Community experience, research and management field work by Siddhartha Yadav

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

TOPIC FOREWORD ACKNOWLEDGEMENT ABBREVIATIONS EXECUTIVE SUMMARY

PAGE NOS. i ii iii‐vi vii‐viii

TABLE OF CONTENTS OBJECTIVES AND METHODOLOGY DETAILS OF ACTIVITIES DISTRICT PROFILE OF GORKHA DISTRICT HEALTH PROFILE OF GORKHA CRITICAL APPRAISAL OF DELIVERY SERVICES AT GORKHA HOSPITAL EPIDEMIOLOGICAL STUDY A FIVE YEAR PLAN ON ELIMINATION OF LEPROSY FROM RUPANDEHI DISTRICT LEARNING REFLECTIONS ANNEXES

1‐2 3‐5 6‐13 14‐43 44‐51

52‐57 57‐75

76 77

C O M M U N I T Y E X P E R I E N C E , R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K 2 0 6 3

This report has been prepared and submitted to the Department of Community Medicine and Family Health (DCMFH) as a part of the Bachelor of Medicine, Bachelor of Surgery (MBBS) curriculum. Besides fulfilling the requirements of this curriculum, this report encloses within itself our experiences of hospital management system, district health management, conducting an epidemiological study, preparing a five year plan and many more aspects. This field, for sure, has ingrained so many changes in us as an individual and as a group. Starting from group discussions during our orientation classes to enlightening interactions and interviews with various important persons, from planning of our own field visit to five year plans on health related matters, from a scratch of data to the huge piles of data for epidemiological study, all these have instilled an overview of the practical scenario of our life in future. And, this has made all of us confident enough to face all what might come during our professional life. We had the knowledge and experiences of three different districts and the health care delivery systems at different levels. Those of us who belong to foreign countries also got an opportunity to learn different cultures, enjoyed the natural beauty of Nepal. Despite some limitations of logistics and travelling facilities, this field trip, in the end, was cherished by all of us and it was completed smoothly. Finally, we would like to express that in the future this field program should be continued with some improvements e.g. provisions of logistics, travelling facilities.

P a g e | i

Group B3

C O M M U N I T Y E X P E R I E N C E , R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K 2 0 6 3

Nine‐week long field trip, in 3 different places where all were new and unknown, has now successfully come to an end. All these 63 days we came across so many faces, with their helping hands and valuable words and suggestions, who made this field trip a comfortable and successful one. First of all we would like to mention our thanks is to the Department of Community Medicine and Family Health (DCMFH), who organized this field trip for us and provided us with all the guidance and support we needed. We would never forget to thank our respected Campus Chief, Prof. Dr. D.N. Shah., Assistant Campus Chief, Prof. Dr. B.M. Pokharel, and Head of the Department, Community Medicine and Family Health, Prof. Dr. I.B. Shrestha. Our special thanks goes to Dr. Sharad Onta and Dr A.B. Joshi who supported us with their expert opinion and suggestions throughout the field, Mr. Shiva Sapkota for his constant help throughout the trip and Mr. Ramesh Sigdel for his invaluable supervision and guidance. Our gratitude goes to all the teachers and staffs of DCMFH. We are grateful to all the distinguished guest lecturers from various walks of life for managing some time for us out of their precious time and busy schedules and enlightening us during our orientation classes. Here are the people who have special places in our hearts. Their names will never be forgotten and so will be their help and support. Special thanks to all of them: 1) Mr. Achyut lamichhane, District health officer, Gorkha. 2) Dr. Kiran Regmi, Medical Officer, Gorkha District Hospital (GDH). 3) Dr. Senendra Raj Uprety, Medical Superintendent(MS), Mahendra Adarsha Chikitsalaya (MAC), Chitwan. 4) Mr. Mohammad Daud, District Public Health Officer, Chitwan. 5) Dr. Binod Parajuli, Director, Siddhartha Children and Women Hospital (SCWH), Butwal. 6) Mr. Ram Chandra Khanal, District Public Health Officer, Rupandehi. Lastly, we would like to extend our heartiest thanks to all who directly or indirectly helped us in making this field program successful. Thank You.

P a g e | ii

C O M M U N I T Y E X P E R I E N C E , R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K 2 0 6 3

A AHW AIDS ANC ANM ARI ASL

Auxiliary Health Worker Acquired Immuno‐Deficiency Syndrome Ante Natal Checkup Auxiliary Nurse Midwifery Acute Respiratory Infections Authorized Stock Level

Bacillus Calmette Guerin

Control of Diarrhoeal Diseases Child Health Program Comprehensive Leprosy Training Contraceptive Prevalence Rate Couple Year Protection Confidence Interval

B BCG

C CDD CHP CLT CPR CYP CI

D D/J DCMFH DDC DH DHO DoHS DOTS DPHO DPT3 DTCO DTLA

P a g e | iii

Dhami Jhankri Department of Community Medicine and Family Health District Development Committee District Hospital District Health Office Department of Health Services Directly Observed Treatment Shortcourse District Public Health Office Diphtheria Pertusis and Tetanus 3 doses District Treasury Control Office District Tuberculosis and Leprosy Assistant

C O M M U N I T Y E X P E R I E N C E , R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K 2 0 6 3

E EPI

Expanded Programme on Immunization

Follow Up Female Community Health Volunteer Family Planning Family Planning Program Fiscal Year

Gorkha District Hospital Gross Enrollment Rate

Health Assistant Hospital Development Committee Health Education Hepatitis B Health Information, Education and Communication Human Immunodeficiency Virus Health Management Information System Health Post

Iodine Deficiency Disorder Information, Education and Communication Integrated Management of Childhood Illness International Non Government Organization Institute of Medicine Intra Uterine Devices

Kredistanstalt Fur Weindranfkaw

Low Birth Weight Leprosy Control Division Leprosy Elimination Monitoring

F F/U FCHV FP FPP FY

G GDH GER

H HA HDC H.E. Hep B HIEC HIV HMIS HP

I IDD IEC IMCI INGO IOM IUD

K KFW

L LBW LCD LEC

P a g e | iv

C O M M U N I T Y E X P E R I E N C E , R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K 2 0 6 3

LMIS

Logistic Management Information System

MAC MB MBBS MCH MCHW MDT MMR MO MoF MS

Mahendra Adarsha Chikitsalaya Multi‐bacillary Bachelor in Medicine Bachelor in Surgery Maternal and Child Health Maternal and Child Health Worker Multi Drug Therapy Maternal Mortality Rate Medical Officer Ministry of Finance Medical Superintendent

N NCDR NER NG NGO NIP NMR NP NTP

New Case Detection Rate Net Enrollment Rate Nepal Government Non Government Organization National Immunization Program Neonatal Mortality Rate Nor Plant National TB Program

Out Patient Department Oral Polio Vaccine 3 doses Out Reach Clinics Oral Rehydration Solution

O OPD OPV3 ORC ORS

P PB PEM PHC PHC‐ORC PP PPH PR

Pauci‐bacillary Protein Energy Malnutrition Primary Healthcare Centre Primary Health Care‐Out Reach Clinic Post Partum Post Partum Haemorrhage Prevalence Rate

S SCWH SGA SHP

P a g e | v

Siddhartha Children and Women Hospital Small for Gestational Age Sub Health Post

C O M M U N I T Y E X P E R I E N C E , R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K 2 0 6 3

STD

Sexually Transmitted Disease

Treatment Tuberculosis Trained Birth Attendants Total Fertilization Rate Tetanus Toxoid 2 doses

T T/t TB TBAs TFR TT2

U UNFPA USAID

United Nation Fund for Population Activities United States AID

V VDC VDC VHW Vit A VSC

Village Development Committee Village Development Committee Village Health Worker Vitamin A Voluntary Surgical Contraception

W w.r.t. WDR WHO

P a g e | vi

with respect to Western Development Region World Health Organization

C O M M U N I T Y E X P E R I E N C E , R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K 2 0 6 3

In accordance with the MBBS curriculum of the Institute of Medicine (IOM), Maharajgunj, final year students have to participate in a nine week long community field program which gives an insight about aspects of District health management system. This field program starts with orientation classes, group division, allocation of the field sites and provision of logistics to each of the groups. This way we, group B3, of 23rd batch with 7 members were posted at 3 different places for 3 weeks at each place from 2063/8/10 to 2063/10/13.

We were posted at

1) Gorkha District Hospital, Gorkha from

2063/8/10 to 2063/9/1

2) Mahendra Adarsha Chikitsalaya, Bharatpur, Chitwan from

2063/9/2 to 2063/9/22

3) Siddhartha Children and Women Hospital, Butwal from

2063/9/23 to 2063/10/13

At different places we conducted various activities starting from the district profile, district health management system and critical analysis that we performed in Gorkha. Gorkha is a typical hilly district of Western Development Region (WDR) with 3 electoral constituencies, 13 ilakas, 66 VDCs, and a municipality. It carries a population of 2, 88,134 with a population growth rate of 2.24. The average household size is 4.9 and the population density of the district is 80 persons/sq.km. The health care system in Gorkha district is served by Government supported health institutions, Non Government Organizations/International Non Government Organizations (NGOs/INGOs) supported health institutions, community based hospital, and others such as Dhami/jhakaris and Ayurvedic ausadhalyas. There is a district hospital in Gorkha, 3 Primary Health Care Centres (PHC), 10 Health Posts (HP), 55 Sub Health Posts (SHP), and 286 Primary Health Care/Outreach Clinic (PHC/ORC) under government based health institutions. The District Health Office (DHO) looks after the health related activities in the district and conducts various programs like National Immunization Program (NIP), Control of Diarrhoeal Disease (CDD), control of Acute Respiratory Infection (ARI), Nutrition programs under child health program. Similarly other infectious disease control also conducted. Several health promotion programs are also conducted by the DHO. Regarding the health indicators of Gorkha district, vaccines’ coverage are as follows: BCG‐ 75.53%, DPT3, Polio & Hepatitis B‐73.38%, Measles‐73.68% (lower then the national values except for Hepatitis B). Severe dehydration was seen in 3.3% of the children with diarrhea. Contraceptive prevalence rate was found to be 33.9%. Cure rate of Directly Observed Treatment Shortcourse (DOTS) is 88% and the case detection rate is 51%. Routine safe motherhood services are available in all 66 VDCs and 1 municipality. There are no major epidemics in the district recently. The top 5 morbidities of the district are skin diseases, ARI, worm infestations, gastritis and diarrhoeal disease. We also critically analysed the delivery services of Gorkha District Hospital. Delivery service is one of the most important services provided in the district hospital as it is the place where cases requiring referral arrives first from the peripheries. So it is mandatory that delivery services provided

