100,000 population. A total of 691 new leprosy cases were detected in 2075/76. Banke reported 257 new cases this year which is the highest number in this Province. Meanwhile, there were no any new cases reported from Rukum-East. Similarly, Gulmi and Arghakhanchi have reported 1 and 3 cases respectively. (Table 2.14.2).

Table 2.14.2: Details of new Leprosy Cases (2075/76) Districts Total New Cases NCDR Disability Grade-2 Rukum East 0 0.0 0

Rolpa 7 0.3 0

Pyuthan 11 0.5 0

Gulmi 1 0.0 0

Arghakhanchi 3 0.1 0

Palpa 25 1.0 0

Districts Total New Cases NCDR Disability Grade-2 Nawalparasi West 48 1.3 4.2

Rupandehhi 123 1.2 2.4

Kapilbastu 117 1.8 1.7

Dang 35 0.6 0

Banke 257 4.4 10.1

Bardiya 64 1.4 7.8

691 1.4 5.5 Province 5

The table 2.14.2 show the total new cases, new case detection rate and disability grade-2 of this Province. Out of total reported 691 new cases, Banke had the highest disability grade -2 (10.1%) followed by Bardiya (7.8%) found. However, 7 districts had maintained 0 disability grade-2 in this Province though the average rate of this Province was 5.5 percent in terms of disability grade-2 rate. Strengths, Weakness and Challenges of Leprosy control Program

Table 2.14.3: Strengths, weakness and challenges for the leprosy control programme Strengths Weaknesses Challenges . Commitment from political . Low priority for leprosy . To eliminate at Province and level –government's programme at periphery district level commitment to Bangkok . Low motivation of health . To maintain access and quality Declaration for Leprosy workers of services in low endemic . Accessible of leprosy service . Very few rehabilitation mountain and hill districts . Free MDT, transport service activities . To strengthen surveillance, for released from treatment . Inadequate training and logistic, information, and job cases and other services for orientation for newly oriented capacity-building for treating complications recruited health workers general health workers, and an . Uninterrupted supply of and refresher trainings for efficient referral network MDT focal persons and . To assess the magnitude of . Good communication and managers disability due to leprosy collaboration among . Poor institutional set-up . To further reduce stigma and supporting partners and inadequate human discrimination against affected . Improving participation of resources persons and their families leprosy affected people in . Problem for reaction and . Insufficient activities in low national programme complication management endemic districts for reducing . Contact examination/ at periphery level the disease burden surveillance of patient, . Poor result-based output, . To maintain access and quality family members and recording and reporting of service at HF level neighbours contact examination . Strengthening of index case & activities contact surveillance, recording . Poor coverage and and reporting system monitoring of LPEP in implementing districts . Higher prevalence rate of . Expand awareness . MOSD, Local Level leprosy case in compared to programs to overcome 69

Strengths Weaknesses Challenges national figure social stigma . Organize leprosy screening camps to identify hidden cases in the community . Higher grade-2 disability . Screening of leprosy for . MOSD, Local Level rate early detection and prompt and complete treatment . Orient health workers in the endemic districts

HIV/AIDS and STI Control Program Background With the first case of HIV identification in 1988, Nepal started its policy response to the epidemic of HIV through its first National Policy on Acquired Immunity Deficiency Syndrome (AIDS) and Sexually Transmitted Diseases (STDs) Control, 1995 (2052 BS). Taking the dynamic nature of the epidemic of HIV into consideration, Nepal revisited its first national policy on 1995 and endorsed the latest version: National Policy on Human Immunodeficiency Virus (HIV) and Sexually Transmitted Infections (STIs), 2011. A new National HIV Strategic Plan 2016-2021 is recently launched to achieve ambitious global goals of 90-90-90. By 2020, 90% of all people living with HIV (PLHIV) will know their HIV status by 2020, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy, and by 2020, 90% of all people receiving antiretroviral therapy will have viral suppression. Overview of the Epidemic Starting from a ‘low level epidemic’ over the period of time HIV infection in Nepal evolved itself to become a ‘concentrated epidemic’ among key populations (KPs), notably with People who Inject Drugs (PWID), female sex workers (FSW), Men who have Sex with Men (MSM) and Transgender (TG) People in this Province as well. Progress and major achievements HIV Testing Services HIV Testing and Counseling sites in this Province that including non-government and government sites operating in this Province also maintaining their linkages with KPs as well as with 14 ART sites of this Province as well as PMTCT sites.

Table 2.15.1: Service Statistics HIV Testing and Counselling for the period of BS 2073/74- 2074/75 Indicators 2073/74 2074/75 2075/76 Total tested for HIV 123227 131466 117026 Total Positive reported 556 664 417 The number of HIV tested is 117026 in FY 2075/76 which is slightly decreased in compared to FY 2074/75 . Similarly, the number of positive cases reported is also decreased than previous fiscal year.

Table 2.15.2: District wise Service Statistics HIV Testing and Counselling in 2075/76 Tested for HIV Positive reported Districts 2073/74 2074/75 2075/76 2073/74 2074/75 2075/76 Rukum East 0 0 0 0 0 0 Rolpa 220 128 575 1 2 4 Pyuthan 8805 5958 23 6 3 7 Gulmi 173 152 181 16 20 15 Arghakhanchi 6505 7008 503 20 16 7 Palpa 6710 2328 2865 89 82 58

Tested for HIV Positive reported Districts 2073/74 2074/75 2075/76 2073/74 2074/75 2075/76 Nawalparasi West 1793 1835 2039 33 24 23 Rupandehi 394 761 2077 115 148 64 Kapilvastu 4455 4812 6533 103 107 106 Dang 8157 774 178 9 13 34 Banke 5237 5671 3662 95 98 89 Bardiya 2460 3497 2595 17 13 10 Province 5 44909 32924 21231 504 526 417

Table 2.15.2 present the service statistics of HIV testing and counseling. The HIV testing among twelve district was higher in Kapilvastu (6533) whereas the positivity yield among HIV testing is higher in Kapilbastu. There was no any positive case of HIV reported in Rukum East. Aiming at the elimination of mother to child transmission, Ministry of Health and Population, Nepal taking a major transformative measure this fiscal year, providing lifelong ART for all identified pregnant women and breastfeeding mothers with HIV, regardless of CD4, along with prophylaxis treatment for their infants as well. The rollout of the lifelong treatment adds the benefits of the triple reinforcing effectiveness of the HIV response: (a) help improve maternal health (b) prevent vertical transmission, and (c) reduce sexual transmission of HIV to sexual partners. Prevention of Mother to Child Transmission (PMTCT)

Table 2.15.3: Service statistics on PMTCT for the period, 2075/76 Indicators 2073/74 2074/75 2075/76 Tested for HIV ANC and Labour 78836 98414 95795 HIV Positive pregnant women 43 129 38 Total deliveries by HIV+ mothers 15 25 20 Mothers received prophylaxis and ART 33 35 32 Babies received prophylaxis 16 25 20 Table 2.15.3 reveals the three years trend of service statistics on PMTCT. Provincial commitment is to eliminate vertical transmission of HIV among children by 2021, in line with Ministry of Health and Population. The number of women attending ANC and labor who were tested and received results had decreased then previous year. The number of tested HIV positive pregnant women decreased by129 to 43 in F/Y 2075/76 compared to 2074/75. The coverage for PMTCT was still low . Number of babies received proplyaxis also decreased in FY 2075/76.

Issues and recommendation

Table 2.15.4: issues recommendation of HIV/AIDS Program Issues/Constraints Recommendations Responsibility

HIV/AIDS program mostly Provincial government should implemented from non- take the lead and establish government sector network in the system MOSD, HD, Local Level

Integrate HIV/AIDS program in basic health services

Limited ART centres Expansion of ART Centres in the sub-districts level to make accessible in the communities MOSD, HD, Local Level

Disaster management

Background Nepal is one of the most multi-hazard prone Countries. Globally Nepal has ranked in 4th position in terms of risks of climate change and 11th positioned in terms of earth quakes. We have a long history of suffering from different natural disasters such as earth quake, landslides, floods and soil erosion etc. and epidemiological diseases such as bird flu, swine flu, dengue, scrub typhus, diarrhea, Cholera etc. Nepal’s National Disaster Risk Reduction Policy (2018) was endorsed by the National Disaster Risk Reduction and Management Council meeting held on 18 June 2018 and has been drafted in line with the Disaster Risk Reduction and Management Act (2017). It is Nepal’s first policy aimed at ensuring a long-term provision towards disaster risk reduction and management. This Province has both hilly and Terai districts with risks of multi hazard at any time. Recognizing this risk, Province has formulated provincial disaster management committee on the chairmanship of honorable social development minister Sudarsan Baral on 2075/3/26. Objectives  To assess the disaster risks and make disaster preparedness plan in the Province.  To manage the disaster incidents of Province.  To make coordination with concerned agencies for the management of disaster  To formulate the RRT and CRRT in the Province.  To make Early warning System well-functioning.  To monitor and strengthen the functions of hub hospitals and satellite hospital.  To keep the record of disaster incident and make analysis  To reduce vulnerability and mitigation of disaster through better planning process. .  To make instant response and effective decision making.  To encouraging and empowering the local community to own disaster management. Disaster Management Activities in Province 5  Provision of Buffer Stock  Outbreak Management

SN Outbreak Palika/ District Number of affected Number persons of Death Diarrhoea Shantinagar, Dang 1576 1 Musikot Municipality, Gulmi 188 1 Rainadevi Rural Municipality, Palpa 62 Measles Rajpur Rural Municipality, Dang 2549 2 Krishnanagar Municipality, Kapilbastu 18 3 Food Poisoning Satyawati Rural Municipality, Gulmi 14

Tinau Rural Municipality, Palpa 170

CHAPTER III: CURATIVE HEALTH SERVICES The Government of Province, province no. 5 is committed to improve the health status of rural and urban people by delivering high-quality health services. In December 2006 the Government of Nepal began providing essential health care services (emergency and inpatient services) free of charge to destitute, poor, disabled, senior citizens, FCHVs, victims of gender violence and others in up to 25-bed district hospitals and PHCCs and for all citizens at health posts in October 2007. The Constitution of Nepal has guaranteed the basic health services emergency services as the fundamental human right of the people and province government is in the line of implementing those rights. From FY 2075/76, the Government of Province, province no 5 gave special home-based care to the people above age 84 years by providing treating and care at home from health worker. This is the social responsibility and respect for elderly people from the Government of Province to fulfill their basic halth care needs. From FY 2076/77, the Government of Province, province no. 5 is also adopted hosital based free treatment to patient of Chronic Respiratory Diseases (COPD and related disease) up to Rs 50,000. This program will help to reduce financial burden of poor people on treatment of COPD and related disease in the province. The core objective of the Government of Province to provide quality curative services with specialized care to reduce morbidity and mortality by ensuring the early diagnosis and prompt treatment form district and province level hopstitals. The detail policy and strategy on curative health services is in the process of finalization. Major Services Available in Hospitals According to the hospital’s available human resources as well as infrastructure their Major services are operated. As reported by following hospital on Annual Health Review FY 2075/76, the information about major hospital services are as below: Table 3.1.1: Major services available in Hospital under province 5:

Name of Hospital Available Services . Dermatology . General Medicine . Obstetrics and . Cardiology Gynecology . Neurology . Orthopedics Surgery . Nephrology . Physiotherapy . Psychiatric . Pathology Lumbini Provincial Hospital: . Pediatrics . Radiology . General Surgery . ECG/Endoscopy . Dental Surgery . Audiology . ENT . Dental Hygiene . Gastroenterology Surgery . Bio-Medical . Uro Surgery Engineering . Neuro Surgery . OPD, IPD, MCH . Lab/ X- ray/ . Emergency USG/ECG Arghakhachi Hospital . Surgery . Pharmacy . Ambulance . Medicolegal services

