Strengthening and Activating district Health System (SAHaS)

Fifth Bi- Monthly Report May / June, 2017 (Baishak / Jestha)

District: Dhading

Submitted by: Ganga Thapa Project Officer Public Health Foundation Kathmandu, Nepal List of Acronyms

AG Advocacy Group

ANC Antenatal Check Up

C4D Communication for Development

D(P)HO District (Public) Health Office

FCHVs Female Community Health Volunteers

FHD Family Health Division

MToT Master of Training for Trainer

VDC Village Development Committe

HFoMC Health Facility operational Management Committee

H-MG Health Mother Group

HP Health Post

MEAL Monitoring and Evaluation LearningOfficer

NGO Non-Governmental Organization

NPHF Nepal Public Health Foundation

PHCC Primary Health Care Center

PO Project Officer

SAHaS Strengthening and Activating District Health System

SHP School Health Program

SM Social Mobilizer

WASH Water Sanitation and Hygiene

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Table of Contents

Content List of Acronyms ...... i Table of Contents ...... ii List of Tables ...... iii List of Figures ...... iii CHAPTER I - Introduction ...... 1 1.1 Glimpse of the district ...... 1 1.2 General information of VDC...... 2 1.3 Relevance of the Project ...... 4 1.4.1Objectives of SAHaS Project ...... 4 1.4.2Activities of the SAHaS Project ...... 4 CHAPTER II - RESULTS ...... 7 2.1 FCHVs and HealthMothersGroup ...... 7 2.2 Mother Group Meeting...... 8 2.3 Participants in Mothers Group Meeting ...... 9 2.4 Ethnicity of the participants in H-MG Meeting ...... 10 2.5 Participation of Lactating Mothers in H-MG Meeting ...... 11 2.6 Participation of Pregnant women in H-MG ...... 11 2.7 Participation of Social mobilizers and Health workers in H-MG meeting ...... 12 2.8 Health Facility Operation Management Committee ...... 13 2.9 Sex of the participants in HFOMC Meeting ...... 13 2.10 Ethnicity of the participants in HFOMC Meeting ...... 13 2.11 Participation of Social Mobilizers in HFOMC Meeting ...... 13 2.12 Advocacy Group Meeting ...... 14 CHAPTER III - CONCLUSION ...... 15 CHAPTER IV – CHALLENGES AND WAY FORWARD ...... 16 4.1 Key challenges: ...... 16 4.2 Way Forward ...... 16 CHAPTER V - LESSON LEARNED ...... 17

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List of Tables Table 1: Total number of FCHVs andH-MG ...... 7 Table 2: Number of H-MG conducted ...... 8 Table 3: Participants in H-MG Meeting ...... 9 Table 4: Participation of Health workers and Social mobilizers in H-MG meeting ...... 12 Table 5: HFOMC Meeting conduction ...... 13

List of Figures Figure 4: Ethnicity of the participants in H-MGmeeting ...... 10 Figure 5: Participation of Lactating Mothers in H-MG ...... 11 Figure 6: Participation of Pregnant women in H-MG ...... 11

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CHAPTER I - Introduction 1.1 Glimpse of the district

Dhading is one of the eight districts of with Dhadingbesi as its district headquarters. The district covers an area of 1,926 square kilometers (744 sq. mi)1.It is the only district of Nepal extending from the northern Himalaya to the southern Mahabharata and is considered as the longest district of Nepal.

The district spreads from 27'40" E to 28'17" E and 80'17"N to 84'35"N1. The mountain range Ganesh Himal is the predominant mountain located in Dhading and some of its peaks are over 7,000 meters (23,000 ft).The district is bounded by Kathmandu, Rasuwa and Nuwakot in the East, Gorkha in the West, Rasuwa and Tibet in the North and Makwanpur and Chitwan in the South. The population of Dhading comprises Hindu religion (72.6%) followed by Buddhism (20.3%). Some of the other minor religions in are Prakriti and Jain. Very small proportion of population follows Christian and Muslim religion (6.27% and 0.3% respectively. Dhading district has 2 Municipality and 11 Rural Municipality after the election held on Baisakh 31, 2074. Below are the list of our working VDCs and Municipality and Rural Municipality S.N Working VDCs Municipality/Rural Municipality Ward no. 1 Nalang Siddhalekh Municipality 1, 2