P a g e | vii

C O M M U N I T Y E X P E R I E N C E , R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K 2 0 6 3

at district hospital be of optimum standard. But in Gorkha district hospital, a large number of cases (31 cases out of 131 cases reported to the hospital within last 5 months) are referred out of the district to other centres. In the fiscal year 2062/63 only 28.45% of total women who came for their first Ante Natal Checkup (ANC) visit came for the delivery in the hospital. On interviewing the patients, most of them expressed that they were not satisfied with the service of the hospital. On interviewing the nurses, we came to know that there were underutilizations of the resources. For the last two years no instrumental deliveries had been conducted in the hospital despite the availability of resources and manpower. Our observations revealed that the delivery systems needed improvements. We then conducted an epidemiological study in Chitwan. It was a hospital based retrospective cohort study on adverse reproductive outcomes associated with teenage pregnancy at Mahendra Adarsha Chikitsalaya (MAC), Bharatpur. This study included 4,101 deliveries of which 790(19.27%) were of age group 15‐19. Majority of our cohort were Bramhins/Chhetris(56.76%). The result of our study showed that the teenage mothers had significantly increased incidences of preterm labour (p<0.001), low birth weight babies (LBW) (p<0.001) and small for gestational age babies (SGA) (p<0.005). Although the risk of Postpartum Hemorrhage (PPH), stillbirth, low Apgar score of baby at birth and Neonatal death were higher in teenage mothers, this was not statistically significant. In Rupandehi, we prepared a five year plan on elimination of leprosy from Rupandehi district. This is because Rupandehi is one of the 31 districts within Nepal and one of the 5 districts in Western Development Region(WDR) which is yet to achieve Leprosy elimination. It has the highest prevalence rate (1.5) among the districts of the WDR. Also the trend of proportion of grade2 disability among new cases is increasing. This shows that the patients are presenting late for treatment. The trend of child proportion among new patients is also increasing which shows that the disease is active and spreading in the district. Defaulter rate in the district is also on the rise as compared to that of last year and so is the female proportion among the new cases. Hence, we chose to prepare a five year plan on Leprosy elimination. The plan consists of two phases: an elimination phase of three years and a post‐elimination phase of two years. In the phase of elimination, the target will be to reduce the Prevalence Rate(PR) of leprosy per 10,000 population to below 1. The major activities in this phase will include active case detection and early and effective management of the diagnosed cases. The activities of the second phase will focus on maintaining good quality of leprosy services, further reduction in cases and strengthening surveillance system following elimination. The total budget for the program will be of Rs. 43,35,000. Appropriate suggestions and comments have been made throughout the report in the concerned sections. We hope that these findings and recommendations will be of help to the concerned authorities in the days to come.

P a g e | viii

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

1. GENERAL OBJECTIVE To understand the health care delivery system of the district and to develop skills on various aspects of management.

2. SPECIFIC OBJECTIVE 1. To describe the existing health care delivery system of the district in terms of effectiveness, limitations, costs, accessibility and availability in order to find out the level and the quality of health care system in that area. 2. To observe and participate in the activities of the public health sector and to gain practical experience in health care management. 3. To be familiar with the roles and observe the activities of the Government Organizations, Non Government Organizations (NGO), and International Non Government Organization (INGO) as well as their coordination with the hospitals. 4. To conduct an epidemiological study. 5. To review critically any health activities of DHO/DHO or health facilities of hospital. 6. To make a five year plan on a relevant topic.

3. METHODOLOGY Study type

P a g e | 1

Municipality DHO Hospital NGO/INGOs

Data Analysis

Secondary data review

Formal Meeting

DDC Resource Centre Informal observation

Additional Information

Both descriptive and analytical in terms of qualitative and quantitative information. Data collection and Analysis process

PHC/HP/SHP Primary data

Information Sharing

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

4. TOOLS OF INFORMATION COLLECTION For the collection of information, following tools were used: Observation checklists Guidelines for interview Questionnaire Discussions agenda Format for record review

5. ETHICAL CONSIDERATION Information was collected only after permission of responsible authorities.

P a g e | 2

2063

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

GORKHA Date 2063/8/10

Activities Duration Arrival at Gorkha, meeting with District Health Officer, 1 day arrangement of accommodation & food, arrangement of meeting with key persons of DHO and District Hospital.

2063/8/11

Meeting with the key persons, rapport building, discussion about the objectives Meeting with local development officer, rapport building Data collection from hospital and DHO, involvement in various hospital activities e.g Out Patient Department (OPD), morning rounds, autopsy etc, interviews with key persons etc. Data analysis and interpretation Visit to PHC, HP, SHP Visit to Lions eye centre. Visit to Tulsi‐Meher HIV/AIDS support center. Involvement in Expanded Program on Immunization (EPI) micro planning in DHO Preparation for presentation and report writing

2063/8/12 2063/8/13‐2063/8/20

2063/8/21‐2063/8/22 2063/8/23 2063/8/24 2063/8/25 2063/8/26 2063/8/27‐2063/8/28 2063/8/29 2063/9/1 2063/9/2 P a g e | 3

Presentations at DHO recommendations Preparation to leave Gorkha Left Gorkha in the morning

and

submission

1 day 1 day 8 days

2 days 1 day 1 day 1 day 1 day 2 days

of 1 day 1 day

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

CHITWAN Date 2063/9/2

2063/9/3

2063/9/4

2063/9/5‐2063/9/6

2063/9/7‐2063/8/12 2063/9/13‐2063/9/15 2063/9/16

2063/9/17‐2063/9/18 2063/9/ 19‐2063/9/20 2063/9/21 2063/9/22 2063/9/23

Activities Arrival at Chitwan, meeting with Medical superintendent of MAC, arrangement of accommodation & food. Meeting with the District Public Health Officer, arrangement of the meetings with staffs of DPHO, rapport building, discussion about the objectives Meeting with staffs of MAC, rapport building, discussion about our objectives, observation of the various departments of the hospital Involvement in various hospital activities e.g OPDs, rounds etc, interviews with key persons like gynecologists, surgeons, Medical Officers (MO) in the emergency etc., Going through various hospital data, choosing the topic for epidemiological study Literature review for conducting epidemiological study and data collection from the maternity registers Data analysis and interpretation Visit and observation of the other medical institutions like College of Medical Sciences, Bharatpur, Cancer hospital, Bharatpur etc. Report writing and typing Report writing and Preparation for the presentation Presentations and acknowledgement for the co‐ operation Preparation to leave Chitwan Left Chitwan in the morning

Total Duration: 21 days P a g e | 4

Duration 1 day

1 day

2 days

6 days 3 days 1 day

2 days 2 days 1 day 1 day

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

BUTWAL Date 2063/9/23

2063/9/24

2063/9/25

2063/9/26‐2063/9/27 2063/9/28

2063/9/29 2063/10/1‐2063/10/3 2063/10/4 2063/10/5‐2063/10/9 2063/9/10 2063/9/11 2063/9/12 2063/9/13

Activities Arrival at Butwal, meeting with medical superintendent of SCWH, arrangement of accommodation & food, arrangement of meeting with key persons of SCWH Meeting with staffs of SCWH, rapport building, discussion about the objectives, observation of the hospital services and the infrastructures Involvement in various hospital activities e.g OPDs, rounds etc, interviews with key persons like gynecologists, surgeons, MOs in the emergency etc. Data review, analysis and group discussion Discussion with medical superintendent about our plan and visit to DPHO Bhairahwa, arrangement of meeting with staffs of DPHO Bhairahwa Meeting with staffs of DPHO Bhairahwa, rapport building Data review, interpretation, group discussion on choosing the topic of five year plan Literature review for preparing five year plan Preparation of the five year plan Discussion about our prepared five year plan with MS of SCHW and DPHO‐chief Presentation, acknowledgement and recommendations at DPHO Bhairahwa Presentation at SCHW and appraisal of their help and well maintenance of the hospital services Left Butwal and came back to Kathmandu

Total Duration: 21 days

P a g e | 5

Duration 1 day

1 day

2 days 1 day

1 day 3 days 1 day 4 day 1 day 1 day 1 day 1day

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

Gorkha, one of the most important historical place is a hilly district situated in the western Development Region of Nepal. It covers an area of 3610 sq. km. It is surrounded by Dhading and China in the East; Tanahun, Lamjung,Manang and China in the West; China in the North and Chitwan, Tanahun and Dhading in the South. The district is famous for its historical importance, temples and natural beauty of tourist attraction.

1. GEOGRAPHICAL LOCATION

Latitude: 27.15 to 28.45(north) Longitude: 84.27 to 85.85°E Elevation: 228 meters to 8163mts. The highest place of the district is Mt.Manaslu at an altitude of 8163 m whereas the lowest place is at an altitude of 228 m from the sea level.