Name of Hospital Available Services . SSU, OCMC . OPD, IPD, MCH . OCMC,DOTS,ART Palpa hospital Tansen . Emergency . Medicolegal services . Ambulance . Pharmacy . OPD, IPD, MCH . DOTS Palpa hospital Rampur . Emergency . Medicolegal services . Ambulance . Pharmacy . Pharmacy Service . OPD, IPD, MCH . Blood Bank . Emergency . Medicolegal Services . Lab/ X- ray/ USG/ECG Pyuthan Hospital . Anesthesia . CEOC,OCMC,DOTS,ART . Central Billing . Lab service with Gene X-pert System . SSU . Ambulance Service . Dental Services . Electronic Health Record . ER with Defibrillator & Patient . Central Billing Monitor System . Surgical services (CS and all . Special Clinics( Safe Bhim Hospital emergency lifesaving surgery Abortion care, . Anesthesia immunization and . Lab/ X- ray/ USG/ECG Growth Monitoring, . Blood Bank FP, ATT and ART) . Medicolegal Services . 24 hors pharmacy Services . Safe motherhood - . OPD services including Dental OPD CEONC services, CAC, . Emergency services PAC services . Laboratory Services- Blood Bank, . Preventive services – Culture, TFT Immunization, FP, Gulmi Hospital . CR X-ray , ECG services, USG MCH, Nutrition . Indoor Patient Department services . Social Services - SSU, with SNCU OCMC, Health . Surgical Services – CS, Appendectomy, insurance Minor OT, Plaster . Central e-Billing . Others - ART , STI clinic, DOTs, Leprosy, Medico-legal, . OPD, Dressing, ART, DOTS . Normal OT . Lab, Xene X pert, CD4 count, . Pharmacy, Radiology Kapilbastu Hospital . Emergency and OCMC . OCMC, SSU . Delivery and LSCS, Indoor, SNCU

. Emergency OT . Digital x-ray service . 24 hour delivery Prithivi Chandra Hospital . USG from latest technology based services along with

Name of Hospital Available Services machine C/S . Gene-xpert services . ART, OCMC, DOTS . 24 hour pharmacy services services, SSU . Ortho ,ENT , Gynae, Psychiatric, Mdgp. . Modernized OPD services postmortem house with mortuary system . ANC/PNC . OPD . Family Planning . Emergency . ART/DOTS,OCMC, . Indoor Rolpa Hospital SSU . Lab/X-ray . Emergency Blood . C/S (CEONC Site) Transfusion Services . Safe Abortion . Medicolegal Services

The above information is collected by annual review of 2075/76, presented by respective hospitals. Rapti Provincial Hospital, Bardiya Hospital and Rukum East Hospital were not reported their services in details. Status of Human Resource in Hospitals Human resource is the core component of the hospital to provide quality curative with specialized health care service from hospitals. They play a key role in developing, reinforcing and changing the culture of an organization. Without human resources, we can’t do efficient use of other resource and deliver the proper services. So human resource should be fulfilled in time and should be in proper management. 13 hospitals under provincial government had the following HR status in FY 2075/76: Table 3.2.1: Human Resources of Hospital under province 5: Doctors Paramedics Fulfilled SN Name of Hospital Sanctioned Fulfilled Sanctioned Fulfilled % Lumbini Provincial Hospital, 1 116 51 212 179 70.1 Butwal, Rupandehi Rapti Provincial Hospital, 2 23 10 36 39 83.1 Tulsipur, Dang 3 Bardiya Hospital 15 4 26 21 61.0 4 Rolpa Hospital 2 2 14 8 62.5 5 Pyuthan Hospital 14 4 27 15 46.3 6 Palpa Hospital 3 2 14 12 82.4 7 Rampur Hospital, Palpa 14 4 28 7 26.2 8 Gulmi Hospital 15 5 26 11 39.0 9 Arghakhanchi Hospital 3 3 13 10 81.3 10 Kapilbastu Hospital 4 3 14 10 72.2 Prithbi-Chandra Hospital 11 15 4 25 13 42.5 Nawalparasi West 12 Bhim Hospital Bhairahawa 5 4 22 21 92.6 13 Rukum East Hospital 0 0 0 0 0.0 Total 229 96 457 346 64.4

Table 3.2.2: Doctor/Population, Paramedics/population and Nursing staff/population ratio in governmental sectors are as follows:

SN Human Resources Number Total Population in prov 5 Population ratio Total Dr. in services in 1 government health sector 173 4999454 1:28899 Total Paramedics works in 2 government sector 1915 4999454 1:2611 Total nursing staff works in government health 3 sector 1359 4999454 1:3679

Table 3.2.3 Contact list of Hospitals under province:

sn Hospital Name Phone Email Office chief Mobile Dr. Prakash 1 Bheri Hospital 081-520120 [email protected] Thapa 9858020419 Prof. Dr. Sangita 2 Rapti Accedmy of [email protected] Bhandary Health Science, Ghorahi Dang 3 Dr. Rajendra Lumbini 071-540201 [email protected] Khanal 9857029587 Provincial Hospital 4 Dr.Pratap Rapti Provincial 082-521624 [email protected] Pokherel 9847845594 Hospital 5 Bardiya Hospital 084-420027 Dr. subash [email protected] pandey 9858032177 6 Rolpa Hospital 086-690621 Dr.sushil Acharya Reugha [email protected] 9857825361 7 Pyuthan 086-460691 Dr. Amrit Panthi Hospital [email protected] 9841363317 8 Palpa Hospital 075-520154 Dr. Puspa Raj Tansen [email protected] Gyawoli 9851231967 9 Rampur 075-400154 Dr.Bijay Pariyar Hospital Palpa [email protected] 9841182212 10 Gulmi Hospital 079-520024 Dr.Uttam pachya [email protected] 9851188826 11 Arghakhanchi 077-420188 Dr.Kapil Gautam Hospital [email protected] 9841144481 12 Kapilbastu 076-560200 Dr. Kishor Hospital [email protected] Banjade 9851033053 13 Prithbi Chandra 078-520188 [email protected] Dr Moh. Nurul Hospital Hoda 9857047009 Nawalparasi West 79

14 Bhim Hospital 071-527793 [email protected] Dr Nabin Bhairahawa Darnwal 9857063400 15 Rukum East Dr. Rajendra G.C Hospital 9858054120 16 Chisapani Dr. Vijaya Khanal Hospital 9855072933 Nawalparasi west 17 Shivraj Hospital [email protected] Dr. Ved Maharajgunj Chaudhary 9803776058 18 Pipara Hospital [email protected] Dr. Ranjita Banganga [email protected] Kumari Mahato 9844313586 19 Lamahi Hospital, 082-520202 [email protected] Dr. Akash Dang Belbase 9847866585

Infrastructure and Equipment Adequate and well-structured infrastructure is very important to deliver the high quality service. As the country transitions into federal form of governance with specific mandates for local, provincial and federal government, this also provides an opportunity to reorganize the health system for optimal delivery of high quality health services. Health infrastructure development standard 2017 classifies health institutions into five levels based on a minimum set of health services: community level (Health Posts or Community Health Units); Primary Hospitals; Secondary Hospitals; Tertiary Hospitals; Academic or Super-specialty hospitals. In province, there is the provision of Secondary Hospital and one provincial health Science Academy. It is the responsibility of the province to identify needs for health infrastructure development, Prepare and implement plans of development and upgrading of infrastructure to provide the quality health services. Table 3.4.1: Status of Infrastructure of Hospitals under Province 5 S Hospital Emergen OPD IPD Maternity OT Lab Pharma Doctor's Nurse's Other SS OCM N Name cy Ward cy Quarter Quarter Staff U C Quarte r 1 Lumbini Not Not Not Not Sufficie Not Not Not Not Not Ye Yes Provincial Sufficient Sufficie Sufficient Sufficient nt Sufficie Sufficien Sufficient Sufficient Sufficie s Hospital nt nt t nt 2 Rapti Not Not Not Not Not Not Not Under Under Not No No Provincial Sufficient Sufficie Sufficient Sufficient Sufficie Sufficie Sufficien Constructi Constructi Sufficie Hospital nt nt nt t on on nt 3 Bardiya Not Not Not Not Not Not Not Not Not Not Ye Yes Hospital Sufficient Sufficie Sufficient Sufficient Sufficie Sufficie Sufficien Sufficient Sufficient Sufficie s nt nt nt t nt 4 Rolpa Not Not Not Sufficient Not Sufficie Sufficien Not Not Not Ye No Hospital Sufficient Sufficie Sufficient Sufficie nt t Sufficient Sufficient Sufficie s Reugha nt nt nt 5 Pyuthan Not Not Not Not Not Not Not Not Not Not Ye Yes Hospital Sufficient Sufficie Sufficient Sufficient Sufficie Sufficie Sufficien Sufficient Sufficient Sufficie s nt nt nt t nt 6 Palpa Not Not Not Not Not Not Not Not Not Not No Yes Hospital Sufficient Sufficie Sufficient Sufficient Sufficie Sufficie Sufficien Sufficient Sufficient Sufficie Tansen nt nt nt t nt 7 Rampur Not Not Under Under Not Not Not Sufficient Sufficient Not No No Hospital Sufficient Sufficie Constructi Constructi Sufficie Sufficie Sufficien Sufficie Palpa nt on on nt nt t nt 8 Gulmi Not Not Not Not Not Not Not Not Not Not Ye No Hospital Sufficient Sufficie Sufficient Sufficient Sufficie Sufficie Sufficien Sufficient Sufficient Sufficie s nt nt nt t nt 81

S Hospital Emergen OPD IPD Maternity OT Lab Pharma Doctor's Nurse's Other SS OCM N Name cy Ward cy Quarter Quarter Staff U C Quarte r 9 Arghakhanc Sufficient Sufficie Not Not Sufficie Sufficie Sufficien Not Not Not Ye Yes hi Hospital nt Sufficient Sufficient nt nt t Sufficient Sufficient Sufficie s nt 1 Kapilbastu Sufficient Sufficie Sufficient Sufficient Sufficie Sufficie Sufficien Not Not Not Ye No 0 Hospital nt nt nt t Sufficient Sufficient Sufficie s nt 1 Prithbi Sufficient Not Not Not Not Not Not Not Not Not Ye No 1 Chandra Sufficie Sufficient Sufficient Sufficie Sufficie Sufficien Sufficient Sufficient Sufficie s Hospital nt nt nt t nt Nawalparas i West 1 Bhim Not Not Not Not Not Not Not Not Not Not No No 2 Hospital Sufficient Sufficie Sufficient Sufficient Sufficie Sufficie Sufficien Sufficient Sufficient Sufficie Bhairahawa nt nt nt t nt 1 Rukum East 3 Hospital

In this province, most of the provincial hospitals had no adequate space and buildings for different departments. Relatively, Kapilbastu hospital and Arghakhanchi hospitals had adequate space within the buildings whereas Rampur hospital's some buildings were on under construction. Table 3.4.2: Hospitals Major Equipment

Hospitals CT CT scan MRI Monitor Autoclave USG Suction Analyzer Microscope X-Ray Dialysis Endoscopy Anesthia machine ECG C-ARM X-ene Expert Phototherapy O2 concentrator Lumbini Provincial 1 NA 21 4 3 11 11 4 5 5 1 5 1 NA NA 4 2 Hospital Rapti Provincial Hospital NA NA 6 5 1 7 7 3 1 3 1 1 NA 1 NA NA NA Bardiya Hospital 0 0 5 NA NA 1 3 NA 2 0 NA 1 2 NA 1 NA 2 Rolpa Hospital Reugha 0 0 1 NA 1 2 4 1 3 0 NA NA NA 0 0 NA 4