2 Khari Jwalamukhi Rural Municipality 5

3 Chainpur Jwalamukhi Rural Municipality 6,7

4 Agnichok Tripurasundari Rural Municipality 5,6

5 Tripureswor Tripurasundari Rural Municipality 7

6 Salyantar Tripurasundari Rural Municipality 1,2

7 Jaymrung Nilkanta Municipality 10, 11

http://ddcdhading.gov.np

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1.2 General information of VDC

General Salyantar Chainpur Jaymrun Agnichok Tripuresh Nalang Khari District information g wor Total

No. of FCHV 10 10 10 9 9 9 9 66

No. of HMG 10 10 10 8 9 10 10 68

No. of HFoMC 1 1 1 1 1 1 1 7

Total Population 8141 6505 7122 3667 3465 8246 4440 347755

Under 1 year 172 155 178 102 91 201 107 8005 neo-nates (0-28 203 158 171 92 84 191 103 8021 days)

2 to 59 months 776 660 718 382 318 917 479 35600

6 to 59 months 695 588 635 334 275 823 429 31861

0 to 6 months 86 78 89 51 45 100 53 4002

6 to 9 months 86 78 89 51 45 100 53 4002

6 to 23 months 247 218 244 137 119 292 154 11470

0 to 23 months 333 296 333 188 164 392 207 15472

0 to 35 months 487 426 473 262 224 575 302 22530

1 to 2 yrs (12 to 161 155 86 73 191 100 7468 23 months) 141

12 to 59 months 609 511 547 283 230 722 376 27859

0 to 59 months 781 665 724 385 321 923 482 35864

Adolescent 1824 1384 1635 818 837 1777 996 76419 population(10 to 19 years)

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0 to 14 yrs 2375 1909 2147 1022 958 2597 1391 105187 (Child Population)

29 days to 1 year 166 150 172 99 88 195 104 7741

1 to 4 years 609 511 547 283 230 722 376 27859

05 to 14 years 1592 1243 1424 636 637 1674 908 69323

Married Female 2027 1628 1718 928 860 1914 1061 78251 pop 15 to 49 years

Female Pop 15- 2674 2148 2267 1224 1134 2525 1399 103233 49 years

15 to 24 years 1764 1325 1538 814 758 1625 891 76873

Expected 239 187 202 109 99 225 122 9459 Pregnancies

Expected live 203 158 171 92 84 191 103 8021 birth

20 to 59 years 4113 3261 3401 1797 1731 3949 2079 173276 above 60 years 680 614 733 393 330 773 447 29444

Source: DHO, VDCwise shifted population FY 2072/73 (2015/16)

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1.3 Relevance of the Project Conduction of health mothers group meeting on monthly basis comes under the primary responsibility of FCHVs. Although the health management information system (HMIS) shows that 80 percent of mother group meeting are being conducted as planned but the survey shows otherwise. The recent FCHV survey shows that only 46 percent of FCHVs reported conducting the health mother’s group meeting. Moreover, it is still not revealed how often and actually the health education takes place as the meeting conducted only for saving and credit purpose also is called as mother’s group meeting. Some of the reported problems for irregularities of health mothers groups meeting such as lack of allowance for tea-snacks, lack of appropriate place to conduct meeting, lack of innovative methods for providing health education materials such as audio-visual aid. Experts are of view that one of the factors behind irregular mother’s group meeting is insufficient monitoring and supervision of FCHVs from their immediate supervisor. This might also have led to the sharp decrease proportion of mother group meeting from 85 per cent over the last eight years.

Following the earthquake, the relevance of mother group meeting and regular meeting of HFOMC has increased. Mother group meeting is vital, not only to create more awareness and to increase the demand for service, but also to prevent the delinking of community and health system. Likewise, the substantial improvement in the community health is not possible with the weak local governance. Thus to strengthen the community mobilization and local governance, the mothers group meeting needs to be invigorated and health facility management committee needs to be regular.