Agriculture(cultivable land) Forest

55696 Ha 112676 Ha

15.43% 31.21%

Pasture

59520 Ha

16.49%

Others

133108 Ha

36.87%

1.1 Topographical distribution of land

2. CLIMATE It has variety of climate tropical, sub tropical, cold and alpine because of topographical variance in the land. Annual maximum recorded temperature: 25 c Annual minimal recorded temperature: 14 c Annual rainfall:1492 mm

3. POLITICAL DIVISION

It lies in the Western Development Region, Gandaki zone. It has been divided into: ‐3 electoral constituencies, ‐13 ilakas, ‐1 municipality ( Prithivi Narayan Municipality),

P a g e | 6

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

‐66 Village Develoment Committes (VDCs.) ‐605 Wards (594 of VDCs and 11 for municipality) Its headquarter, Prithivi Narayan Municipality , a place of historical importance, spot of natural beauty and tourist attraction, is around 130 km away from Kathmandu.

4. MEANS OF TRANSPORTATION Roadways are the major means of transportation throughout the district. It has a total road length of around 363 kms.The other means of transportation are cable car in Manakamana , water route in Marshyangdi river, Trishuli river etc. There is also one airport in Palumtar but not in use.There are 7 helipads in the district, out of which 5 are in headquarter and 2 in other areas.

5. DEMOGRAPHY 5.1 General characteristics of population Particulars Total population Male Female Sex ratio Total households Average household size Literacy rate% Population density per sq. km.

2058 census 2,88,134 1,334,407 1,53,727 87 58,923 4.9 49.4 80

Age Group 0‐4 yrs. 5‐9 yrs. 10‐14yrs. 15‐19yrs. 20‐24yrs. 25‐29yrs. 30‐34yrs. 35‐39yrs. 40‐44yrs. 45‐49yrs. 50‐54yrs. 55‐59yrs. 60+yrs.

Male 16,503 19,622 20,149 14,121 7,998 6,498 6,720 6,657 6,596 6,041 5,454 4,483 13,563

P a g e | 7

Female 16,280 19,738 20,216 16,986 12,697 10,624 9,734 9,081 8,082 6,404 5,778 4,297 13,492

Total 32,783 39,360 40,365 31,107 20,695 17,140 16,454 17,538 14,678 12,745 11,232 8,780 27,057

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

5.2 Populatiion pyramid

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

5.3 Total disabled by sex (census 2058) Female Male

Population 757 1083 5.4 Demographic parameters of Gorkha

Parameter Total Population Male Female Sex Ratio Total Households Average Household size

2,88,134 1,34,407 1,53,727 87 58,923 4.9

Population Density per sq. km

Population Growth

2.24

5.5 Vital statistics Vital Statistics Crude Death Rate (CDR/1000)

9.96

Total Fertility Rate (TFR)

4.3

Infant Mortality Rate (IMR/1000 live births)

64.1

Maternal Mortality Rate (MMR/100,000 live births)

415

Child Mortality Rate

102

Literacy Rate Male Female

49.40% 59.60% 40.70%

P a g e | 9

% 41.1 58.9

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

6. HOUSEHOLD CHARACTERISTICS

Total Households in Gorkha is 58,923. 6.1 Household by roof type Roof type Concrete Zinc‐sheet % 0.9 29.3 6.2 Household by annual income

Tile‐sheet 3.0

Thatch 33.1

Others 33.8

Income group <Rs.5000 Rs.5000 –Rs.20,000 Rs.20,001‐Rs.40,000 Rs.40,001‐Rs.50,000 >Rs.50,000

% household 44.3 25.8 13.7 5.8 10.3

6.3 Other developmental household parameters Proportion of households using for cooking Proportion of households having radio facility Access to improved source of drinking water Access to toilet facility

94.34% 59.24% 62.45% 40%

7. SOCIAL CHARACTERISTICS 7.1 Language Most of the population of Gorkha speak Nepali. Other languages used in the district are Gurung,Magar,Sherpa/Bhote,Tamang,Rai/Kirati,Tharu,Newar,Satar,Limbu,Maithali and others.

7.2 Caste/Ethnicity Various ethnic groups and different caste of people resides in the district. They are as follows Caste

Percentage

Brahmin

Chhetri

Gurung

21.3

Newar

8.4

Magar

11.3

Bishwokarma Sarki

4.6 5.6

Damai

2.9

Others

13.9

P a g e | 10

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

7.3 Religion Census

Hindu

Buddhism Muslim Christian Jain

Others

2058 (in %)

72.79

25.2

0.03

0.91

0.79

0.01

8. OCCUPATION AND ECONOMIC CHARACTERISTICS 8.1 Economically dependent and independent population Status Census 2048(Total) Economically independent 1,11,734 Economically dependent 74,004 8.2 Population by major occupation

Census 2058(Total) 1,41,155 88,151

Occupation type Agriculture Government service Business Foreign job Household work

Female 64,553 847

Male 68,960 5,847

Female% 86.0 1.1

Male% 81.7 6.9

910 137 7,480

1,467 2,853 577

1.2 0.2 10.0

1.7 3.4 0.7

Others

1,140

4,656

1.5

5.5

Female % 31.7 5.6 4.9 0.3 40.2 17.3

Male % 22.8 16.5 6.2 4.3 16.3 33.9

8.3 Population by secondary occupation Occupation type Agriculture Govt.service Govt.services Foreign job Household work Others

Female 4,837 860 747 43 6,143 2,637

Male 4,923 3,560 1,340 933 3,513 7,333

9. EDUCATION The literacy rate is 40 %. The male literacy is 59.6% and female literacy rate is 40.7 %. Some indicators of education are: Gross enrollment rate 10.84 Net enrollment rate 8.52 Gross enrollment rate at primary level 126.1 Net enrollment rate at primary level 86.2 P a g e | 11

2063

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

9.1 Descriptions about the schools Types of Schools Primary(1‐5)

Community based Private Total 365 7 372

Lower secondary(1‐8)

Secondary(1‐10)

Higher secondary(1‐12) 8

Total

490

478

9.2 Descriptions about the Campuses T.U Affiliate Associate 1 1 The district also possesses 1 technical institute which is private. 9.3 NER and GER of students

Total 2

Level Primary Lower Secondary Secondary

GER Girls Boys 124.07 128.16 73.95 82.17 40.89 50.61

Total(average) 126.10 78.05 45.74

NER Girls Boys 85.41 87.01 22.78 24.21 7.39 9.6

Total(average) 86.20 23.49 8.49

10. MEANS OF COMMUNICATION Common means of communication like postal services, newspapers etc. are easily available.Modern means like telephones, mobile phones are gaining popularity. 10.1 Postal services

District post office Ilaka post office 1 12 There are also two private courier service. There are public telephone booth in about 44 VDCs. Telephone lines per 1000 population is 1.6 Population per telephone line is about 625 population Population of household having radio facility is 59.24%

P a g e | 12

Others 56

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

11. ENERGY RESOURCES Electricity is a common energy resource. 75% of municipality and 16.2 % of VDCs have electricity facility. Other forms of renewable energy systems installed by various households are: solar system, biogas plants etc. Nearly 94.34% of the total households use firewood as a cooking fuel.

12. DRINKING WATER In Gorkha district,about 62.45% of the total population are benefited by piped drinking water supply.

13. SANITATION Only 40% of the population has access to the toilet facility out of which 18% uses sanitary latrines and the rest 22% uses temporary latrines.

14. SOCIAL SERVICE Various NGOs and INGOs are working in Gorkha district for the upliftment of social status by focusing on various aspects.Organizations like the Red Cross Society, JAYCEES, LIONS CLUB,LEO CLUB etc have long been providing social service to the people of Gorkha.

15. TEMPLES The district has a lot of temples.Some important ones are :Gorakhnath, Kalika, Manakamana, Kamdhenu,Alala Mai, Annapurna etc. It’s also a home to many monastries like Rajen Gumba Namla, Shringi and Karju Chering etc.

16. TOURIST SPOTS Historical spots like Gorkha palace, Ramshah’s chautari, Religious spots like Manakamana temple, Gorakhkali temple and places of natural beauty like Manaslu, various Himalayan ranges are sites of internal as well as foreign tourist.

CONCLUSION Gorkha is a typical example of many districts of Nepal.As there is a black topped road from capital to the municipality of district there is not much problems regarding transportation, communication, electricity, education etc in municipality.However the picture is highly contrasting while talking about VDCs.Because of the topographical variance in the district there are still some VDCs where no motorable roads and telephones are available, higher education is difficult and people are striving to live.Thus though there are few patches of development in urban areas it is still a district of gross underdevelopment when it comes to VDCs.

P a g e | 13

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

1. BACKGROUND

The National Health Policy adopted in 1991 A.D. (2048 B. S.) addressed on the importance of extension of primary health care system to the rural population so that they benefit from modern medical facilities and trained health care providers under the headings of preventive, promotive, curative, basic primary health care, etc. One of the section of the health policy emphasized on the community participation of health care providers at the root level and emphasized on the role of basic health care providers like FCHVs, TBAs, etc. With this background, the term District Health Profile encompasses a set of activities assigned, groups of health care providers involved, the objectives set, the plans formulated and the resources involved in attaining a set target level of quality health of the district. So, it required the broad description of the overall functioning health system in the district from district to the community level, from District Hospital to the Outreach Clinics and FCHVs level.

2. OBJECTIVES 2.1 General Objective To understand the general functioning of the healthcare system in the district. 2.2 Specific Objectives 1) To study about the various health institutions, organizations and centres involved in the delivery of health services in the district. 2) To study about the basic functioning staffing pattern and managerial and financial aspects of the district hospital. 3) To understand the management, staffing and functioning of District Health Office. 4) To study about the flow of information from the district to the community level. 5) To understand about the health care programs conducted in the district and to have a detailed description of the same. P a g e | 14

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

3. METHODOLOGY 3.1 Review documents and records at the DHO

i) Annual Report, 2060/61, 2061/62, Gorkha district. ii) Monthly and tri‐monthly reports. iii) Budget sheets iv) Brochures and pamphlets, etc.