Hospitals CT CT scan MRI Monitor Autoclave USG Suction Analyzer Microscope X-Ray Dialysis Endoscopy Anesthia machine ECG C-ARM X-ene Expert Phototherapy O2 concentrator Pyuthan Hospital 0 0 2 NA NA 1 2 NA 3 0 NA NA 1 0 1 NA 1 Palpa Hospital Tansen 0 0 0 NA 1 1 3 1 1 0 NA NA NA 0 0 NA 0 Rampur Hospital Palpa 0 0 3 NA 0 1 1 1 1 0 0 0 1 0 0 NA 0 Gulmi Hospital O O 3 NA 1 1 2 3 1 0 0 NA 2 1 1 NA 3 Arghakhanchi Hospital 0 0 2 NA 1 1 3 1 1 0 0 0 1 NA 0 NA 3 Kapilbastu Hospital 0 0 1 NA NA 0 1 NA 1 0 0 0 1 0 1 1 2 Prithbi Chandra Hospital 0 0 4 NA 0 3 1 2 3 0 0 0 2 0 0 0 0 Nawalparasi West Bhim Hospital Bhairahawa 0 0 1 NA NA NA NA NA 1 0 0 1 NA NA NA NA NA Rukum East Hospital NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

Major Hospital Indicators Curative health services were provided at all health facilities including outpatient, emergency and inpatient care and free health services. Inpatient services were provided at all levels of hospitals including INGO and NGO run hospitals, private medical college hospitals, nursing homes and private hospitals. Medical camps were also organized to reach the unreached population. Figure: 3.5.1 Reporting rate of public and non-public hospital

2073 /074 2074/075 2075/076 120 100 100 100 94 80 60 38 35 40 29 20 0 Hospital Reporting rate (Public) Hospital Reporting rate (Non Public)

20 government led hospitals are delivering curative health services in addition to many private and INGOs led hospitals, polyclinics, and clinics. All government led hospitals had reported to HMIS 100 percent in the fiscal year 2075/76 whereas non-public hospital had reported to HMIS only 29% in this FY 2075/76 Total OPD new Visits Figure 3.5.2: Total new OPD Visits by Districts in FY 2074/75

200 175.5 180 160 132 140 120 102.3 100 83.9 80.6 75.4 74.7 71.5 71 80 65.3 64.8 62 60.1 60 40 20 0

It is the proportion of total number of OPD new visits to the total population of the catchment area. In the fiscal year 2075/76, the total OPD visit is 80.6% of total population of this province. Districts Palpa, Gulmi and Pyuthan were more than 1 times the total population of the districts which could be due to the referrals from adjacent districts. In contrast, the new OPD visits in Dang and Nawalparasi west were lowest. 84

Inpatient services Inpatient services are provided through inpatient departments at public and non-public hospitals. The inpatient services indicators need to be interpreted with caution because few non-public hospitals had not reported for the all 12 months of year and among those which reported round the year few had reported incomplete. Bed Occupancy Rate (BOR) Bed Occupancy rate is the total no. inpatient days stay in a hospital out of total no. of bed days (365 *total no. of beds available). It shows how the hospital's inpatient department is busy and whether the hospital is crowded or not. The occupancy rate is a measure of utilization of the available bed capacity. It indicates the percentage of beds occupied by patients in a defined period of time, usually a year. It is computed using the following formula: BOR= (Inpatient days)/(Bed days) ×100 Where, Inpatient days = admissions × Average length of stay (ALS), and bed days in the year = number of beds × 365 Figure 3.5.3: Bed occupancy rate of Hospitals in Province 5, FY 2074/75

2073/74 2074/75 2075/76

100 77.8 65.8 56.6 59.2 58.1 50 42.4

0 Non- Public Hospitals Public Hospitals

Though, there is no such standard benchmark for the bed occupancy rate, some people argue that 85 % occupancy is appropriate and well manageable and some also believe that 75 % is good for quality of services and optimum use of resources in the hospital. Regarding comparison to the bed occupancy rate of public and non-public hospitals of province no. 5, bed occupancy rate were increasing in trend in non-public but decreasing in trend in public hospital, this is the concern point for public hospital. Average Length of Stay (ALS): This measure refers to the average number of days that a patient stays in a hospital. It is calculated using the formula: ALOS= Total Inpatient days/Total no. of admissions (discharges)

Figure 3.5.4: Average length of stay in Hospitals, 2075/76

2073/74 2074/75 2075/76

7.0 6.0 6.0

4.9 5.0 4.0 4.0

3.0 2.9 3.0 2.5

2.0

1.0

0.0 Non Public Hospitals Public Hospitals

The average length of stay in non-public hospitals were in increasing in trend whereas decreasing in trend in public hospitals, this trend shows significant difference between services provided by public and non- public hospitals.

Total number of emergency services. Figure 3.5.5 Total emergency services by hospitals in 2075/76

Total Emergency Services

LUMBINI PROVINCIAL HOSPITAL 53729 BHERI HOSPITAL_ BANKE 16198 RAPTI ACADEMY OF HEALTH SCIENCE 13325 RAPTI PROVINCIAL HOSPITAL_DANG 8594 PYUTHAN HOSPITAL 7856 BARDIYA HOSPITAL GULARIYA 7165 PRITHIV CHANDRA HOSPITAL_ NAWALPARASI 7123 PRITHIV BIR HOSPITAL_ KAPILBASTU 6952 GULMI HOSPITAL 6885 ARGHAKHANCHI HOSPITAL SANDHIKHARKA 6331 BHIM HOSPITAL_ RUPANDEHI 5993 Chisapani Hospital, Nawalparasi 4143 LAMAHI HOSPITAL_DANG 3762 ROLPA HOSPITAL REUGHA 3591 PALPA HOSPITAL TANSEN 3224 SHIVRAJ HOSPITAL_ BAHADURGANJ_ KAPILBASTU 2223 PALPA HOSPITAL RAMPUR 1219 PIPARA HOSPITAL_KAPILBASTU 676 0 10000 20000 30000 40000 50000 60000

Tertiary hospitals were more likely to receive more emergency cases. Moreover, strategic location, large catchment area, perceived good quality of services, lower cost, etc can increase the no. of emergency services. Almost 257194 people were served from emergency in Province from public and non-public hospital. 53729 people were served from Lumbini Zonal hospital followed by Bheri hospital, Banke which provided emergency services to more than 16 thousand people. Pipara hospital was found to be serving fewer than 1000 patient in emergency in a FY 2075/76. Total number of Major Surgeries in hospitals The number and types of surgeries could be taken as a proxy indicator for the capacity, management, and policy of the hospital. In the FY 075/76, total of 55546 surgeries have been conducted in province of which 22225 accounts for major surgeries while minor surgeries accounts for 33321 surgeries. Table 3.5.1: Number of surgeries by public hospitals in FY 2075/76:

Name of Hospitals Major surgeries Minor surgeries

Arghakhanchi Hospital Sandhikharka 1217 17

Bardiya Hospital Gulariya 365 148

Bheri Zonal Hospital_ Banke 486 1998

Bhim Hospital_ Rupandehi 656 269 87

Chisapani Hospital, Nawalparasi 538 2

Gulmi Hospital 1055 97

Lamahi Hospital_Dang 0 0

Lumbini Zonal Hospital_ Rupandehi 0 0

Palpa Hospital Rampur 1240 0

Palpa Hospital Tansen 1395 0

Pipara Hospital_Kapilbastu 0 0

Prithiv Bir Hospital_ Kapilbastu 574 410

Prithiv Chandra Hospital_ 2810 278 Nawalparasi

Pyuthan Hospital 259 223

Rapti Academy Of Health Science 2637 735

Rapti Zonal Hospital_Dang 3279 354

Rolpa Hospital Reugha 673 59

Shivraj Hospital_ Bahadurganj_ 209 0 Kapilbastu

Surgery Done By Non-Public 15928 17635 Hospital Total Cases 33321 22225

Top ten morbidities Upper Respiratory Tract Infection (URTI) is the leading cause for the OPD visits in the health institutions of Province no. 5 followed by the Acid Peptic Disease (APD), sometimes joked as national disease of Nepal. Table 3.5.2: The top ten morbidities in OPD visits in FY 2075/76: Rank in Previous Rank Diseases OPD visit % in total OPD FY 2074/75 Upper Respiratory Tract Infection 1 (URTI) Cases 247388 6.14 1 Other Diseases & Injuries-Gastritis 2 (APD) 231560 5.75 2 ARI/Lower Respiratory Tract 3 Infection (LRTI) Cases 169329 4.20 3 4 Falls/Injuries/Fractures 155743 3.87 4

Fungal Infection (Lichen Planus) 5 Cases 131454 3.26 7 Presumed Non-Infectious 6 Diarrhoea Cases 120971 3.00 5 7 Scabies Cases 119678 2.97 6 8 Backache(Muskuloskeletal Pain) 116809 2.90 8 9 Other Anxiety 90366 2.24 58 10 Conjunctivitis Cases 88728 2.20 10 Total 4027109

Diagnostic Services Table 3.6.1: Major Service statistics of diagnostic services in province 5: test test test Total Total Other Virology Virology Parasitology Parasitology Immunology Immunology Haematology Haematology Biochemistry Biochemistry Bacteriological Bacteriological District/Type of District/Type

RUKUM EAST 0 417 576 88 267 77 0 1425 ROLPA 1952 12303 33466 7803 12541 7602 8 75675 PYUTHAN 4253 36847 73499 8032 16100 9619 148 148498 GULMI 2076 21072 55344 5262 9204 7191 1020 101169 ARGHAKHANCHI 1079 12487 20883 3188 5713 2825 404 46579 PALPA 21648 331907 3689017 112322 85451 47082 40573 4328000 NAWALPARASI WEST 3969 21431 53018 9894 14417 6154 507 109390 RUPANDEHI 8237 102800 114155 17311 25659 26804 7107 302073 KAPILBASTU 5213 20757 46155 7522 12451 6788 251 99137 DANG 9072 83856 233908 26401 32784 25321 6722 418064 BANKE 19077 474906 750033 40451 64746 119334 53565 1522112 BARDIYA 5603 21928 99541 13715 14883 12657 203 168530 PROVINCE 5 82179 1140711 5169595 251989 294216 271454 110508 7320652

Figure 3.6.1: Laboratory test distribution

other Test distribution Bacteriological Virology 1% test 4% 1% Parasitology Biochemistry 4% 16% Immunology 3%

Haematology 71%

Table 3.6.2: Major indicators of Diagnostic services in province 5:

NON-PUBLIC PUBLIC Public/Non-Public 2073/74 2074/75 2075/76 2073/74 2074/75 2075/76 Average number of CT Scan per 60 78 81 2 2 2 day Average number of laboratory 4892 7802 16005 3016 2437 3349 tests per day Average number of MRI per day 4 5 21 0 0 0 Average number of radiographic 1234 1310 1385 514 573 658 images per day Average number of Ultrasound per 352 393 423 187 208 261 day Average number of X Ray per day 818 835 860 326 363 395 The average no of all diagnostic services per day are in increasing in trend continuously from FY 2073/74 to 2075/76 in both public and non-public diagnostic center.

Social Service Unit In the past many poor people, senior citizens, helpless people and people with disabilities had difficulties accessing health services due to a lack of medicines, the inability to pay service charges and other reasons. In the spirit of the Interim Constitution, and recognizing the State's responsibility to provide health care services and to make its health policies and programmes more effective, MoHP decided to run on a pilot basis for the two year period of fiscal years 2069/70–2070/71 in 8 hsopital to test the concept and collect experiences and learning. After the federalism it has the responsibility of provincial government to continue and expand the services in the remaining hospitals of province. In this FY, 8 hospitals are conducting social service unit. Figure 3.7.1: Free Service utilized by Ultra poor/poor through the SSU of hospitals

SSU Service Users: Ultra Poor/Poor 2076 2500 1935 2000 1500 1333 1000 514 500 210 280 7 50 19 0

In this FY, Kapilbastu hospital had the highest number (1935) of Ultra poor/poor who used free service through the social service unit whereas the Rolpa hospital had the least number of service users. Figure 3.7.2: SSU Service users by Helpless.