1.3.1 Objectives of SAHaS Project  Capacity building of the Female Community Health volunteers (FCHVs) in order to strengthening the existing functional and re-activate the non-functional MG and HFOMC in 72 VDCs of 9 districts  Re-activation of non-functional Mother’s Group (MG) and Health Facility Operation Management Committee (HFOMC) and strengthen the existing functional MG and HFOMC in 72 VDCs of 9 districts.  Establish advocacy group for the advocacy and sustainability of MG and HFOMC.

1.3.2 Activities of the SAHaS Project  Training for Project Officer and Social Mobilizers  Orientation training to FCHVs of the respective VDCs.

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 Mapping of Mother's Group and HFOMC Meeting  Coordination with local level supporting persons for regular conduction of Mother's Group and HFOMC meeting.  Participate in Mother's Group and HFOMC meeting  Provide refreshment cost to the FCHVs for each Mothers Group Meeting and Health Post In charge for each HFOMC Meeting  Formation of Advocacy group in each working VDCs for the sustainability of H-MG and HFOMC meeting.  Conduction of bi-monthly review meeting.  Provide emergency referral fund

 Celebrate Major health events

1.4 Recording and reporting Under SAHaS project, reporting of data is maintained on monthly basis. Recording and reporting tools were developed for both Project officers and Social mobilizers. Social mobilizers submit their collected data to Project Officer. Then Project Officer prepares monthly and bi- monthly reports of working VDCs of the district. The document/ data prepared by Project Officer are submitted to MEAL officer at NPHF.

1.5 Monitoring The overall task of monitoring lies within NPHF i.e. Program Director & Monitoring and Evaluation Officer from the central level and Program Officers from the district level. The monitoring check list is used by PO. The usual method adopted by PO is discussed with health workers, interactions with mother's groups, FCHVs, verification of SMs work plan, recording and reporting format. In addition to monitoring, on site coaching and instant supportive feedback is provided to improve the quality of work. The joint monitoring at district level is also conducted on need basis.

In addition, regular monitoring is also done by central team of NPHF. The objective of monitoring is to assess the level of coordination with government agencies, district NGO/INGOs,

5 effectiveness of program at VDC level and strengthening of Mother's group and HFOMC with the compliance of refreshment cost to them.

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CHAPTER II - RESULTS

2.1 FCHVs and HealthMothersGroup Table 1: Total number of FCHVs andH-MG

VDC No. of FCHVs No. of H-MG

Salyantar 10 10

Chainpur 10 10

Jaymrung 10 10

Agnichok 9 9

Tripureswor 9 9

Nalang 9 10

Khari 9 10

Total: 66 68

The above table shows the number of FCHVs and Health mothers Group in the project implemented VDCs of Dhading district. Three VDCs of Dhading district (Salyantar, Jaymrung, Chainpur) has 10 FCHVs. Each FCHV has their own Health Mothers Group while in Nalang and Khari one FCHV has two Health Mothers Group in one ward.

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2.2 Mother Group Meeting Table 2: Number of H-MG conducted

VDC No. of H-MG Baisakh Jestha

Salyantar 10 10 10

Chainpur 10 10 10

Jaymrung 10 10 10

Agnichok 9 9 9

Tripreswor 9 9 9

Nalang 10 10 10

Khari 10 10 10

Each FCHV has her own Health Mothers Group and the meeting should be conducted once a month in respective wards and should discuss about the health related topics. The health mothers group has different roles. The major are: Select new FCHV in vacant place, Review the work of FCHVs annually, sharing the learned health-related information to males and females, Motivate other women to participate in Health Mothers Group.

The entire seven VDCs of Dhading district has 100 % conduction of health mothers group meeting in both Baisakh and Jestha month. Different health topics were discussed in the mothers group meetings related to maternal and child health including WASH.

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2.3 Participants in Mothers Group Meeting

Table 3: Participants in H-MG Meeting

VDCs Total number of participants Average number of participants per MG

Month Baisakh Jestha Baisakh Jestha

Salyantar 175 176 17 17

Jaymrung 256 256 26 26

Chainpur 174 174 17 17

Agnichok 223 205 25 23

Tripureswor 243 231 27 26

Nalang 432 408 43 41

Khari 379 373 38 37

The given table gives the total number of participants in the mothers’ group meeting and average number of participants per meeting in the project implemented VDCs of Dhading district. The average number of participants in the mothers group varied from VDC to VDC depending on the no. of H-MG. Nalang VDC had the highest number of participants in average in Baisakh (43) and Jestha (41) while Chainpur and Salyantar has average lower number of participants in both the months.