3.2 Interview

‐ with DHO, personnel of different sections of the DHO (account, record, management, budget, store, training, etc.) ‐ with MCH workers of the district hospital and community health workers. ‐ with hospital staffs (indoor/outdoor service)

3.3 Visit to

‐ different wards of the district hospitals, store rooms, OPD and MCH clinic. ‐ different sections of the DHO. ‐ one PHC (Makaisingh), HP(Bungkot) and one SHP(Raniswara) ‐ different health institutions within the district (Tulsi Meher HIV/AIDS support center, Lions Eye Care Center). 3.4 Observation

‐within the premises and wards of hospital and different sections of the DHO.

3.5 Attending

‐ seminars conducted by the DHO. ‐ micro planning project workshop on immunization for the MCHW, VHW and VDC secretary. ‐ Rounds and OPDs in Gorkha Hospital.

P a g e | 15

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

4. HEALTH H CARE PRO OVIDERS IN GORKH HA DISTRIICT

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

5. DISTRICT HEALTH OFFICE The DHO is integrated with the DHO. The DHO chief is either a senior doctor or the senior Public Health Officer, whoever is more experienced. During our field postings, the DHO was a senior Public Health Officer who had replaced a senior Doctor. The DHO is located in Gorkha Bazaar, the headquarters of Gorkha District. It occupies a three storied building with nineteen rooms with several of its departments/units. 5.1 Objectives 1. The general objective of the DHO is to provide: curative, promotive and rehabilitative health services to the people of Gorkha . These were to be provided through various activities. 2. To provide effective health for all by the conduction of various health, related programs in an integrated manner. 3. To provide constant monitoring and supervision of the health institutes /programs under DHO and for understanding the various problems and overcoming them. 4. To arrange for various training programs and to produce adequate and efficient health related manpower. 5. To collect and maintain record of various activities under it on a regular basis and report to the centre within a given time period.

5.2 Functions DHO is an administrative office for health institutions like District Hospital and PHC’s while Department of health services itself acts as an administrative office for the DHO. Hence it acts as both as an administrative office and a Public Health Care Office. The functions of various sections under the DHO shall be explained later. However, the function of DHO as a whole is summarized as follows: 1. Administrative activities. 2. Planning, Supervision and monitoring of various health programs. 3. Planning and implementation of health related training in collaboration with regional training centres. 4. Preventive and promotive activities including disease control activities. 5. Curative activities under DH, PHC,HP, SHP and various programs. 6. Reporting activities.

P a g e | 17

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

5.3 Staffing

2063

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

5.4 Financial management The DHO has separated account section and maintains an up‐to‐date records of financial activities. 5.4.1 Budgeting The main source of budget for the DHO is the budget released by the Ministry of Finance each fiscal year. Part of the budget also is formed by the fund invested by the DDC in health sector of the district through the DHO. 5.4.1.1 Budget release

Every year the DHO proposes an estimated budget for the new fiscal year to the DOHS which forwards to the National Planning Commission. The approved budget comes into effect after it is announced by the Finance Ministry in National Budget in the parliament. Thence, the Ministry of Finance (MoF) sends and approved authority and program paper which has documentation of approved programs and the budget allocated for the respective headings. The Authority paper of approved budget is then forwarded to the Office of Auditor General (Ma.Le.Ni.Ka) and the Office of Auditor Controller (Ko.Le.Ni.Ka). One copy each of authority and program paper is sent to the DHO. ‐ Budget is released on quarterly basis after the revision of the document by budget expenditure of the previous quarter by the District Treasury Control Office (DTCO). ‐ DDC also hand overs the budget to the DHO to be given to different PHCs, HPs and SHPs. 5.4.1.2 Problem faced by DHO

The budget of the first trimester is not released until the end of the second trimester which poses problems in carrying out the activities of the first trimester. 5.4.1.3 Budget expenditures

Budget is received under two different headings i) Regular Budget ii) Capital Budget

Budget allocated under different headings for the fiscal year 2062/63 is as under: S.No. 1 2 3 4 5 6 7 8 9

Headings DHO, PHC, HP and SHP District Health Office Gorkha Hospital TB Control Health Education and Information Integrated Health Programme Leprosy Control Nutrition Programme Diarrhoea Control

P a g e | 19

Source NG NG NG NG NG, UNFPA NG, UNFPA NG NG, USAID NG

Budget (in NRs) 3,15,000 2,87,42,670 31,48,000 1,42,220 3,62,600 7,50,000 43,000 3,52,820 18,00,230

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

5.4.2 Recording and accounting

Income and expenditure is recorded by different forms/vouchers according to the Nepal Government's Double Entry Book Keeping System. 5.4.3 Auditing and reporting The details of the expenditure of budget under different headings is reported four monthly to DTCO, Division of Health Services and Regional Health Directorate. 5.5 Logistics management Logistics management of DHO is done throught store section. The store section utilises two rooms of the DHO office as well as part of the cold chain building within the premise of Gorkha District Hospital. The store section is staffed by one storekeeper and one cold chain assistant. 5.5.1 Procurement

The store room for western regional level is situated at Butwal (except for vaccines which is situated at Pokhara). The logistics concerned with the management of DHO like stationeries are procured from the DHO itself under a separate budget heading whereas the following types are received from the regional office every 3 months maintaining as Authorised Stock Level (ASL) of five months of all essential drugs. 1. Logistics mainly related with various programs conducted by the DHO viz. EPI (vaccines, cold chain boxes, etc.), FP program (contraceptives), CDD programs, ARI, etc. 2. Logistics also include some essential drugs to be sent to different PHCs, HPs and SHPs. 3. Emergency procurement of drugs in case an epidemic occurs, is done by DHO by keeping certain amount of reserved budget. 5.5.2 Storage and distribution

Store rooms (two in numbers plus one in the cold chain building) keep the logistics required for daily official work (bills, vouchers, etc.). The cold chain room stores logistics related to EPI. The logistics required for the programs conducted each year are received from the NEpal Government whereas essential drugs to be sent to different PHCs, HPs and SHPs are directly sent to the respective centres without being stored as is done with the supplies coming from German Agency Kredistanstalt Fur Weindranfkaw (KFW). The storage of supplies lasts for three months and are replaced every three months. 5.5.3 Recording and reporting

The store section maintains records of all the supplies and logistics and for systematic flow of information, store section follows Logistics Management Information System (LMIS) which, it submits the details to the regional center and to the Logistics Management Division under DoHS. The PHCs, HPs P a g e | 20

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

and SHPs also submit logistics report at the end of every three months following LMIS‐5.

6. HEALTH PROGRAMS BY DHO IN THE DISTRICT 6.1 Family planning The National Health Policy (1991) related to National FP Program aims to provide sustained, adequate and quality FP services to the community level through all health facilities: hospitals, PHCs, HPs, SHPs, PHC‐ORC mobile Voluntary Sugical Contraception (VSC) camps. 6.1.1 Objectives

To assist individuals and couples to: 1. space and/or limit their children 2. prevent unwanted pregnancies 3. improve their overall reproductive health 6.1.2 Targets

Periodic and Long‐term targets for the FPP are as follows: 1. TFR‐ Reduce TFR to 3.5 children per women by the end of 10th five year plan. 2. CPR‐ Increase CPR to 47% by the end of 10th five year plan. 3. FP conitnuing users‐ estimated 2,293,000 couples be using modern contraception by 2017.

FP services are provided at various peripheral health centres as well as maternal and child health clinic at DHO. 6.1.3 Services available for FP

a) At the level of district hospital ‐ all temporary and permanent methods of FP are available at district hospital level. b) At HP and PHC level ‐ all the temporary methods of contraception including Norplant and IUCD are provided by all PHCs and HPs. c) At VDC level ‐ The SHPs provide only Depo, pills and condoms as temporary methods of contraception.

P a g e | 21

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

6.1.4 Outcome of the FP programs implemented by the DHO for the FY 2061/62 and 2062/63 Indicators 1. Numbers of current users Pills Depo IUD NP 2. CYP

Achievement 061/062 799 4266 247 46 1067

062/063 886 4473 252 64 1214

6.2 Safe motherhood The National Safe Motherhood Program aims to reduce maternal and neonatal mortality by addressing high rates of death and disability caused by complications of pregnancy and childbirth. It has recognised every pregnancy to be at risk. 6.2.1 Objectives

To reduce mortality and morbidity among women and new borns during pregnancy, childbirth and postnatal period by combination of health and non‐health related measures. 6.2.2 Targets 1. 2. 3. 4.

To reduce MMR to 300 per 100,000 live births by the end of tenth five year plan. To reduce NMR to 32 per 1,000 live births by tenth five year plan. To increase delivery by health workers to 22% by the end of tenth five year plan. To increase percentage of women attending ANC care (minimum of four times) to 25 by the end of tenth five year plan.

6.2.3 Status of the safe motherhood program Indicators

Achievement 061/062 062/063

1. Expected Pregnancy 2. ANC visit as % of expected pregnancy (adolescent) 3. ANC visit as % of expected pregnancy (all new) 4. % of women with 4 ANC visits among new cases 5. Total ANC visits (New+Old, <20 and >20 years) 6. Average numbers of ANC visits

10162 1550

10384 1481

% of achievement 061/062 062/06 3 3.3 3.3 15.25 14.2

4895 2500 10114 2.11

5338 2645 11335 2.12

48.16 51.07 ‐ ‐

P a g e | 22

51.40 49.55 ‐ ‐

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

6.3 Child Health Programs (CHP) The National Health Policy (1991) incorporates the following four heads under the section of CHP. 6.3.1 Expanded Programme on Immunization It is a priority program of Nepal Government implemented in all 75 districts in order to reduce the infant and child morbidity and mortality through vaccination against vaccine‐preventable diseases viz. BCG, OPV3, DPT3, Hep B and Measles. 6.3.1.1 Objectives 1. 2. 3. 4. 5. 6.