SSU Service Users by Helpess

300 273 250 200 150 100 58 38 50 1 11 2 4 0 0

In this FY, Helpless people who used free service through SSU, were highest i.e 273 in Kapilbastu hospital followed by Lumbini provincial hospital. Rolpa hospital had only one helpless person who used this service. Figure 3.7.3: SSU Service used by Disable Persons

SSU Service used by Disable Persons 350 296 300 250 200 160 150 107 88 100 40 50 11 13 15 0

In this FY disable persons were highest i.e. 296 persons in Rolpa hospital who used free service through SSU followed by Kapilbastu hospital (160), whereas Gulmi hospital had only 11 persons to use SSU. Figure 3.7.4: SSU Service used by Senior Citizens

SSU Service used by Senior Citizens 3000 2759 2527 2500 1845 2000 1705 1500 939 1000

500 332 315 124 0

Out of total, Rolpa hospital had the highest number i.e. 2759 of senior citizens to use free social service followed by Lumbini Provincial hospital. Prithvi Chandra Hospital had the lowest number of senior citizens to use free social service.

Figure 3.7.5: SSU Service used by Victim of GBV

SSU Service used by Victim of GBV 250 209 200 139 150 88 100 100 50 11 9 23 0

Prithvi Chandra Hospital had the highest number i.e. 209 of Gender based violence victims who used free service through social service unit followed by Bardiya Hospital. Rolpa Hospital had the lowest number GBV victims,i.e. 9 who used this service. Figure 3.7.6: SSU Service used by FCHV

SSU service used by FCHV 120 100 100

60 53 40 24 26 20 14 12 4 0 0

In this FY, Kapilbastu had the highest number i.e. 100 of FCHVs, who used free service through the SSU followed by Lumbini Provincial Hospital. Pyuthan hospital had only 4 FCHVs who used SSU service.

One-Door Crisis Management Center Nepal has ratified various international conventions and introduced national laws and policies in response to gender based violence (GBV) issue. Since 2011, the Ministry of Health and Population (MoHP) has established forty-four one-stop crisis management centres (OCMCs) in forty-four districts. These have been set up in response to Clause 3 of the ‘National Action Plan 2010 against Gender Based Violence’ (OPMCM 2010), which calls for the provision of integrated services to survivors of GBV by establishing hospital-based OCMCs. ‘Hospital-based OCMC Operational Manual’ (MoHP 2011) says that OCMCs shall provide the following six kinds of services through multi-faceted coordination with other agencies: . Health services – Immediate treatment of physical and mental health needs of GBV survivors with OCMCs having to stock the equipment and the free health service medicines to provide these services. . Psycho-social counsellingto survivors and perpetrators. • . Legal advice, counselling and support to survivors through district attorneys and legal counsellors. . Safe homes — by directing survivors to safe shelter homes. . Security – by working with the police and district administration offices to provide security to survivors in hospitals, safe houses, and in their communities. . Rehabilitation – by providing further counselling, education, vocational skills training and other livelihood support OCMCs are designed to follow a multi-sectoral and locally coordinated approach to provide GBV survivors with a comprehensive range of services including health care, psycho-social counseling, access to safe homes, legal protection, personal security and rehabilitation support through education, vocational skills training and other livelihood support. In Nepal, many women and children experience gender-based violence (GBV) that results in physical, sexual and psychological damage. There are 8 OCMCs in 8 hospitals of this Province. Major Achievements Figure 3.8.1: Trend of Physical Assault by districts

2073/74 2074/75 2075/76

600 558 521 521 490 490 500 383 383 400 359 323 323 300 200 97 97 89 89 69 69 60 60 31 31 28 28 27 27

100 23 20 20 20 16 16 11 11 8 7 6 6 0 0 0

Physical Assault has slightly declined from 558 in 2074/75 to 521 in 2075/76 in this Province. Out of 8 hospital, Prithvi Chandra hospital has the highest number of cases who attended OCMC. 95

Figure 3.8.2: Sexual Assult

300 276 276

250 234

200

150

100 91 74 74 69 69 69 44 44 38 38 37 37 36 36 36 35 35 28 28

50 25 25 20 20 19 19 15 15 11 11 10 10 9 1 0 0 0

2073/74 2074/75 2075/76

In this FY Sexual assault has slightly increased from 234 to 276 among the cases who attended OCMC. Lumbini Provincial Hospital has the highest number of cases of sexual assault. Figure 3.8.3: Trend of domestic violence by districts

Trend of domestic violence by districts

450 389 389 379 379 374 374 400 363 345 345 344 344 350 300 250 200 150 100 5 5 4 3

50 2 1 1 1 0

2073/74 2074/75 2075/76

In comparison to the previous year, trend of domestic violence has slightly increased from 374 to 389. Out of 8 hospitals, Prithvi Chandra hospital has the highest number of cases of domestic violence.

Figure 3.8.4: Total OCMC Case distribution by districts

Total OCMC Case distribution by District in 2075/76

43 39 52 Prithvi Chandra Hospital 68 Bardiya Hospital 69 Arghakhanchi Hospital

77 Lumbini Provincial Hospital Kapilbastu Hospital 115 Palpa Hospital 828 Pyuthan Hospital Gulmi Hospital

Total OCMC cases are highest in Prithvi Chandra Hospital in this FY, whereas Gulmi hospital has the lowest number of OCMC cases in the Province 5.

Health Care Waste Management Hospital waste is any Waste which is generated in the diagnosis, treatment of immunization of human being in a hospital; this is also called Bio-Medical Waste (BMW). So the hospital waste management is a technique that will help to check the spread of diseases through. Table 3.9.1: WHO classification of Hospital waste:

Waste Categories Description and Examples Non Hazardous: No risk to human health eg: office paper, wrapper, kitchen waste, general sweeping etc 1. General Waste Hazadous: Human Tissue or fluid eg: body parts, blood, body fluids etc 2. Pathological Waste Sharp Waste eg: Needle, scaples, knives, blades etc 3. Sharps Which may transmit bacterial, viral or parasitic 4. Infectious Waste disease to human being, waste suspected to contain pathogen eg: laboratory culture, tissue(Swabs) bandage etc. Eg: Laboratory reagent, disinfectants, Film Developer 5. Chemical Waste Eg: unused liquid from radiotherapy of lab research, 6. Radio-active waste contaminated glasswares etc Figure 3.9.1: Typical waste composition in health care facilities:

Infectious(hazadous health care waste) Chemical/Radioatic 15% e(hazardous health care waste) General(non 5% hazardous healthcare waste) 80%

Source: WHO

Figure 3.9.2: Main Sources of Hospital Waste

A & E OPD X-ray 3% 1% 2%

Wards 26%

Other small areas combined 35% Theatre 17%

Labs Source: WHO 16%

Table 3.9.2: Status of provincial hospital’s Hospital Waste Management: Use of Segregation Autoclaving Needle Use of of risk and Washing SN Hospital Name for risk Cutter/ placenta Remarks non-risk machine waste Needle Pit waste Destroyer Lumbini 1 Provincial Yes No Yes Yes No

Hospital

Rapti Provincial 2 Yes Yes Yes Yes Yes Hospital

Bardiya 3 Yes No Yes Yes No Hospital Rolpa Hospital 4 Yes No Yes Yes Yes Reugha Pyuthan 5 Yes No Yes Yes Yes Hospital Palpa Hospital 6 Yes No Yes Yes No Tansen Rampur 7 Yes No Yes Yes Yes Hospital Palpa 8 Gulmi Hospital Yes No Yes Yes Yes

Use of Segregation Autoclaving Needle Use of of risk and Washing SN Hospital Name for risk Cutter/ placenta Remarks non-risk machine waste Needle Pit waste Destroyer Arghakhanchi 9 Yes No Yes Yes No Hospital Kapilbastu 10 Yes No Yes Yes Yes Hospital

Prithbi Chandra Hospital 11 Yes No Yes Yes No Nawalparasi West

Bhim Hospital 12 Yes No No No No Bhairahawa Rukum East 13 NA NA NA NA NA Hospital

Above table shows all hospitals have good practice in segregation of risk and non-risk waste product. None of the hospital except Rapti provincial hospital has autoclaving for risk waste, so all hospitals need to have purchase the autoclaving machine soon. Bhim Hospital reported poor waste management activities comparing to other hospitals.

100

Minimum Service Standard There are a number of specific standards, guidelines and tools developed to address the need to improve and strengthen the Public hospitals. Some of them provide the infrastructure standards while others focus on specific technical competencies of the service providers. The checklist for Minimum Service Standards for Public Hospital has been developed to bring together all the previous standards, guidelines, tools and other documents that are related to the quality of hospital services. Some hospitals that are practicing at desired level of management practices were also observed to prepare this checklist. Moreover, some additional criterions have been added in order make it more contemporary and practical. This checklist intends to focus more on ‘service standards’ that expects to demand the resources including human, infrastructure, and supplies. According to the level of hospital their minimum service standard score should be maintained by strengthen the quality of services. In FY 2075/76 the MSS score of hospitals are monitored and obtained the following score. Table 3.10.1: Status of MSS score of province 5 hospitals as per revised MSS tool FY 2075/76 MSS Score as per revised MSS Tool Hospital Governanc Clinical Total S Support Maximu Name of Hospital e and Service Percenta MSS Tool N Service m Score Manageme Manageme ge Manageme nt nt nt Secondar 77 56 61 62 939 1 Bardiya Hospital y A Secondar 68 54 45 55 939 2 Pyuthan Hospital y A Secondar 63 63 59 62 939 3 Gulmi Hospital y A Secondar Prithvichandra 61 55 43 54 939 4 Hospital y A Arghakhanchi 68 55 41 55 Primary 761 5 Hospital 6 Chisapani Hospital 46 42 29 40 Primary 761 7 Rolpa Hospital 71 68 35 62 Primary 761 8 Lamahi Hospital 20 31 24 28 Primary 761 Kapilvastu 68 52 39 50 Primary 761 9 Hospital 1 70 71 37 64 Primary 761 0 Bhim Hospital

Table 3.10.2: MSS Score as per MSS Tools, SN Name of Hospital Total score Achieved Score Percentage Remarks 1 Palpa Hospital 350 175 50% 2 Rampur Hospital 350 209 60% 3 Pipara Hospital 350 144 41% 4 Shivaraj Hospital 350 259 74%

101

Major Issues and Recommendations of Hospitals under provincial government: Hospital Major Issue Recommendations Responsibility Name Lumbini Lack of beds for in labor ward for Construction of more MOSD Provincial delivery (42-45 deliveries per 10 bed) indoor and outdoor Hospital Inadequate Quarters for Doctors, building and Dr. Nurses Nurses and Health Worker quarters To address frequent transfer and Full fill of sanctioned MOSD, HD retirement of medical staffs man power

Untrained staffs Develop as a Post MOHP, MOSD graduate Medical Institute Inadequate Equipment Training given to Heath Training untrained staffs center Waste Management Supply of adequate Equipment MOSD Drainage System Prepare proper Waste management plan Hospital management development committee Rapti Inadequate infrastructures, staff Construction of more MOSD Provincial quarters, wards, OPD, compound walls indoor and outdoor Hospital etc. building and Dr. Nurses quarters Lack of consultants, and other assistant level staffs. Full fill of sanctioned MOSD, HD man power

MPDSR ,OCMC & Social Security Programs Extend MPDSR, OCMC MOHP, MOSD and SSU program to this hospital

102

Hospital Major Issue Recommendations Responsibility Name Bardiya Infrastructure Prepare Master plan Hospital MDC, Hospital and work with MOSD accordance.

Full fill of sanctioned MOSD, HD Manpower man power

Establishment of referral mechanism MOHP, MOSD, Referral mechanism and coordination betn different level of HD hospital and health Electrician, & Plumber and IT facility manpower Develop HR Motivation, Salary, hazard, allowance management system MOSD Working social environment Enable working environment Hospital MDC, MOSD, HD

Rolpa Hospital Lack of Building, upgrading 50 Beded Prepare master plan Hospital MDC, hospital and work with MOSD accordance Irregular electrical power supply Supply of generator Motivation and incentive, Training for MOSD staff Develop HR management system MOSD

Pyuthan Inadequate and old Prepare Master plan MOSD, Hospital Hospital infrastructure/buildings/quarters and work with HDC accordance. Inadequate human resources MOSD, Hospital Full fill of sanctioned HDC man power

Arghakhanchi Need to upgrade 50 beded specialist Upgrade 50 beded MOSD Hospital hospital. specialtiast hospital.