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2.4 Ethnicity of the participants in H-MG Meeting

Jestha 6 23 64 6 0

Khari Baisakh 8 32 53 7

Jestha 25 27 26 22 1

Nalang Baisakh 27 28 26 19

Jestha 22 57 15 6 r

Baisakh 33 39 18 10 Bramhan Tripreswo Jestha 29 35 17 19 Chhetri

Baisakh 8 47 17 28 Janajati Agnichok Dalit Jestha 43 9 31 13 5 0thers

Baisakh 46 20 22 8 4 Jamrung Jestha 44 6 31 16 2

Baisakh 43 6 32 17 2 Chainpur Jestha 27 3 58 7 4

Baisakh 27 2 59 7 4 Salyantar 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Figure 1: Ethnicity of the participants in H-MGmeeting Majority of VDCs have highest proportion of Janajati and Chhetri than other ethnic groups. This is because the majority of the population of the project implemented VDCs are Janajati and Chhetri. After Janajati and Chhetri, Brahmins are other major ethic groups. Dalits are encouraged to participate as a member of mothers’ group meeting by the guideline of FHD. Dalits were in less number than other ethnic groups as their population is fewer than others.

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2.5 Participation of Lactating Mothers in H-MG Meeting participation of lactating mothers 9 8% 8 7% 7% 7 6 5 4% Baisakh 4 3% 3 2% Jestha 2 1% 1% 1% 1% 1 0 0 0 0 0 Salyantar Chainpur Jaymrung Agnichok Tripreswor Nalang Khari

Figure 2: Participation of Lactating Mothers in H-MG

The participation of lactating mothers in mothers’ group meeting is very crucial for health of mothers and children because the major health topics discussed in H-MG meetings are related to maternal and child health. The figure shows Jaymrung and Salyantar VDC has higher proportion of lactating mothers participating in mothers group than other VDCs.

2.6 Participation of Pregnant women in H-MG Participation of pregnant women 16 14% 14

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8 Baisakh 6

4 3% Jestha 2% 2% 2 1% 1% 1% 1% 1% 0 0 0 0 0 0 Salyantar Chainpur Jaymrung Agnichok Tripreswor Nalang Khari

Figure 3: Participation of Pregnant women in H-MG

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The participation of pregnant women in mothers’ group meeting is very crucial for health of mothers and children because the major health topics discussed in H-MG meetings are related to maternal and child health. The figure shows that khari VDC has higher proportion of pregnant women participating in H-MG in the month of Baisakh however Jaymrung VDC has highest proportion of pregnant woman participating in H-MG meeting in the month of Jestha.

2.7 Participation of Social mobilizers and Health workers in H-MG meeting Table 4: Participation of Health workers and Social mobilizers in H-MG meeting

VDCs Number of HMG Participation of Social Participation of Health conduction Mobilizers Workers

Month Baisakh Jestha Baisakh Jestha Baisakh Jestha

Salyantar 10 10 0 0 10 10

Chainpur 10 10 0 0 0 10

Jaymrung 10 10 0 0 10 10

Agnichok 9 9 9 2 6 6

Tripreswor 9 9 2 9 6 7

Nalang 10 10 0 4 6 6

Khari 10 10 8 0 0 0

Above figure shows quite less participation of SM in the H-MG meeting as they are assigned to 2-3 VDCs. Due to the busy schedule of HP in charge, they couldn’t participate in more H-MG meetings.

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2.8 Health Facility Operation Management Committee VDC No. of HFOMC Meetings Conducted

Baisakh Jestha

Salyantar 1 0 0

Chainpur 1 0 0

Jaymrung 1 0 1

Agnichok 1 0 0

Tripreswor 1 0 0

Nalang 1 0 0

Khari 1 0 0

Table 5: HFOMC Meeting conduction Health Facility Operation and Management Committee meeting is conducted once a month in every VDC. It is the responsibility of the Health Post In-charge to conduct the meeting as he/she is the member secretary of the committee. Each VDC has one Health Facility Operation and Management Committee. Above figure shows that HFOMC meeting was only conducted in Jaymrung VDC in Jestha month.