Achieve sustain vaccine coverage >90% in national level with >80% in all districts. strengthen and sustain vaccine and logistics management. maintain polio‐free status. eliminate maternal and neonatal tetanus by 2005 and sustain. reduce measles mortality by 50% from 2003 level. introduce new vaccines into EPI. 6.3.1.2 Targets

All infants (under one year of age) for BCG, DPT, OPV, Hep B and measles vaccines and all pregnant women for TT2+. Routine immunization under EPI (incl. HepB) is achieved by monthly vaccination program in all VDCs through immunization centres. There are altogether 286 PHC‐ORC (3‐5 in each VDCs). The VHW, MCHW as well as the secretary of the respective VDCs are called on for training programs on regular basis and micro‐planning projects are implemented with the help and support from the community people on regular basis. The VDCs are divided in different groups and the immunization schedule is made accordingly. The MCH clinic in the district hospital also provides immunization service every tuesdays. 6.3.1.3 Outcome of EPI Programs/Activities DPT III Polio III Measles Hep‐B III BCG

P a g e | 23

Units Nos. Nos. Nos. Nos. Nos.

Targets 061/062 9240 9240 9240 9240 9240

Achieved 062/063 061/062 9268 6849 9268 6810 9268 6322 9268 NA 9268 7211

% of Achievement 062/063 061/062 062/063 6801 74.12 73.38 6801 73.70 73.38 6829 73.90 73.68 6801 ‐ 73.38 7000 78.04 75.52

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

6.3.2 Nutrition program Malnutrition remains a serious obstacle to child survival, growth and development in Nepal, the most common form of malnutrition being PEM, micronutrient deficiency (iron, iodine and vit A deficiency). 6.3.2.1 Objectives 1. control of PEM 2. control of IDD 3. control of vit A disorders 4. control of anaemia 5. control of Low Birth Weight (LBW) 6. protection and promotion of breast feeding 6.3.2.2 Targets 1. To reduce severe and moderate malnutrition among children under three years of age at 40% by 2007. 2. To reduce iron deficiency anaemia in pregnant women to 58% by 2007. 3. To reduce subclinical vit A deficiency among children under 5 years of age to 19% by 2007. 4. To reduce nutritional blindness by vit A deficiency among pregnant women to 3% by 2007. The DHO, Gorkha district conducts regular programs and mass campaigns of Vit A supplementation as set by the Nepal Government. Also it regularly conducts awareness programs on Breast Feeding Week (1st to 7th of every August). Health workers like FCHVs, MCHWs give education to mothers about the importance of exclusive breast feeding. There is also provision of providing iron tablets to every pregnant woman after 4 months of pregnancy. 6.3.2.3 Outcome of nutrition program Programs/Activities New Growth Monitoring Total Growth Monitoring (Avg. nos. of visits) PP treated with vitA Iron tablets distributed to pregnant mothers

P a g e | 24

Targets Achieved 061/062 062/063 061/062 23486 26643 12579

% of Achievement 062/063 061/062 062/063 13667 53.55 51.29

‐

1.73

‐

NA NA

NA 9146

3657 NA

4137 6535

‐ NA

‐ 71.45

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

6.3.3 Control of Diarrhoeal Diseases (CDD) The DHO carries various programs and trainings at different level to achieve an optimum control of diarrhoeal diseases, the status of which is reflected by the following indicators. Indicators Achievement 061/062 062/063 New Total Cases 11388 10385 % of Severe dehydration 376 (3.30%) 105 (1.01%) Treatment by ORS 10193 (89.51%) 8979 (86.46%) 6.4

Disease control programs

6.4.1 Tuberculosis The National TB program (NTP) and DOTS activities have expanded through the Gorkha District. It is available in five treatment centers and forty two sub‐centers. Hundred percent of the district population has now access to treatment. The treatment success rate is 86%. Gorkha has the Case finding rate of 63.2%. TB program in Gorkha, more or less like in other Districts, also conducts TB awareness programs in the district among the traditional healers, school children, FCHV and other groups. The DTLA stated that the traditional healers were in fact co‐operative when they were counseled that they themselves can acquire the infection during their ‘Phuk phak’ process and hence were convinced in sending a person with signs and symptoms of TB to DOTS centre. 6.4.1.1 Status of the program in 2062/063 PROGRAM/ACTIVITIES 1.Suspected sputum examination 2.New smear examination 3.Follow up sputum 4.New smear +ve 5.New smear ‐ve 6.Extra pulmonary TB

P a g e | 25

UNITS Nos.

TARGET 1200

ACHIEVED 1185

% ACHIEVED 98.75

Nos.

3600

3528

Nos. Nos. Nos. Nos.

534 120 72 48

493 119 57 54

92.32 99.16 79.16 112.5

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

6.4.1.2 Outcome of the program in the district INDICATORS 1.DOTS Coverage w.r.t. population 2.Case detection rate 3.T/t success rate 4.Sputum conversion rate 5.T/t completion rate

061/062 100%

062/063 100%

73% 79.65% 84 81

63.2% 86% NA NA

6.4.2 Leprosy Leprosy is still a major infectious disease in our part of world while most of the countries of world have eliminated it (prevalence rate < 1/1000 population). However, the prevalence rate of leprosy in Gorkha is 0.89/10,000 population. The new case detection rate is 0.89/10,000. The lack of awareness and the still prevalent conservative stigma of leprosy continue to hide the disease especially in the less exposed areas and the higher hilly region of the district. 6.4.2.1 Status of the program in 2062/63 PROGRAM/ACTIVITIES UNITS 1.Rapid inquiry VDC 2. School health School education 3. Supervision & Times Monitoring 6.4.2.2 Outcome of the program

TARGET 5 12

ACHIEVED 5 12

% ACHIEVED 100% 100%

93%

OUTCOMES OF THE PROGRAM 1.New case detection rate 2.Prevelance rate 3.Defaulter 4.Prevelance 5.Grade II disability among new cases

061/062 0.45 0.91 0 28 6.6

062/063 0.47 0.89 0 28 0

6.4.3 Malaria Malaria is a disease commonly seen in Terai. However Gorkha is also one of the 65 hilly districts of Nepal considered at risk of malaria. There is no provision for active case detection in the district except at times of epidemics. 6.5 Other programs P a g e | 26

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

6.5.1 HIV/AIDS Following programs are done by DHO 1. HIV/AIDS day celebration on Dec. 1 every year. 2. School health programs 50 times in a year. 3. District level HIV/AIDS review workshop once. o For the next year, DHO plans to do following programs: 1. HIV/AIDS day celebration. 2. School health program, 500 times. 3. Meeting of district AIDS coordination committee – 2 times.

6.5.2 IMCI IMCI was started this year in Gorkha. It has done following programs since starting of this program: 1. Training of trainers program. 2. IMCI training for health workers. 6.6 Health promotion Such a section doesn’t exist in its active form in DHO, though it should have existed by rule.

6.7 Training and HIEC Following trainings were carried out by DHO in the year 062/063 1) FCHVs refresher review training – 4 monthly 2) Orientation for health workers on FCHV program – once 3) TBA review, refresher, supervision, meeting 4) IMCI training for trainers, health workers

PROGRAMS/ACTIVITIES 1. Health education (H.E.) information center improvement 2. Review & planning of the H.E. programs. 3. H.E. exhibition 4. Education materials 5. School health programs 6. Health education corner 7. Health promotion interaction 8. Street plays 9. Cinemas, slide show, advertisement 10. Gender sensitization workshop 11. Health information on newspaper 12. Digital radio listeners club

P a g e | 27

UNITS District

TARGET 1

ACHIEVED 1

% ACHIEVED 100

Times

100

Times Pieces Times Days Times Times Times

3 20,000 200 280 18 15 438

3 20,000 200 221 18 15 406

100 100 100 78.92 100 100 92.69

Times

100

Times

100

District

100

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

7. GORKHA DISTRICT HOSPITAL 7.1 Introduction Gorkha District Hospital, the first hospital of Gorkha District, was established in 2029 B.S. Situated in Prithvi Narayan Municipality‐3, it occupies about nineteen ropanis of land. It is a fifteen bedded hospital with a staff of around twenty people. The hospital has been providing emergency, OPD, Indoor, Maternal and Child Health (MCH), Family Planning (FP), Post mortem, laboratory and radiological services to the people of Gorkha. The hospital comes under the Western Regional Health Directorate. Government of Nepal Ministry of Health and Population Department of Health Services (DoHS) Western Regional Health Directorate District Health Office, Gorkha Gorkha District Hospital 7.2 Hospital development and support committee The hospital development / support committee has been established with the aim to assist the hospital in maintaining its services by involving the community and mobilizing the local resources. It is an independent body which plays an important role in planning, implementation and evaluation of various activities of the hospital. 7.2.1 Members The hospital development / support committee consists of 9 members. It is headed by a chairman selected by other members of the committee. The structure of the committee is as follows:‐ 1. Chairperson 2. Member Secretary: medical superintendent of Gorkha District Hospital. A DHO(whoever is senior) 3. Representative from District Administrative Office. 4. Representative from District Development Committee 5. Chief of Municipality office 6. Representative from district chamber of commerce and finance 7. Representative district red cross society P a g e | 28

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

8. Female representative of the ward‐3 9. Indoor incharge of the hospital The chairperson of the current body is Mr. Badri Bahadur Maskey 7.2.2 Activities The hospital development / support committee meets every three months or earlier when necessary to discuss and monitor activities of the hospital and to recommend improvement required in the services. The hospital development / support committee has its own budget formed by the income from various services provided by the hospital and which is used for improvement of hospital infrastructure and services. Also the proposed expenses for a fiscal year by the hospital has first to be approved by the committee before being implemented. The hospital development / support committee through its own resources has been fulfilling the lacking manpower in the hospital. 7.3 Human resource management The hospital itself has a total of 23 staffs. Since, the district health office (DHO) also contributes to the management of the hospital, many staffs from the DHO have been posted at the hospital. Also, few staffs have been provided by the hospital development / support committee. The overall staffing pattern is( including staff from DHO posted at hospital and staff from Hospital development/support committee).