Need of equipment ( Culter counter Supply of Culter machine, Gene X-pert machine and counter machine, Gene MOSD auto analyser, TFT machine). X-pert machine and auto analyser, TFT machine).

Establish blood bank. Need of blood bank.

103

Hospital Major Issue Recommendations Responsibility Name MOSD, redcross Bhim Hospital Manpower Full fill of sanctioned MOSD man power

Prepare Master plan Old building and work with accordance MOSD, Hospital HDC Medical Recording and reporting Establish EHR system MOHP, MOSD Palpa Hospital Lack of appropriate infrastructure and Full fill of sanctioned MOSD Tansen building. man power

Lack of adequate staff. Prepare Master plan and work with Lack of medicine store room. accordance MOSD, Hospital Problem in sanitation and pure HDC drinking water.

Palpa Hospital Governance and Management Rampur 1.Organizational management 2. Medical records and information management 3. Quality Management Clinical Service Management 4.Surgery/Operative Service 5. Medicolegal Services 6.Diagnostic and lab services Hospital Support Services 8. Hospital Canteen 9.Transportation and Communication 10.Repair, Maintenance and Power Supply Prithibi Governance and Management Chandra Hospital 1. Infrastructure 2. Human Resources 3.Motivation

104

Hospital Major Issue Recommendations Responsibility Name Clinical Service Management 4. Human Resource 5. Infrastructure 6. Equipment Hospital Support Services 8. Human Resources 9. Electricity Backup Gulmi Hospital Lack of HR Fulfill HR MOSD, HD, Lack ambulance Timely Budget PHTC, PHLMC Lack of office vehicle allocation Inadequate sanctioned post as per Budget allocation secondary A level standard &M survey Inadequate budget Increment budget for Difficult to retain HR health service(only Limited medical equipment 3.75% ) Poor provision of essential drugs Incentives from MOSD Lack of HR and budget for special clinic Budget allocation/ Research adequate supply Admin/finance More budget allocation/regular supply from logistic office Guideline for special clinic and budget allocation Orientation in research methodology Orientation to MS Kapilbastu Manpower Fulfill HR MOSD Hospital Utilization of Grands Lack of local support Problem in rapport between inter Regular meeting department staffs between inter department staffs. Hospital MDC No award and punishments system Lack of staff quarter and waste management. Construct Staff quarter and waste management plan MOSD

The above issues are collected accordance with the report presented by respective hospital’s chief.

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Hospital Services Expansion Plans: Hospital service expansion plan for coming year Hospital Name Service expansion plan for coming Remarks year Lumbini Provincial Hospital Nephrology Services Neurology Services Cardiology services Rapti Provincial Hospital Specialized child care hospital (establishment of NICU / ICU) Prefab building of 25 bed Bardiya Hospital No any plan Rolpa Hospital Dental Services Hospital dev. Comm. had procured 1 dental chair Pyuthan Hospital No any plan

Arghakhanchi Hospital Bed expansion Bhim Hospital Lab services strengthen 24 hrs services X- ray services 24 hrs service OPD queue management/ token system

Palpa Hospital Tansen No any plan

Palpa Hospital Rampur Consultant Service and to provide all services from 50 bedded hospital. Digital X-ray, USG service Minor OT/ Ceserean Section ART Service Lab service Ambulance Hospital Transportation Prithibi Chandra Hospital Proper human resource management. Separate CSSD Laundry Department Waste management with autoclave method 24 hr Laboratory services Maternity building construction (OT, Post-op, SNCU) Reconstruction of Indoor toilets & bathroom.

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Hospital Name Service expansion plan for coming Remarks year Housekeeping Canteen improvement X-ray services 24 hr. (on call basis) Gulmi Hospital No any Plan Kapilbastu Hospital Dental service Budget and Manpower Physiotherapy Budget and Manpower Ambulance early budget allocation Ortho service C-arm equipment The above plane is prepared accordance with the report presented by respective hospital’s chief.

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CHAPTER IV: AYURVEDA AND ALTERNATIVE MEDICINE Background Ayurveda health system is considered world's oldest health care system with scientific evidences. Before the emergence of allopathic treatment system, Ayurveda and other alternative medicinal practice were prevalent in the country. In spite of being an oldest treatment as well as healthy life style maintaining system, Ayurveda health system has not been given enough attention while planning and allocating budget. The importance of Ayurveda health system is now slowly being realized by the decision makers with the rise of non-communicable diseases and excessively high treatment cost of treating those diseases. A proper ayurvedic and alternative health information system is yet to be developed. So very limited health information regarding health information could be retrieved.

Table 4.1: Human resources in Ayurveda Health services in province: S.N. Office Position Sanctioned Fulfill Vaccant posts posts posts 1 Provincial Ayurved Ayurved Specialist 5 1 4 Chikitsalaya Ayurved Doctor 2 2 0 Kaviraj 3 3 0 Staff Nurse 2 2 0 Radiograffer 1 1 0 Lab Technician 1 1 0 Baidya 4 4 0 Lab Assistant 1 1 0 A.N.M. 5 5 0 2 Rapti Ayurved Ayurved Doctor 1 1 0 Chikitsalaya Kaviraj 1 2 Samayojan hun baki Baidya 1 1 0 3 Lumbini Ayurved Ayurved Doctor 1 1 0 Chikitsalaya Kaviraj 1 1 0 Baidya 1 1 0 4 Palpa A.H.C. Ayurved Doctor 1 1 0 Kaviraj 1 1 0 Baidya 2 2 0 5 Gulmi A.H.C. Ayurved Doctor 1 1 0 Kaviraj 1 1 0 Baidya 2 2 0 6 Arghakhanchi Ayurved Doctor 1 1 0 A.H.C. Kaviraj 1 1 0 Baidya 2 2 0 7 Kapilvastu A.H.C. Ayurved Doctor 1 2 Samayojan hun baki Kaviraj 1 1 0 Baidya 2 2 0 8 Pyuthan A.H.C. Ayurved Doctor 1 1 Education Leave Kaviraj 1 1 0 Baidya 2 2 0 108

9 Rolpa A.H.C. Ayurved Doctor 1 1 0 Kaviraj 1 1 0 Baidya 2 2 0 10 Banke A.H.C. Ayurved Doctor 1 1 0 Kaviraj 1 1 Education Leave Baidya 2 2 0 11 Bardia A.H.C. Ayurved Doctor 1 1 0 Kaviraj 1 1 0 Baidya 2 2 0 Total Ayurved Specialist 5 1 4 Ayurved Doctor 12 13 0 Kaviraj 13 14 0 Baidya 22 22 0

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Table 4.2: Health infrastructure in Ayurveda health Services in province: S.N. Instrument/ Provincial Rapti Lumbini Palpa Gulm Argha Kapil bastu Pyutha Rolpa Banke Bardia Equipment Ayurved Ayu Chi, Ayu Chi, A.H.C i khanchi A.H.C n A.H.C. A.H.C. A.H.C. A.H.C. Chikitsalaya, Dang Butwal A.H.C. A.H.C. Dang 1 Microscope 1 need 1 1need ------2 Clorimeter 1 need 1 1 ------3 Sentrifuge 1 need 1 1 ------4 Fridge 1 need 1 1 ------5 Hot air oven 1 need 1 1 ------6 Autoclave 1 need 2 - 1 6 1 1 1 1 1 1 7 Micro Pipate need 2 5 ------8 Dry-bath - 1 ------9 Auto Analizer 1 - 1 need ------10 Sirodhara table 1 1 1 1 1 1 1 1 - 1 1 11 E.N.T. set 2 1 1 1 4 1 1 1 1 1 1 12 B.P. set 10 1 3 2 3 2 3 3 1 1 2 13 Weight machine 3 1 2 2 1 1 1 2 - 1 1 14 Baby weight machine 1 need 1 2 ------15 Steam –box sitting 1 need 1 2 1 3 1 1 need 1 2 2 16 Desk top computer 2 2 2 2 1 2 2 1 2 1 1 17 Laptop 4 1 - 1 3 1 2 2 1 1 1 18 Printer 2 1 1 2 2 1 1 need 2 1 2 19 Nadi-swedan yantra - - - 1 - - - - 1 - - 20 Grinder –machine 1 1 1 - 1 - - - - 1 1 21 Gluco meter - - - 2 - - 1 - - - - 22 Steam- box Laying 1 need - need - - 1 - 1 - - - 23 Power back-up 2 - need 1 1 1 1 1 1 1 1 24 Inverter - - 1 - need - - 1 - - 25 Projector need need need need need need need need need need need 26 U.S.G machine 1 ------27 X-ray machine 1 ------28 Solar heater 1 - - 1 ------29 Washing machine 1 ------30 Deluxe bed 7 ------Note:-Deluxe bed-7,coulter-1,digital water bath -1,easy light machine -1,sonac R3 U.S.G. liner probe-1,Droni table- 1,dispenser flask-1 are needed for Provincial Ayurved Chikitsalaya,Bijauri,Dang. 110

Service statistics of Ayurveda Health Facilities The figure 6.1.1 shows the people served by the major Ayurveda health facilities in Province no. 5. Palpa Ayurveda Health Center had served around 46 thousand patient in the FY 2075/76 followed by Lumbini Ayurveda Hospital, and so on. There is no any Ayurveda Health centre in Rukum East. The figure shows that there is large proportion of people who believe in Ayurveda health system Figure 4.1: Number of people served from Ayurveda health facilities in 2075/76

Total OPD

50000 46415 45000

40000 36123 35000

30000 24648 23695 21310 19715 25000 19614 15219 14681

20000 13971

15000 9362

10000 5252 5000 0

Figure 4.2: Age wise Data:

300000 250005 250005 250000 228352 228352

200000

150000 143018 131236 131236 106987 106987 100000 97116

50000 15978 9126 6852 5675 3019 2656 0 0-5 yrs 6-15 yrs Above 15 yrs All

The figure 4.2 Age wise data shows most of people of above 15 yrs were served and least 0-5yrs Age group were served from Ayurveda health facilities in Province no. 5.

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Table 4.3 Disease wise cases treated S.N. Name of Dis. /Disso. Total S.N. Name of Dis. /Disso. Total 1 Fever 5330 16 Vataja Disease 32831

2 Respiratory Dis. 13839 17 Rh. Arthritis 11831

3 Gastritis 51648 18 Gout 9947

4 Diarrheal Dis. 7059 19 Blood Dis. 3626

5 Abdominal Dis. 22729 20 Urinary Disorder 5041

6 Diabetes/ DM 4117 21 Obstetric Dis. 5391

7 Jaundice 2607 22 Gynecological Dis. 10013

8 Anemia 1474 23 Ano-Rectal Dis. 9033

9 Cardiac Dis. 1338 24 Ophthalmic Dis. 1119

10 Hypo/Hypertension 7656 25 ENT. Oral, Dental 4277

11 Edema 1751 26 Dis. Of Head 3714

12 Worm 1241 27 Mental Dis. 640

13 Skin Dis. 6999 28 Pediatrics dis. 6384

14 Wound/ Abscess 3539 29 geriatric Dis. 5398

15 Traumatic 2524 30 other/ Misc. 6919

TOTAL 250005

The table 4.3 Shows the majority of disease falls on vataja Disease and minority falls on mental Disorders served by the Ayurveda health facilities in Province no. 5.