2.9 Sex of the participants in HFOMC Meeting Each Health Facility Operation and Management Committee should have female as a member of the committee. In both project implemented VDCs, every HFOMC have female members in the committee.

2.10 Ethnicity of the participants in HFOMC Meeting The members of HFOMC should also consist of representative from Dalit ethnicity. All the seven VDCs have representatives from dalits in every HFOMC meeting though the number of dalits is lower than other ethnic groups.

2.11 Participation of Social Mobilizers in HFOMC Meeting SAHaS Project has also the provision of providing refreshment cost to HFOMC for 3 times in the project duration. HFOMC meetings was conducted only in Jaymrung VDC in Jestha only. Due to the election and busy schedule of Health post in charge HFOMC meeting could not conducted in Baisakh and Jestha month.

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2.12 Advocacy Group Meeting SAHaS Project has a component of formation of advocacy group for the sustainability of conduction of mother’s group meeting and HFOMC meeting so that the proportion of mothers group meeting and HFOMC meeting will not decrease in near future. Social Mobilizer has formed Advocacy group in each project implemented VDCs. Advocacy Group meeting is conducted bi-monthly.

Table 7: Member of Advocacy group

S.N Members of Advocacy Group 1 Health-Post/PHC incharge

2 Social worker 3 Social worker

4 School Principal 5 FCHV Table no 8: Number of Advocacy group meeting conducted

Advocacy group meeting was not conducted on Baisakh and Jestha months as the meetings takes place once in two month and also due to the influence of election.

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CHAPTER III - CONCLUSION

The project SAHaS has been implemented in the 7 VDCs of Dhading district since August (Bhadra) month with objective to strengthen and activate the mothers group and HFOMC meeting that have to be conducted in the VDCs every month. Both projects implemented VDCs have ward based number of FCHVs. To carry out different programmes in the community level, it is crucial to coordinate with FCHVs and Mothers’ Group who can motivate community people to participate in health education sessions.

After the implementation of project, the number of conduction of Health Mothers Group has drastically been increased. All the seven VDCs had cent percent conduction of Health Mothers group meeting in the month of Baisakh and Jestha. The mothers groups discuss about different health related topics in the meeting. The topics include: ANC, PNC, sanitation and hygiene, immunization, nutrition, uterine prolapsed, menstrual hygiene, hand washing, balvita, danger signs during pregnancy etc. there are various roles of mothers group in the community which are directly or indirectly related to maternal and child health and the health of the community.

HFOMC meeting was conducted only in Jestha month in Jaymrung VDC only due to the election. The community people especially mother group members are satisfied with the project and are demanding for its long run.

Advocacy group has been formed in all the VDCs for the sustainability of the SAHaS Project.

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CHAPTER IV – CHALLENGES AND WAY FORWARD

4.1 Key challenges:  High expectation of HP, PHC, DHO staffs (especially allowance and refreshment for FCHV reporting day)  Less participation of SM in MG meeting since SM is assigned for 3 VDCs.  Quick turnover of SM

4.2 Way Forward  SM should coordinate with Health post staff, and build rapport with the community people.  SM should coordinate with newly elected chairperson and members of respective VDCs for support and continuation of H-MG meeting.  Coordination with Government staff in district as well as VDC level  Rigorous Monitoring of SM by field visit

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CHAPTER V - LESSON LEARNED

Participation of Social Mobilizers

The seven VDCs of Dhading district are non-adjoining so it is very difficult for single SM to move from one VDC to another VDC due to which there is less participation of SM in H-MG and HFOMC meetings. Utilization of Emergency Fund Though there was enough budget of emergency fund for complicated delivery cases, it is less utilized in the VDCs since there are no such cases in the VDCs in both Baisakh and Jestha months.

Refreshment cost The number of participants in mothers group meetings vary from ward to ward but the refreshment cost is equal to every mothers group. So there is unequal distribution of refreshment cost to the FCHVs making them dissatisfied.

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