P a g e | 29

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

Human Resource Management Medical Superintendent

Technical Staff

Administrative Staff

Medical Officer ‐3

Health Assistant ‐ 1

Staff Nurse 4

Radiograph er‐1

AHW ‐ 3

ANM ‐4

Lab Assistant ‐ 3

Driver ‐ 1

P a g e | 30

Peon ‐ 14

Lab Technician‐ 1

Nayab Subba ‐ 1

2063

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

7.3.1 Staffing

7.3.1.1 Staff of Gorkha District Hospital S.NO

Post Title

Level

Medical Superintendent Medical Officer Staff Nurse Health Assistant Radiographer Nayab Subba Lab Assistant

Ninth

2. 3. 4. 5. 6. 7. 8. 9. 10.

Auxiliary Nurse Midwife (ANM) Auxiliary Health Worker (AHW) Peon

Seventh Asst. fifth Asst. fifth Asst. fifth Asst. fifth Asst. fourth Asst. fourth Asst. fourth ‐

Gazetted/Non‐ Gazetted Gazetted

Sanctioned

Gazetted Non‐Gazetted Non‐Gazetted Non‐Gazetted Non‐Gazetted Non‐Gazetted

2 3 1 1 1 1

2 3 1 0 1 1

0 0 0 1 0 0

1 2 0 0 0 0

Non‐Gazetted

‐

0 0

Fulfilled Vacant On education leave 0 1 ‐

7.3.1.2 Staff from DHO working at Gorkha District Hospital S.NO Post Title Level 1 Medical Officer Seventh 2. Staff Nurse Asst. fifth 3. Lab technician Asst. fifth 4. Lab Assistant Asst. fourth 5. ANM Asst. fourth 6. Auxiliary Health Worker (AHW) Asst. fourth 7. Peon ‐

Gazetted/Non‐Gazetted Gazetted Non‐Gazetted Non‐Gazetted Non‐Gazetted Non‐Gazetted Non‐Gazetted ‐

Number 1 1 1 2 1 2 1

7.3.1.3 Staff appointed by hospital development and support committee S.NO 1. 2. 3.

Post Title ANM Driver Peon

Number 1 1 4

7.3.2 Medical Superintendent and District Health Officer Currently, the posted District Health Officer, Mr. Achyut Lamichhane, also looks after the management of the hospital. The trend is that amongst the staffs of Gorkha District Hospital and District Health Office, whoever is the senior most in terms of rank, will look after the management of both the hospital and District Health Office. P a g e | 31

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

7.4 Financial resource management

Hospital has following financial resources:

1. 2. 3. 4.

Government budget Assistance from Shinyo‐yen, Japan Ambulance OPD /x‐ray and lab charge.

7.4.1 Budgeting The financial management of Gorkha district hospital is divided into budgets of NG and budget under HDC. The budget is divided into respective hands and the expenditure is carried out accordingly. The budgeting process is divided into: 7.4.1.1 Budget Release The NG’s budget is released monthly. In the beginning of each fiscal year, the approved budget description is sent to the account section of DHO Gorkha from Ministry of finance (MOF). 7.4.1.2 Budget of Fiscal Year 2063/2064 under Ministry of Health Under the budget sub‐heading number 70‐3‐150 , Gorkha District Hospital has been allocated a sum of rupees thirty one lakh and thirty thousand for the fiscal year 2063/2064 B.S. The sum has been divided under following budget heads:

Budget Head No.

Budget Head

Amount

1.01 1.02 1.03

Salary Allowance(Bhatta) Transfer, Travelling Expenses and Daily Allowance Uniform Drinking Water and Electricity Tariff Office Expenses Maintenance Fuel and Related Social Services Subsidy Drugs

2,400,000.00 2,40,000.00 4,000.00

1.04 2.01 2.03 2.05 2.06 3.03 4.02

18,000.00 40,000.00 30,000.00 1,500.00 3,500.00 2,75,000.00 1,25,000.00

7.4.1.3 Budget of fiscal year 063/064 under hospital development and support committee The hospital development/support committee generates income from the service charge of various services provided in the hospital. Additional sources of income include the drug shops it has given on rent and interest from its previous funds. The expenditure headings include salary of staffs P a g e | 32

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

under it, sterilization fuel, maintenance expenses, purchase of medicine and equipments. The total income estimated for the year 063/064 is Rs. 17,12,504.28 and the estimated expense is 13,81,132.00. Hence the committee aims to generate an income of Rs. 3,31,372.28 this year which can be used the following year for development and maintenance of the hospital. 7.4.1.4 Budget for Ambulance Services The hospital development/support committee has established a separate fund for smooth functioning of ambulance services provided by the hospital. The income generated from the ambulance is used for the maintenance and fuel of the ambulance. Also, the driver of the ambulance, appointed by the committee, gets his salary from this fund. In fiscal year 062/063, the ambulance services generated a net profit of Rs. 3,12,738.25. The proposed income and expenses for this year is: Income: Expenses: Savings:

Rs. 8,12,738.25 Rs. 5,17,000.00 Rs. 2,95,738.25

7.5 Services provided by Gorkha District Hospital 1. Emergency service 2. OPD service 3. IPD service 4. X‐ray 5. Laboratory services 6. FP/MCH (Institutional clinic) 7. Minor operations Gorkha hospital has served for only around 4‐5% of total population of the district. In the hospital though average length of stay was in decreasing trend, bed occupancy rate was in increasing trend for the three years. Similarly percentage of female patients was in decreasing trend for the last year 2062/63. 7.5.1 Performance indicator of Gorkha Hospital S.N 1 2 3 4. 5 6 7

Performance indicators Total OPD visit as % of total population Average length of stay Bed occupancy rate Delivery conducted as of expected pregnancy (%) Death rate among discharged patient % of female patient Bed turnover interval

P a g e | 33

2060/61 4.4

2061/62 5

2062/63 4

2 days 51.6 2.2

1.9 days 66.2 2.6

1.6 days 67 2.8

1.6

1.0

0.7

62.12 1.9 days

64.37 1 days

60.59 0.7

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

7.6 Morbidity status

7.6.1 Top ten diseases

Rank

Disease‐DHO

Hospital

National

1 2 3 4 5 6 7 8 9 10

ARI Skin Intestinal worms Diarrheal diseases Gastritis PUO COPD Ear infection Sore/ eye complaints Pain abdomen

ARI Skin Fall/Injuries Gastritis Diarrheal diseases Enteric fever Intestinal worm UTI RTI Toothache/other mouth complaints

Skin disease ARI Diarrheal diseases Intestinal worms Gastritis Pyrexia Ear infection Chronic bronchitis Sore/eye complain Toothache

The foremost causes of OPD visit was found to be ARI in the district both in hospital and DHO whereas it is skin disease in the national level. 7.6.2 Top 5 In‐door diseases for the FY (2062/63)

Disease

Percentage

Enteric fever

27.41

Diarrheal disease

21.68

ARI

17.53

Gastritis

17.43

Falls/injury/fracture

15.94

7.6.3 Seasonal trends of diseases When the disease pattern was analyzed as per season, it was found that the maximum numbers of cases were found to be reported in the Jyestha, followed by Asad, Shrawan and Bhadra in the year 2062/63. Similarly it was minimum in the Poush followed by Magh and Falgun.

P a g e | 34

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

2060/61

2061/62

d As ha

M ag h Fa lg un Ch ai tra Ba isa kh Jy es th a

Po us

gs ir

ik M

ar t

As wi

dr Bh a

ra Sh

S easonal trend in OPD

1800 1600 1400 1200 1000 800 600 400 200 0 wa n

No.s of cases

2062/63

7.7 Medico legal aspect In the district maximum numbers of medico‐legal cases were found to be of asphyxia followed by cerebral failure. Causes

Male

Female

Total

Asphyxia Cerebral failure Poisoning

7 5 2

9 1 0

16 6 2

CPA (Cardio‐Pulmonary Arrest) Gun‐shot Hypovolemic shock Total

1 1 1 17

1 0 0 11

2 1 1 28

8. OTHER HEALTH CARE CENTERS IN THE DISTRICT 8.1 PHCs There are 3 PHC in the district. They are located in: 1. Arughat PHC 2. Makaisingh PHC 3. Jaubari PHC 8.1.1 Makaisingh PHC Situated in the hill top across the Trishuli river in Kurintar Makaisingh PHC is a 4 and half hour bus ride from the district headquarter which is some 24 kms in length of rural road. It comprises well P a g e | 35

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

built and well furnished two buildings one each for indoor and OPD services with staff quarters just by the side. The rooms are spacious and adequate as a Primary Health Care Center. 8.1.1.1 Infrastructure The PHC owns two well furnished buildings one each for Indoor service and OPD services. a) Indoor‐ consists of wards (Male, Female), Copper T/NP room, Store, Delivery room (with two beds and one delivery table) b) OPD‐ consists of 8 rooms (Dressing, Lab, OPD room, Pregnacy test room, office‐2 rooms, cold room and store) The PHC also has separate quarter for doctor and two other buildings as staff quarters. 8.1.1.2 Services

Treatment Service‐ Daily OPD Service‐ Daily Emergency Service‐ 24 hours Lab Facilities‐ Daily Tuberculosis Treatment‐ Daily Leprosy Treatment‐ Daily Malaria Treatment‐ Daily Nutrition Program‐ Daily ORT Corner Immunization Service‐ Once a month, every 6th day of Nepali month. ARI Treatment‐ Daily Family Planning Service‐ Daily o Counseling o Condom, Pills distribution o Nor‐plant o IUD Safe Motherhood Program‐ every week Monday and Thursday 8.1.1.3 Charges

Services 1. Sputum (Malaria) 2. Blood TC, DC, ESR, Hb 3. Blood Sugar 4. Blood Urea 5. Stool RE/ME 6. Urine RE/ME 7. Pregnancy Test

P a g e | 36

Charge (NRs.) Free 10 for each 50 50 10 10 100

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

8.1.1.4 Logistics management The drugs required by PHC only are received and a stock level is maintained minimum of one month and maximum of five months (Contraceptives, TB and Leprosy drugs). Reporting is done to the district level every 3 months following LMIS. The emergency order point (EOP) is of one month and Authorised Stock Level is maintained of five months. 8.1.1.5 Catchment area