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Issues and recommendations

Table 4.4: Issues and recommendations in Ayurveda and Alternative Medicine

Key Issues Recommendation Responsible Stakeholders Inadequate human resources for Review the organogram MoSD/HD ayurved services MoHP

Problem in reporting system Develop a systematic reporting system for MoSD/HD, MoHP Ayurveda health services Almost no any review and planning Incorporate ayurved issues in all review and MoSD/HD, MoHP programs for ayurved programs planning workshops Low priority for Ayurveda programs Allocate adequate program and budget for the MoSD/HD Ayurveda health activities MoHP

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CHAPTER V: HEALTH MANAGEMENT INFORMATION Health management information system (HMIS) is a system whereby health data are recorded, stored, retrieved and processed to improve decision-making. HMIS data quality should be monitored routinely as production of high quality statistics depends on assessment of data quality and actions taken to improve it Figure 5.1: Reporting status of public health report:

2073/74 2074/75 2075/76 120 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 99.8 99.8 99.8 99.1 99.1 98.9 98.9 98.8 98.8 97.8 97.8 97.4 97.4 96.6 96.6 96.3 96.3 96.1 96.1 95.8 95.8 95.7 95.7 95.1 95.1 100 94.1 80.7 80.7 80

Figure 5.2: Reporting status of Hospital health report:

2073/74 2074/75 2075/76 120 100 100 100 100 100 100 100 100 87.5 87.5 86.7 86.7 84.4 84.4 80.6 80.6 80 75 68.2 68.2 67.9 67.9 66.7 66.7 59.9 59.9 57.1 57.1 54.6 54.6 52.1 52.1

60 50 50 49 49 46.9 46.9 44.7 44.7 42.7 42.7 40.6 40.6 37.6 37.6 37.5 37.5 35.4 35.4 34.9 34.9 34.8 34.8

40 31 25 25 25 22.6 22.6 20 17.8 8.8

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Figure 5.3: Timeliness of public health reporting status:

2074/75 2075/76 2076/77 100 90 90 90 80 70 68

60 54 51 51 51 51 49 49 50 41 41 39 39 37 37 37 37 35 35 33 33

40 32 31 31 31 31 28 28 28 28 27 27 27 27 26 26 25 25 23 23

30 21 21 21 21 20 20 18 18 17 17 15 15 14 14 14 20 14 11 11 9 9 9 6 10 4 1 0

Figure 5.4: Timeliness of Hospital reporting status:

2073/74 2074/75 2075/76 90 81 81 80 70 61 61 60 50 38 38

40 33

30 23 17 17 17 17 15 15 14 14 20 13 11 11 10 10 10 10 9 8 8 8 7 6 6 6 6 4 4 4 3 3 10 3 3 2 1 0

The above chart shows that receiving timely reports seems to be a challenge in Health system. For the quality data, the data should be complete, accurate, relevant and timely (CART). So data entry and data analysis is less priority task on health system. The task of preparing the timely report and posting it on time should be given priority. From the health office, health directorate and the health service department, the feedback system needs to be implemented from time to time.

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HMIS in DHIS2 platform: DHIS2 (District Health Information System) is a customizable free open source software (FOSS) which can be designed and upgraded according to users' need on their own. DHIS2 is developed by the Health Information Systems Programme (HISP) as an open and globally distributed process with developers and is coordinated by the University of Oslo with support from NORAD and other. Nepal implemented this software Nationally for HMIS online reporting system from FY 2073/74. Initially, the report was collected from health facilities to District Public Health/Health Office. From FY 2075/76, report was submitted by 753 palika’s health section, after DHIS2 training conduction. In province 5, 109 palika’s Health section reported to monthly report through DHIS2.

Issues and recommendation:

Key Issues Recommendation Responsibility

Capture and flow of health Logistic support and training to health Local level/HO/HD information from local levels facility and local level

Verification and analysis of health At 3 levels- Local, district and health Local level/HO/HD information directorate

Poor and untimeliness reporting Training and monitoring for regular Hospitals/ HD from government and private reporting hospitals

Different regular reporting Integrating/interoperability of MoSD/HD systems are established in Health different regular reporting system by sectors. (air pollution measuring establishing IHIMS section in province devices and ambulance tracing health directorate. system)

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CHAPTER VI: PROVINCE HEALTH LOGISTICS MANAGEMENT CENTRE An efficient management of logistics is crucial for effective and efficient delivery of health services as well as ensuring rights of citizens of having quality of health care services. PHLMC has established under the Ministry of Social Development province no. 5 in FY 2075/76. The major function of PHLMC is to procure, store and distribute health commodities, vaccines, equipment, health diagnostic test kits and Ayurveda medicines for the hospitals under provincial government and health facilities under local level government through Health offices of 12 districts. It also involves in supporting basic health logistics management, support public procurement system for different levels, LMIS (Logistics Management Information system) program, repair and maintenance of bio-medical, Effective management of vaccine and cold chain equipment and instruments. It also involves in the preparation of specification and technical document for the procurement of commodities. Main Objective of PHLMC Procurement  Need identification  Annual procurement plan  Forecasting and quantification  Pipeline Monitoring  Preparation of Technical Specification.  Review and Analysis LMIS report  Procurement method Tender preparation, Tender publication, BID evaluation and contract award  Monitoring and supervision. Storage  Good Storage practices ( 13 Storage guideline )  Store management,  Cold chain management  Effective Vaccine Management. Distribution  Push system  Pull system  Mixed system PHLMC works with the following Logistic cycle:

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Type of Commodities 1. Program commodities:  EPI  Anti-rabies  CB-MNCIH  TB vaccine/ Anti  Mental  Leprosy Snake venum  RH/FP  HIV/AIDS  Malaria/Kalazar  Laboratory  Nutrition chemicals 2. Essential Medicines 3. Surgical and Equipments 4. Laboratory and Birthing centre equipments 5. Diagnostic and test kits. 6. Disaster/Emergency commodities 7. Ayurvedic Medicine and equipments 8. Others commodities

Program commodities are purchased by Federal government and essential medicines, surgical and equipment and others are purchased by provincial government. The following figure shows the procurement and supply chain of commodities:

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Procurement & Supply chain

Program Issues and recommendation:

Issues Recommendation Responsibility . No timely and regular supply of the . Budget provision for standard program commodities from center. warehouse for effective storage of drug . No on time LMIS reporting from LLGs and vaccine. (HFs). . LMIS recording and reporting system . The Hospitals and LLGs did not record must be established at district level and report of LMIS. (Online and Manual hospital and Palikas. both) . Provision of sufficient budget for MOSD, . Quality space problem for proper transportation of program commodities MOHP storage. and monitoring budget. . No proper requisition for program . Timely performance review at district commodities (Drugs). Example: level for quality service improvement Vaccine, TB drugs etc. and proper requisition for . Transportation problem (especially for commodities. Program commodities.) . Budget provision for cold chain . Not fulfill Refrigerator Technician and equipment. (Walk-in cooler Biomedical engineer. compressor, AVR 10kva, zip lock, foam pad and AEFI kit box.)

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CHAPTER VII: PROVINCE HEALTH TRAINING CENTRE

The health care delivery system has remained competent in providing health care services up to the community people through developing skilled human resources. But at the same time, the training system still needs to be improved to the provincial level to meet the international standard. Skilled human resource for health is the main component to cater quality health services to the people. Ministry of Social Development Province no. 5 thus accord high priority for the development of competent human resource through quality training program for improved health care service delivery. The provincial health training system is an integrated and cross-cutting effort towards meeting the training needs for quality health care delivery throughout the province. To produce skilled health personnel in province 5, Health Training Center has established under Ministry of Social Development Province no. 5 in FY 2075/76. The main objective of the Health Training Center:  Assess training requirements of Health personnel and prepare training plans based on the program’s requirement.  Plan, implement and train health workers as demanded by programs.  Design, develop and refine teaching, learning materials to support implementation of training programs.  Develop/improve capacity of trainers to deliver quality training at provincial level.  Co-ordinate with all National and International, Governmental and Non-Governmental Organizations to avoid duplication of training and improve quality of training.  Supervise, monitor, follow-up and evaluate training programs.  Conduct operational studies to improve training efficiency and effectiveness etc. Innovative works from PHTC in FY 2075/76: Advanced Training For FCHVs: o Training Duration: 90 days (3 phages:30+30+30) o Curriculum covers mainly MNCH/FP o Main focus on skill enhancement: about 80% practical (class room demonstrations, return demonstration, role-play and practice at different HPs and Hospitals). Objective of the advanced FCHV Training: o To increase the access to health services among M/DAG community and people residing at remote/hard to reach areas through enhancing knowledge and skills of FCHVs from those areas. Major Criteria for Selection of Participants o From hard to reach/remote areas or from M/DAG community o SLC completed o Age: 20-40 years o FCHVs from Rolpa and Kapilvastu participated in 1st phase training

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CHAPTER VIII: PROVINCE PUBLIC HEALTH LABORATORY Province Public health Laboratory (PPHL) is the provincial reference laboratory under the Ministry of Social Development Province 5. The organogram of province public laboratory:

As the organization has just established, mainly two types of action plan are made. 1. Short term action plan: • Formulation of Provincial Lab Policy • Quality Control Monitoring for TB/Malaria Slide Microscopy • Documentation of number of Medical Labs on Province • Supervision, Monitoring and capacity building of Laboratory and Personals in Province. • Licensing and renewal of new/old Category C and D Laboratories of Province. • Training activities related with laboratory. • Basic and refresh or TB Training for laboratory personnel working at TB lab. • Capacity building training for laboratory personals. • Quality Control Training for laboratory personals.

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• Biosafety and biosecurity training. 2. Long term action plan: • Land acquisition and building construction for PPHL. • Develop research wing at province level. • Establishment of laboratory for molecular and special tests.

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CHAPTER IX: HEALTH INSURANCE PROGRAM Background Nepal is committed to access to quality health care for all its citizens. Although good progress has been made on improving access, much remains to be done. Out-of-pocket expenditure still puts vulnerable households at risk of catastrophic spending and prevents them from using services. Existing social health protection schemes are fragmented and often fail to provide financial protection against catastrophic spending and are not always based on medical needs. Thus, there was a need to develop a health care financing pre-payment system and to pool risks to minimize financial hardships. The Health Insurance Program (HIP) was funded in the government’s budget for 2011/12 (2068/2069). The government then adopted the National Health Insurance Policy in 2014. Under this policy the government established the semi-autonomous Social Health (Health Insurance) Security Development Committee (SHSDC) in 2015 to implement the program to promote pre- payment and risk pooling to mobilize financial resources for health. The SHSDC is chaired by the Ministry of health Secretary with membership from the Ministry of Finance, MoH, DoHS and experts. Vision, Objectives and Strategies Vision: To improve the overall health situation of the people of Nepal. Objectives:  Ensure access to quality health service (equity and equality).  Protect from financial hardship and reduce out-of pocket payments  Extent to universal health coverage Strategy: To implement health insurance program gradually throughout the country by increasing enrolment through awareness activities at the community level and special protection for poor and marginalized people by coordinating with government and private health service providers. The main features of the Social Health (Health Insurance) Security Program are as follows:  It is a voluntary program based on family contributions. Families of up to five members have to contribute NPR 2,500 per year and NPR 425 per additional member.  It provides subsidized rates for families whose members have a poverty identity card.  Enrolment continues throughout the year in implemented districts.  Insurees have to renew their membership through annual contributions.  Benefits of up to NPR 50,000 per year are available for families of up to five members with an additional NPR 10,000 covered for each additional member. The maximum amount available per year is NPR 100,000.  Insurees have to choose their first service point but can also access services from government PHCCs and hospitals and listed private hospitals.  Insurees can access specialized services elsewhere that are not available at the first service point on production of a referral slip from their first contact point.  It is cash-less system for members seeking health services. Upon presenting their SHSP membership ID card at a health facility, members are able to receive the health services and drugs covered by the benefit package without having to pay at any stage

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 For emergencies insurees can access services from any service point and any referral specifies hospitals without a referral slip.  The program is IT-based with enrolment assistants using smart phones.  SHSDC acts as the service purchaser while government and listed private hospitals provide the services. Programme Implementation Health Insurance program is being implemented in 9 districts of Province 5 namely Bardiya, Banke, Rukum East, Rolpa, Pyuthan, Arghakhanchi, Kapilvastu,Palpa and also added Rupendehi from this fascial year. Health Insurance program is being scaled up in all other districts. The list of health facilities implementing Health Insurance program across 9 districts of Province are listed in the table 7.1.1. (Sourcel Health Insurance Board, Province 5)

Table 7.1.1: List of health facilities offering social health insurance services District Health Facility District Health Facility Tahun PHC District Hospital, Khasauli PHC Arghakhanchi Kaligandaki Eye Hospital Thada PHC, Arghakhanchi Arghakhanchi Lumbini Medical College Balkot PHC, Arghakhanchi Palpa Palpa District Hospital District Hospital, Gulmi United Mission Hospital Sandikharka Eye Hospital Rampur Hospital Kapilvastu District Hospital Lions Lakaul Eye Hospital Pipara Hospital Bardiya District Hospital Kapilvastu Shivaraj Hospital Rajapur PHC Harnampur PHC Bardiya Magargadi PHC Maharajgunj Hospital Sorahawa PHC District Hospital, Rolpa District Hospital, Pyuthan Lamahi Hospital, Dang Khalanga PHC Rapti Academy of Health Pyuthan Bhingri PHC Science Rolpa Rapti Proviancal Hospital Holeri PHCC Bheri Zonal Hospital, Nepalgunj Sulichour PHC Nepalgunj Medical College, Tharmare HP Nepalgunj Nepalgunj Medical College, Bhingri PHC Banke Kohalpur Lumbini Provincal Hospital Fattewal Eye Hospital, Nepalgunj Bhim Hospital Bankatua PHC Khajura PHC Rupendehi Universal Medical College Laxmanpur PHC Rana Ambika Eye Hospital Devdaha Medical College Rukum East Kol PHC

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Utilization of Social Health Service Table 7.1.2 shows 416129 population are insured across 8 social health insurance implementing districts. Palpa has the highest percentage of insured population and 63.7% populations are insured as compared to total population of Palpa district for social health insurance. (Source Health Insurance Board, Province 5).