The VDC covered by the PHC are:

1. Makaisingh 2. Tanglichok 3. Ghumlichok 4. Darbung 5. Fujel 6. Mankamana 7. Ghyalchok 8. Ghairung 9. Takling The total population falling under the catch up are of Makaisingh PHC is estimated to be approximately 46, 306. 8.1.1.6 Reporting The village health workers (VHW). Maternal and Child Health Workers (MCHW) need to submit their report of the month by the 3rd of every month of Nepali calendar. The PHC submits the report to the district level by the end of 7th day of every month of Nepali calendar which should reach the district not late than 10th day of the month. 8.2 HPs There are 10 HP in the district. 8.2.1 Bungkot HP 8.2.1.1 Services 1. Treatment which includes a. b. c. d.

daily health check up daily treatment of mental illnesses free distribution of medicines available in the health post. Referral 2. Family Planning a. Counseling P a g e | 37

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

b. Distribution of temporary methods of contraception like pills, condoms, depo, etc. 3. Nutrition Program a. Nutrition education b. Keeping weight of child c. Treatment/referral of malnourished child/mother d. Distribution of Vit A and Iron tablets 4. Control of Diarrhoeal diseases a. Treatment/referral b. Education 5. Acute Respiratory illness a. Treatment/referral according to condition 6. Malaria and Kalazar a. Collection of blood samples/sending for examination b. Treatment according to guidelines 7. Immunization Program a. Education b. Program 8. Tuberculosis a. Collect the sputum samples of suspected cases b. Treat the confirmed cases according to DOTS guidelines 9. Leprosy a. Treatment and prevention 10. Safe Motherhood a. Examination of pregnant women b. Health education regarding safe motherhood. c. Distribution of iron tablets during pregnancy, albendazole distribution and provision of Vit A to women within 6 weeks of delivery. 11. AIDS/STD a. Treatment/referral of AIDS or STD suspected cases

P a g e | 38

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

12. Health Education a. Environmental health education b. Personal hygiene and cleanliness c. Encouraging the construction and use of toilets in the area. 8.2.1.2 Infrastructure

The Bungkot HP is situated at a distance of nearly 10 kms from the district headquarter and is a 2 hour bus ride. It has got a single storeyed building with nine rooms which are distributed accordingly: Store‐2, OPD‐1, Medicine Distribution room/Ticket Counter‐1, ANC‐1, Observation‐1, Delivery room‐1, Dressing room‐1, Administration‐1. The rooms are spacious and cleanliness is maintained to the best possible at the outset. 8.2.1.3 Staffing Pattern

The following are the staffs allocated for the Bungkot HP 1. 2. 3. 4. 5.

HA‐1 AHW‐1 ANM‐1 VHW‐1 Peon‐2

8.2.1.4 Coverage

The following VDCs with a total population of 8,325 are covered by the Bungkot HP: Namjung, Borlang, Asrang, Finam, Raniswara, Nareswar 8.2.1.5 Logistics

The HP maintains an Authorised Stock Level of 5 months for the following:

Logistics related to FP and Nutrition. Essential drugs are received directly from the district health office once a year. There is no refrigerator in the HP so vaccines for immunization campaigns are received once every month. According to the HP incharge, the distribution of drugs from KFW takes place in public so as to maintain transparency. In the store room when visited, the drugs for mental illnesses were expired. 8.3 SHPs There are 55 SHPs in the district.

P a g e | 39

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

8.4 Lions Eye Care Center Among very few non‐governmental organizations providing health care service in Gorkha district, Lions Eye Care Centre is a major one. It was established in 2nd of Baisakh, 2061 under the technical assistance of Himalayan Eye Hospital, Pokhara and is proposed to be handed over to the Lions Club within the next two years. It is staffed by an eye care specialist and 2 staffs for handling of instruments. Though located in the district headquarter it also provides eye care to the people of Bungkot, Khoplan, Namjung, Fujel, Mudchok, Mirkot and Finam VDCs.

It has got a daily patient flow rate of 20‐22 persons. 8.4.1 Costs

Ticket Fee‐ Rs. 20

Investigations‐ Free

Minor Surgery‐ Rs. 75/Rs. 150 8.4.2 Services towards the Community A. Training Programs in technical support of Himalayan Eye Hospital, Pokhara a. To HW of 66 VDCs (HP and SHP incharges) b. To the school teachers (To the health teacher of every school located within the municipality) c. To the drug retailers

B. Eye Camps a. Conducted once every 2 months in the clinic itself b. Screening camps conducted in Harmi, Ghyalchok, Batase and Bungkot whereas surgical camp was conducted at Bhachchek VDC. c. The Center conducted 12 mobile health camps and 25 eye camps in the fiscal year 62/63 8.5 Primary Health Care‐ Out Reach Clinic (PHC‐ORC) There are 286 PHC‐ORC in the district. Also known as “Gaunghar Clinics” these are carried out to make the basic health services available at the door steps. The PHC‐ORC are usually run by VHW,MCHW once in the month on a fixed date. It provides the following services: 1. 2. 3. 4. 5. 6.

FP services & advice Pregnancy test & advice Health education Basic treatment FCHV training F/U meeting

P a g e | 40

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

9. COLD CHAIN SYSTEM

The cold chain room of DHO, Gorkha is furnished with four freezes of which one defreezer and two refrigerators are functioning at present. It also has one generator (kerosene fueled) and one preparation table. Vaccines to be preserved in cold chain room are of two types: 1) Heat sensitive‐ Polio, Measles‐ maintained at ‐15 to ‐25 degree celsius in defreeze.

2) Cold sensitive‐ maintained at +2 to +8 degree celsius.

Ice pack conditioning is done to send these two types of vaccine in the same box to the periphery though they are received in 'carriers' called 'igloo' with half litre capacity from Regional Cold Chain Store in Pokhara. 9.1 Ice pack conditioning ‐ 15 to 25 packs of ice are placed in preparation table and waited for sometime (15‐20 mins) after which the part of water and ice separated and it is given a sticker of 'conditioned'. 9.2 Cold chain boxes

Vaccines are supplied in Cold Chain boxes of which there are two types.

i) Luxemburg‐ containing 44 ice packs

ii) CB‐ 55/36‐ containing 36 ice packs (24 along with vaccines) 9.3 Route of Supply

P a g e | 41

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

DISTRICT COLD ROOM SUB‐CENTRES IN PHCS -

3 in numbers supplied with one defreezer and one refrigerator only Makaisingh PHC has electricity

REFRIGERATOR CENTRES IN AAP PIPAL (HOSPITAL), MANBU (HP) AND SRIDIVAS (SHP)

3 in numbers only Aap pipal has electricity.

SUPPLY CENTRES -

5 in numbers Machhekhola, Bhachchek, Takumajh, Baddada and Bungkot VDCs.

HEALTH POSTS

IMMUNIZATIONS CENTRES

P a g e | 42

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

For efficient coverage of immunization program, the district of Gorkha is divided in four groups: Group A ‐Immunization program on first week of every month (Nepali calendar). ‐ 1st to 8th of Nepali month. ‐ Bungkot, Makaisingh, Dhuwakot, Gumda and Manbu.

Group B ‐ Immunization programs on second week of every month (Nepali calendar). ‐ 9th to 15th of Nepali month. ‐ Taku, Bhachchek and Jaubari.

Group C ‐From 20th to 26th of every month (Nepali calendar). ‐ 3rd week of Nepali month. ‐ Khachok and Aruchanaute.

Group D ‐Immunization program conducted only 6 months in a year. ‐ Baisakh to Asadh and Bhadra to Mangsir of every Nepali year.

Vaccines are carried in cold chain boxes to the respective VDCs just before the immunization days and distributed in cold boxes to the EPI clinics where immunization is done.

P a g e | 43

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

1. OVERVIEW The safe motherhood program of Government of Nepal aims to decrease maternal mortality and morbidity by standardizing basic maternity care and emergency obstetric care at appropriate levels of the health care system. Delivery services is one of the most important services provided in the district hospital as all the cases within the district requiring referral arrive here first. Hence, it is essential that the quality of services provided here should be of optimum standard. If delivery cases have to be referred out of the district, it can result in delay in reaching and receiving care which can have grave consequences. Also, many women may not have resources to seek care in other districts. In Gorkha District Hospital, a total of 131 delivery cases reported in the first five months of fiscal year 063/064, the details of which are shown in the table below: Number Total number of cases reported at hospital 131 Number of referred cases 31 Number of deliveries conducted 100 Number of episiotomy 4 Number of instrumental deliveries 0

2. RATIONALE 1. During our review of records of first five months of fiscal year 063/064 (till mangsir), we found that 31 (24%) cases out of total 131 cases reported at the hospital for delivery were referred out. This means that about one‐fourth of the cases had to seek care outside the district and hence delay in reaching and receiving care could have occurred. Also the issue of resources for these women remains. 2. Of the 1004 women who came for first Ante Natal Checkup (ANC) visit in the hospital, only 286 (28.48%) came for delivery in the hospital in fiscal year 062/063. Our interview with some women coming for ANC visit to the hospital revealed that they were not willing to deliver their baby at Gorkha District Hospital (GDH). The main reason cited was that the services in Gorkha District Hospital was not good.

P a g e | 44

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

3. Of the total delivery, 15% require instrumental assistance. In GDH, no instrumental delivery was conducted in the last two fiscal year in spite of having the instruments and trained manpower to use them. This means that the cases requiring instruments are being referred out and there is underutilization of resources. 4. Our observation also revealed that the delivery services were not up to the mark and there was room for improvement. Hence, we carried out an analysis on why there was large number of referrals, underutilization of resources and poor quality of service.