Table 7.1.2: Status of social health service utilization in FY 2075/76 Indicators Total Population Insured Households Insured population Insured Percentage Palpa 250717 41246 159728 63.7 Bardiya 471691 23371 84311 17.8 Pyuthan 240302 10440 35239 14.6 Arghakhanchi 201935 14901 43307 21.44 Kapilvastu 653511 10868 47179 7.21 Rolpa 235903 5950 19302 8.18 Rukum East 57565 1501 5078 8.82 Banke 588279 10285 21985 3.73 Rupendehi 1037110 NA NA NA Total 3737013 118562 416129 11.13

Above table shows that out of total population of health insurance program launched district only 15.41% people are covered under health insurance excluding data of Rupandehi district, which is very low coverage. To extent the program more effectively, there should be needed of public awareness program of health insurance. For this, it appears that all sectors should assist in promoting health insurance programs.

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CHAPTER X: CONTRIBUTION OF THE LOCAL LEVEL GOVERNMENT AND COMMUNITY

Under Article 35 of the fundamental right of the Constitution of Nepal 2072, every citizen shall have the right to free basic health services from the state and no one shall be excluded from emergency health services. Since the constitution of Nepal has the responsibility of the local government to provide free basic health and sanitation services to its people, the contribution and involvement of the local government in the health service is indispensable. In province 5, there are 109 local level government including 4 Sub-Metropolitan, 32 Municipalities and 73 Rural Municipalities. The major program endorsed by these local governments for contributing free basic health services to their people are as follows:

District Palika’s Health activities Bardiya 1. Daughter Protect Program: Provides Rs. 2000 per daughter for the care and nutritional expenses of the daughters born from the Geruwa rural municipality. 2. Ambulance Service: An ambulance has been purchased and operated for six health posts from the Barbadia Municipality. 3. School Health Education program: Conducting sickle cell anemia’s education on school health curriculum at Barbadia Municipality. 4. Health Awareness program: All over 40 years of aged people, BMI has been checked and given card and counseling services from Bansgadhi Municipality. 5. Electrophoresis machine purchased for sickle cell examination in Barbadia, Rajapur and Thakurba. 6. Extended laboratory service at Padnah, Baniabar and Dhadwar Health Post. 7. Managed a specialist physician at Bardiya Hospital by Gularia Municipality. 8. Born in a health institution and registered within 35 days, the mother is given Rs.500 and Rs. 350 to FCHV for each case. Banke 1. Baijanatha Palika have added NRP 1000 in incentive for women having institutional delivery. 2. Baijanath Palika have been providing cost free ambulance services for pregnant women for institutional delivery in all health post of the palika from this fiscal year 3. Narainapura : Growth Monitoring program in all ward of the palika, home visit from health worker for PNC. Dang 1. Addition Rs. 2000 given to mother who delivered in health institutions, free ambulance service for institutional delivery, Rs. 150 per day for nursing staff and Rs. 100 per day for office helper incentive are given who worked in HF by Bangachuli Palika. 2. Free ambulance service to institutional delivery, snake bite patients, supporting Rs. 10000 for chronic disease suffered patients by Gadawa Palika 3. Appointment of health workers contract in health institutions with increased pressure of the patient by Gadawa Palika. 4. Conducting eye treatment camp, 89 cataract patient’s free operation was supported by Rajpur Palika. 5. Measles outbreak was managed with the help of WHO, Department of Health services in Rajpur Palika. Pyuthan 1. Conducting My year, "I Healthy, My Country Healthy" campaign and commitment was done in every community of Local level. 2. Health care at home and free eye care for senior citizens over 60 years was conducted by Pyuthan Municilapity. 3. Conducting deputy Mayer Health Koseli program in Sworgdwari Municipality. 4. Supporting for chronic patients on treatment by Sworgdwari Municipality. 5. Conducting Public health awareness program in community and laboratory established in

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Gaumukhi Palika. 6. Conducting Model health service program based on proposal in Mallarani Palika. 7. Establishing emergency service fund for referring mother in birthing center of Sarumarani Palika. 8. Establishment and conduction of health laboratory services in health posts of Sarumarani Palika. Rolpa 1. Establishment and conduction of health laboratory services in health posts of Tribeni Palika. 2. Extra Rs. 1000 was given to mother who complete 4 ANC visit and delivered in Health institution in Tribeni Palika. 3. Establishment of 15 beds hospital in Thawang Palika. 4. Free ambulance services for mothers coming on birthing center in Runtighanti Palika. Kapilbastu 1. Free distribution of sanitary kits for postpartum mothers in Shivraj Palika. 2. Scooter distribution for physical disabled women in Mayadevi Palika. 3. Free ambulance services for mothers coming on birthing center in Mayadevi and Suddhodhan Palika. 4. Ghee, honey and hen distribution for mothers who complete 4 ANC and delivered in institution in Banganga Palika. Rukum 1. Free distribution of nutrition kits( bathin soap-1, laundry soap-1, oli-1 liter,Jwano, Jira, Pulses etc) for postpartum mother who delivered in institution. 2. Distribution of travel incentive for nursing staff for conducting of PNC home visit. 3. Distribution of travel allowance to FCHV on monthly meeting held in health facility. Palpa 1. Conduction of specialist health camp on Rambha, Rainadevi, Ribdikot andtinau Palika. 2. Establishment and conduction of health laboratory services on Rambha, Purbakhola, Bagnashkali, Rainadevi and Mathagadhi Palika. 3. Health care at home- Tansen, Bagnashkali and Mathagadhi 4. Financial support to chronic patients- Ribdikot, Bagnashkali 5. Weighing machine distribution to primary school- Ribdikot Gulmi 1. Health education on prayer time of school-Chatrakot Paliaka 2. Free distribution of calcium tablet for pregnant women-Kaligandaki 3. Health camp conduction- Many palika 4. Establishment and conduction of health laboratory services- Many palika 5. Free ambulance for mother travelling to deliver on institution- All palika 6. VIA camp conduction on all ward of palikas Rupandehi 1. Establishment of immunization building. 2. Initiation of child insurance program. 3. Nutrition bag distribution. 4. Nutrition incentive distribution to mothers. 5. Financial support of Heart, Kidney and Cancer’s patients from Local level.

The above information are collected from presentation of annual review 2075/76 presented by Health offices. Health offices Arghakhanchi and Nawalparasi west did not provide the above information.

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CHAPTER XI: PROGRAMS CARRIED OUT BY PROVINCE IN FY 2075/76 After the establishment of provincial government, FY 2075/76 is the first fiscal year performing provincial program under province. The main activities carried out by province in Health sector are as follows: • Establishment and operation of Rukum-East hospital. • Establishment of health training center, provincial health logistic management center and provincial public health laboratory. • Land acquisition process in Lamahi Dang has been further enhanced for setting up of Trauma Center • Equipment connected (3 location) for air pollution measurement. • Provided home-based health care to above 84 years senior citizens (15898 person).

• Free specialist health camps (18) conducted in remote and unreached areas. • Advanced FCHV training conduction • Distribution of birthing center’s equipment (17 set) for expansion and establishment of birthing centers. • Arrangement of Merchury Room and Merchury Refrigerator (11 Hospital). • Distribution of health equipment for operating and expanding snakebite services (12 set) • Construction of Panchakarma Hall (1 place) • Ambulance Distribution (8 ) • Hospital waste management (10 place) • Distribution of laboratory equipment in different districts (16 places) to expand the laboratory. • Procurement of CT-Scan Machine for Rapti Provincial Hospital Dang. • Procurement and distribution of Essential Medicines, Surgicals, Diaster commodities, Ayurved Medicines to different health facilities. • Procurement and distribution of X-ray machines, USG machines to different places. Service statistics of home based health services above 84 years age of people :

Sn District Total Clients Common Diseases

1 Nawalparasi west 1658 COPD, 2 Rupandehi 1891 Asthma,

3 Palapa 1283 Hypertension, Ear/Eye 4 Gulmi 1925

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Sn District Total Clients Common Diseases

5 Kapilbastu 1825 problem,

6 Arghakhanchi 537 Arthritis, Cough, 7 Pyuthan 890 ARI, 8 Rolpa 460 Mental 9 Dang 0 problem, 10 Rukum East 1717 Diabetes,

11 Banke 1752 Headache, Thyroid etc. 12 Bardiya 1960

Total 15898

The above data are collected during the presentation of annual review 2075/76 presented by respective health offices. The above table shows that Banke has the highest number of services whereas Dang has no services at all. Budget implementation status in Health Sector in province 5 in FY 2075/76

Budget Source Budget Received (In Budget Expenditure Expenditure in % Thousand) (In Thousand)

Conditional Budget 66,87,27 49,55,85 74.11

Provincial(non- 81,13,34 61,07,72 75.28 Conditional) Budget

Total 1,48,00,61 1,10,63,57 74.75

Total Physical progress: 86.89%

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CHAPTER XII: PROGRAM TO RUN IN FY 2076/77

Background In FY 2076/77, provincial government of province 5 has brought popular program to improve the living standard of their people. By conducting the following programs through the Ministry of Social Development, it will help to improve the health status of the people of the province and raise the standard of living of the people:-

 Studies and research in health sector.  GPS device connection and operation for ambulance tracking.  Herbal processing and Ayurbedic Medicine production.  Programs to incorporate health-related content into the school curriculum.  Vitamin K purchase for children born in a health institution  Operation of Neuro and Ortho specialized services at Lumbini provincial Hospital  Building a master plan to strengthen the hospital's service.  Medico Legal Training for Dr.  NICU Service operations on Rapti provincial Hospital.  Supporting up to Rs. 50,000 for COPD related patients.  Purchase medicines and buffer stock for epidemic conditions  Operation of palliative care at Lumbini Provincial Hospital  CEONC Robson Criteria surveyed in hospitals with high service pressure.  Purchasing two ambulances with ICU setup for provincial hospital.  SSU, OCMC and MPDSR Services expansion in all Hospital under province.

Total Budget allocated in FY 2076/77: Budget Source Budget( Rs.in thousand)

Conditional 76,56,59

Non- conditional 74,40,65

Total 1,50,97,24

The total budget of the province no 5 =19,80,01,09 thousnds Total budget of the Ministry of Social Development =2,87,41,32 thousands Program budget for health from the state government = 74,40,65 thousands Out of total provincial budget only 3.75% budget allocated in Health sector.

Main issues in conducting program:  Difficulty in operating the health program due to lack of Human resources.  Difficulty in managing and delivering healthcare services due to lack of rules and regulations.  Procedural complexity in collaboration with federal, provinces and local levels.  Lack of institutional and health workers capacity building and necessary facilitation.  Province level health information and statistics should not be updated.

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 Program are formulated with traditional way, not factual based. Upcoming preferences:  Extension of specialized and specialist healthcare facilities to various hospitals in the province.  Special emphasis on the creation of policies, rules, regulations, procedures and guidelines for health sector.  Special emphasis will be given by the Health Office on the promotion of local level capacity and technical facilitation.  Special initiative to fulfill vacancies in health institutions.  Management of infrastructure construction budget of health institutions.  O&M Survey’s management of health care structures.  Strengthen provincial health statistics and formulate a fact-based plan.  Effective implementation with special emphasis on the on-site facilitation and monitoring of health programs.

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CHAPTER XII: EXTERNAL DEVELOPMENT PARTNERS

The outcomes discussed in the previous chapters are the results of combined efforts of the Ministry of Health and Population, Ministry of Social Development and its development partners (multilateral, bilateral and international organizations and national NGOs). The Ministry of Social Development, Health Directorate acknowledges its partnership with these organizations and their large contributions to Nepal’s health sector. This chapter lists the programme focus of these organizations and their contact details. Partners have also provided technical assistance in their areas of expertise. Development partners support the government health system through a sector-wide approach (SWAp). The SWAp now supports the implementation of the new Nepal Health Sector Strategy (NHSS, 2016–2021). The Joint Financing Arrangement (JFA) has been signed by various partners and the government. The JFA describes in detail the arrangement for partners’ financing of the NHSS. The JFA elaborates the pool funding arrangement and parallel financing mechanism as bilaterally agreed between the government and the donor partners The presence and support of EDPs in province 5 has been continuous from previous government system to exiting new federal context in Nepal. Ministry of Social Development and Provincial Health Directorate is being coordinating and facilitating for health sector work with the EDPs. Ministry of Social Development, Health Directorate have initiated to collect the list of EDPs working in province- 5 from 1 November 2018 to map the core activities of the project, geographical coverage and targeted beneficiaries and major contribution in health sector in province5. Provincial Health Directorate, Ministry of Social Development, Health Service Divvision organized a joint meeting with EDPS in MoSD on 6th November 2018. To the date 27 EDPs are found working in the health sector in province 5. Guiding Principles

Government Stewardship

Governance and Accountability

Global, National and Provincial Development Agenda

Quality of Care

Evidence Driven

Equity and Access

Right Based

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Short introduction of some external development partners working in province 5 are as follows:

1. WHO

Core Intervention Areas Geographical Accomplishments (FY 2075/76) Coverage

WHO-IMMUNIZATION PREVENTABLE All 12 District of  Technical support in Measles Outbreak DISEASE Province 5 investigation and ORI in Kapilvastu and Dang • Technical Assistance:  Technical support in AEFI investigation in (sustaining Polio free status, NNT Gulmi, Kapilvastu and Palpa Elimination and JE & Rubella  Technical support in on Immunization ToT, Control; achieving Measles and Vaccinator Training and AEFI investigation Rubella Elimination and Full  Successfully controlled Rubella and Immunization Goals) Congenital Rubella Syndrome • Introduction of new and  Controlled Hep B in children and certified underused vaccine (fIPV, Rotavirus vaccine, HPV] Capacity Building: Immunization, VPD surveillance, AEFI investigation and outbreak investigation • Supervision-Monitoring of RI program WHO- HEALTH SYSTEM STRENGTHENING (Provincial Level) Technical support on: • Develop Provincial policies, strategies, guidelines and plan, Health Information management and documentation • Ensure health commodity security, quality health service delivery • Health financing for universal health coverage

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2. United Nations Children’s Fund (UNICEF)

Core Intervention/s Geographic Accomplishments (FY 2075/76 Coverage

A. HEALTH: All 12 Districts of  Maintained immunization supply chain at Immunization and Province province and district level  EPI action plan developed to increase Immunization Supply 6 Palikas of Kapilvastu coverage area through BNA Chain(ISC) & MNCH pogram: (Krishnanagar,  Completed site-readiness assessment ( 22 HFs a. Capacity building of child Suddodhan , of 7 Districts) as per Cold Chain Equipment health services / quality Maharajgunj, Optimization Plan 2019-21; for equipment improvement at different level Kapilvastu, and installation. Bijayanagar and b. Support in monitoring &  Enhanced routine immunization, and assisted mentoring tasks Shivraj All 36 palikas of 5 in facilitating outbreak response /joint c. Communication and social MSNP districts monitoring worked /on-site coaching for cold mobilization activities (Kapilvastu, chain /MNCH/EPI commodities together with d. Technical support for Nawalparasi BS West, PHLMC/HD and National teams. PMTCT to prevent & control Bardiya, Rolpa, and  Supported for maternal/ neo-natal, MPDSR, AIDs, and for emergency Rukum East) PMTCT, ART service ( in procurement of ARV supply Province, Kapilvastu, drugs, and its supply even in stock-out time; from the UNICEF central level. B. NUTRITION: Nawalparasi BS West, Rupandehi, Dang,  Accomplished integrated planning for MSNP Multi-sectoral Nutrition Plan Banke, Bardiya, Rukum and implementation of planned activities in all (MSNP): Capacity building on East, Rukum East, 36 municipalities of 5 districts, and approx. integrated planning for MSNP Lumbini Province 11000 G1000D HHs benefitted and implementation of the Hospital, Bheri Zonal  Budget allocation by local government for plan Hospital MSNP Comprehensive Nutrition-  . Constrained Capacity Building activity, which specific Interventions is planned in current FY. Accomplished (CNSI): capacity building on NiE and commodity a. Capacity building of HWs support (RUTF, MNP, ReSoMAL, F75, F100, and commodity support on and others for CNSI) IMAM, IYCF linked wirh MNP, Support to NRH, Nutrition in Emergency (NiE), b. Refresher/training on CNSI including Adolescent Girls IFA Supplementation.

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3. United Nations Population Fund (UNFPA)

Core Intervention Geographical Accomplishments (FY 2075/76) Areas Coverage

• Policy support Arghakhanchi,  Health and population approach paper and Kapilvastu, • Adolescent Sexual periodic pan finalized. Pyuthan, Reproductive  FP2020 Commitment rolled at subnational level. Rolpa, Health (ASRH) Rukum East,  Supported the accreditation of a FP Training site in • Family Planning Rupandehi Kapilvastu • Strengthen supply  Capacity Enhancement: chain management  Total 38 HWs- NSV, Mini-lap, IUCD • RH in humanitarian setting  20 IUCD and Implant insertion removal sets Supported to PHTC  Total 3157 women benefited from VSP (3085- Implants and 72-IUCD insertion)  Raised awareness on benefits, myths and misconception of FP (3421 women, girls and newly married couples benefited)  Mobilization of religious leaders on FP services  Provincial prepositioning of dignity kits and RH kits.

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4. USAID’s Strengthening systems for Better Health Activity (SSBH)

Geographical Core Intervention Areas Accomplishments (FY 2075/76) Coverage

 Provide Technical  Provincial  Participatory Assessment of Assistance to Provincial and Government Health Systems and Institutional Local government in their Province-5 Capacity of all health facilities of efforts to improve health 26 municipalities.  26 Local outcomes, particularly in the Governments of  Developed Customized Technical area of: Dang, Banke and Assistance Plan (TA) for 26  Health System and Bardiya municipalities. Governance  Providing Technical Assistance in;  Health Management  Clinical Coaching and mentoring, Information System  (15 health facilities of Program  Maternal, Newborn, Child districts) Health and Family Planning  Generation and use of Evidence,  Health Equity and Private Sector Engagement  (Developing NHFS 2015 and NDHS 2016 Provincial Analysis, Province Profile)  Health Systems support  ( Provincial/municipal Health Policy, Acts, guidelines formation)

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5. Save the children

Core Intervention Areas Geographical Accomplishments (FY 2075/76) Coverage

TB Program  Palpa, 1935 new TB cases diagnosed

 Sputum Courier to microscopic Rupandehi, and enrolled in treatment Nawalparasi- center & Gen Expert 48 MDR TB cases and ensured West, for treatment through DR  Contact Tracing Kapilvastu, referral center  Childhood TB management Pyuthan, Rolpa, 385 eligible children received Dang, Banke & , IPT  Isoniazid Preventive Therapy Bardiya (IPT)/TBPT (9 districts)  FAST strategy  Banke and  DR TB Management Surrounding  Pay for performance Districts DR Referral Centre

HIV Program  6 districts 18169 HIV testing, 46 Positive case find out and enrolled in  Behavior Change  6 districts Communication (BCC) ART  Rupandehi & 298 CABA children are receiving  Community Lead Testing (CLT) Banke the cash  Oral Substitute Therapy (OST)  11 district 2437 PLHIV received service from CHBC and CCC for their  Community and Home based (except Rukum- East) adherence and virological care (CHBC) monitoring  (11 districts)  Community Care Center (CCC)  CABA Cash Transfer program

Malaria Program  All districts (as 222 malaria cases reported via  Case based Investigations per case mobile SMS system, where 98% notification) (218) cases were investigated as  Foci Investigations per protocol  Engaging private sector for Test, treat and reporting

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6. Suaahara II- Good Nutrition Program

Core Intervention Areas Geographical Accomplishments (FY 2075/76) Coverage

. Nutrition & Health Services All districts . 56414 Household visited and counselled on of Province 5 . WASH Integrated Nutrition . Homestead Food . Enhanced the capacity of health workers, FCHVs for Production and Market increasing the quality of nutrition & health services Linkage . Contributed to diversified food production & . SBCC- Counseling via consumption Home Visit, Group . Advocated Nutrition Governance- local leaders Mobilization and trained on Multi-sectoral Nutrition Bhanchhin Aama Radio . Facilitated governments in forming Nutrition & Food Program Security Steering Committees & in roll out of MSNP II . Roll out of Multisectoral Nutrition Plan-II

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7. WFP-Support to the Health Sector Program

Core Intervention Geographical Accomplishments (FY 2075/76) Areas Coverage A. Implementation Rukum East: • Distributed and feed 122.46 Mt nutritious Total - (73 food(fortified Rice, Lentils, Oil, Salt) to 7218 Student of School Meal Schools) of ECD to Class 8 in 73 Schools as mid day meal) Program- • 10 PSA(Jingle on MHN, Nutrition, WASH has been aired by Local FM in Magar Kham language and nutrition Nepali Language) B. WASH in School • Support to National Vitamin A program and deworming day in Schools C. Radio Jingle • WASH Related intervention has been implemented in through Local FM 73 Schools (MHM Training, Sanitation related material support, tippy tap Installation, Street drama) • TOT training to 9 Staff on WASH from 3 Rural municipality.

8. FAIRMED NEPAL

Core Intervention Areas Geographical Accomplishments (FY 2075/76) Coverage Health System Strengthening Kapilvastu-10 Orientation to 3 Municipalities on Local Level Rupendehi-4 Health Planning Nawalparasi- Training to 20 HFOMCs 4 Maternal & Neonatal Health Total 18 ToT on NTDs (1 batch) Municipalities Neglected Tropical Disease of Province 5 3 HFs supported for lab –service expansion Disability inclusive Leprosy Screening Camps (3 sites)- 9 new cases Development detected Water Sanitation & Hygiene 360 school children from grade 8 to 10 oriented on sign/symptoms, preventive measures of NTDs Promote health education and improve utilization of MNH services through FCHVs using SATH tool in 13 mothers groups

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9. Ipas Nepal

Core intervention Areas Geographical Coverage Accomplishments (FY 2075/76)

. Training /Post Rolpa- 2930 women served for safe training support for abortion service safe abortion 13 health facility( 10 Local government) Post Abortion contraception . Quality Improvement Palpa- Condom-31% . Advocacy 16 health facility(9 Local Implant-8% . Research/studies government) Injectable- 27% Argakanchi- IUD- 3% 13 health facility(6 local government) Oral-20% No method- 15% Resource leverage from local governments for SAS

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