3.OBJECTIVES 3.1 General objectives To evaluate the current delivery services of Gorkha District Hospital and critically review the findings. 3.2 Specific objectives 1. To identify the infrastructure for delivery services in GDH. 2. To evaluate and analyze the logistics, human resources, procedure and recording of delivery services in GDH. 3. To evaluate the quality in terms of its strength and weaknesses of delivery services by comparing it with a standard. 4. To identify the problems faced in management and delivery of delivery services in GDH. 5. To give necessary practical recommendations so as to aid in the improvement of the delivery services in GDH.

4. METHODOLOGY 1. Literature review 2. Observation 3. Interview with ‐ Doctor ‐ Staff Nurse ‐ ANM ‐ Pregnant women 4. Secondary data analysis

P a g e | 45

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

5. PROBLEM TREE High number of women seeking delivery services outside the district

High number of referrals.

Women going out on their own for better care

E C

Inadequate facilities and low quality services.

FOCAL PROBLEM

Lack of physical Infrastructure

Unavailability of trained staff

Delivery procedure not according to standard

Inadequate counseling

Lack or under utilization of logistics.

A U S E

Additional help/Doctor may be unavailable

Inadequate space in the procedure and waiting room

P a g e | 46

Improper recording of procedure.

Single person on duty/no system of on call

Hygiene not properly maintained

Radiant warmer out of order.

No counseling on breast feeding & newborn

Insufficient number of beds in procedure and waiting room

Vaccum and forceps are not being used.

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

6. FINDINGS AND COMPARISIONS 6.1 Physical facilities There is one procedure room and one waiting room for delivery. The procedure room in the hospital is very small. The space is enough only for one health worker to work at a time. Hence, even if an assistant is available, he/she can’t be of much use. The room doesn’t have enough natural light and ventilation. 6.2 Logistics There is one delivery table and one neonatal table in the procedure room and a single bed in the waiting room. Since this fulfills the need of only one delivery at a time, any pregnant woman who arrived for delivery while a delivery is being conducted has to be referred. It also had a weighing machine, suction machine, radiant warmer and oxygen cylinder for the baby. For the protection of the health worker, there are boots and aprons. There is also a safety box for disposal of sharps and a basin for washing hands. Comparison with standard has been given below: Standard* Sphygmomanometer Stethoscope Baby Weighing Scale Fetal Stethoscope Instrument Sterilizer Dressing forceps (Stainless steel) Kidney basins (Stainless steel Sponge bowls (Stainless steel Thermometer Hand brush Heat source Syringe and needles Suture materials Catheters Adult ventilator mask and bag Mouth gag Surgical gloves Scissors Artery forceps ‐1 Blunt end scissor ‐2 Cord ties ‐2 Sponge forceps‐1 Needle holder‐1 Stitch Scissor ‐1 Dissecting forcep ‐1 Vaginal speculum large and small Mucus extractor Neonatal face mask Ventilatory bag Suction catheter Suction apparatus‐ foot operated or electrical Infant laryngoscope with spare bulb and batteries.

P a g e | 47

Gorkha District Hospital Present Present Present Present Main sterilizer (autoclave) is used Present Present Present Present Not present in procedure room. No external heat source Present Present Patient party has to bring from outside if needed Present Present Present Present Present Absent Present Present Present Present Absent Only large speculum present Present Present Present Present Present Absent

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

Endo‐tracheal tubes Absent Vacuum extractor Present Obstetrics forceps Present Fetal heart rate monitor Present *WHO. Mother Baby Package: Implementing Safe motherhood in countries. Geneva: Maternal and Family health Program, Division of family health, WHO.

As it can be seen from the table, most of the necessary logistics are available. However, some life saving logistics like Infant laryngoscope and Endo‐tracheal tube for infants are not present. Some necessary logistics like catheter has to be brought by the patient party from medical shops outside, if required. 6.3 Staffing Among the trained hospital staffs involved in conducting delivery, the post of a medical officer is vacant, two staff nurses are on educational leave and one Auxiliary Nurse Midwife (ANM) has been appointed by the Hospital Development Committee. The indoor on duty staff nurse or ANM is the only one who is involved in conducting delivery. Since there is no system of on call, she cannot expect help from other staff nurses or ANMs. However, she can call the doctor, if available, for any complications. 6.4 Procedure

6.4.1 Care during labour Standard* Taking and recording temperature, pulse and blood pressure at regular intervals (4 Hourly) Fetal well being assessment: Amniotic fluid assessment Fetal heart rate monitoring

Infection prevention: Clean environment. Hand Washing by the service provider Use of clean instruments. Use of gloves during vaginal examination, during delivery of the infant, and in handling the placenta. Care with the use and disposal of sharp instrument Procedure: Monitoring throughout the labour Administration of oxytocin if required. P a g e | 48

Gorkha District Hospital Since, partograph is not filled, these procedures are not done at regular intervals.

Done clinically A monitor exists and is used. However, since partograph is not filled, this is not done at regular intervals. After each delivery, the room is cleaned. Although handwashing is practised, it is not according to standard technique. Clean delivery kit is used and all other instruments required are sterilized. Done

Staffs are very careful in handling the sharp instruments. Done Although, administration of oxytocin is practised,

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

Guarding the perineum during 2nd stage Repair of third degree perineal tear by a doctor.

Prophylactic use of ergometrine Controlled cord traction Placental examination after delivery of placenta Observation of mother after delivery

they have been used even when not required to accelerate the labour. Done. All types of perineal tear are repaired by the on duty staff. They say, doctors are not to be ‘disturbed’ for it. Not done. Done Done After delivery, mothers are shifted to indoor and monitored for a minimum of six hours before discharge.

*WHO. Mother Baby Package:Implementing Safe motherhood in countries. Geneva: Maternal and Family health Program, Division of family health, WHO.

6.4.2 Essential newborn care Standard# Cleanliness, clean delivery and Clean delivery: cord care Clean hands, perineum, surface, cutting, ties Nothing applied to the cord stump Thermal protection Warm place of birth Dry the baby with warm cloth Provide warm environment by skin‐to‐skin or wrapping in warm clothes Delay bathing Breast‐feeding

Early and exclusive breast‐feeding within first hour of birth No prelacteal feeds or other fluids, no pacifiers Eye care Clean eyes immediately after birth Initiation of breathing If no cry at birth check for breathing, if no breathing initiate resuscitation: ‐ aspiration of mouth and nose, ventilation: ‐ ventilation by bag and mask at health facility Immunization BCG at birth Management of pre‐term baby, LBW baby and any other illness. #

Gorkha District Hospital Handwashing practice not appropriate.

No external source of heat Done Skin to skin wrapping not done. No counseling for kangaroo mother care. Not appropriately counseled. Early and exclusive breast‐feeding within first hour of birth advised. Not counseled effectively. Done Done

Called on vaccination day. Done accordingly or referred if necessary.

WHO. Mother Baby Package:Implementing Safe motherhood in countries. Geneva: Maternal and Family health Program, Division of family health, WHO.

P a g e | 49

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

6.4.3 Counselling Standard#* Counselling on Breast feeding Counselling on newborn care Counselling on family planning

Gorkha District Hospital Not appropriately done Not appropriately done Not appropriately done

#* Government of Nepal, National Maternal and Neonatal health essential service package, Kathmandu: Family Health Division, Dept. of Health Services, Ministry Of Health and Population. 2006

7. DISCUSSION It can be seen from the tables that most of the procedures, although performed, are not being done in appropriate way. Monitoring of blood pressure, temperature and pulse at regular intervals is vital since it gives clue to many serious maternal conditions such as sepsis or pre‐eclampsia. Also, the handwashing practice is not according to standard. This may lead to infection. Effective counselling of mother on breast feeding, newborn care and family planning was also not done. The physical infrastructure do not meet the requirements as there is inadequate lighting, ventillation and space. Also, it is felt that there is underutilization of the logistics such as vacuum extractor and forceps as they had never been used in the past two fiscal years. Hence, some cases which could have been managed by vacuum or forceps are being referred. The reason behind most of these problems is the staffs’ tendency to finish the delivery as soon as possible as is evidenced by inappropriate use of oxytocin and not filling partograph. They say that since they have to look after the indoor and conduct the delivery at the same time, they are under pressure to finish the delivery faster. Also, doctors may not be available when needed since they are not required to stay in the hospital at all times.

8. RECOMMENDATIONS 1. Establish a system of on‐call so that additional manpower is available on arrival of a case of delivery. The first on‐call should be the nurses and she should be called as an additional manpower whenever a case of delivery arrives. The second on‐call should be the doctor and he should be called in cases of complications or when expert help is needed. They should be kept on rotation basis during off hours and should be available within the hospital premises (All the nurses and doctors have quarters within the hospital premises). 2. The medical officers should see to it that the partograph is filled regularly. They can also provide technical help if the nurses are finding it difficult to fill the partograph. 3. Since, three post of trained health workers for conducting delivery are vacant, they should be fulfilled. This can be done by requesting the ministry or getting additional staff through hospital development/support committee. The existing staffs should be sent for refresher training so that they are more confident in using the available logistics. 4. In long term, Physical infrastructure needs to be improved in such a way that the delivery room is spacious, well ventilated and adequately lighted.

9. CONCLUSION Women coming to GDH for delivery services usually arrive in the late stage and many with complications. Referring such cases to other hospitals outside the district takes longer duration, which P a g e | 50

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

can in turn lead to severe maternal and fetal complications, the gravest being maternal and fetal death. Since, GDH is the referral centre for SHPs, HPs and PHCs in the district, it is essential that the services provided here are of optimum standard. Instead of referring too many cases, GDH should aim to manage most of the cases within the district. For this, improvement in quality of services by proper management of staffs is essential. Since, GDH has the infrastructure for conducting Caesarean section, it should, in long term, try to make use of it.

P a g e | 51

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

ADVERSE REPRODUCTIVE OUTCOMES ASSOCIATED WITH TEENAGE PREGNANCY: A HOSPITAL BASED RETROSPECTIVE COHORT STUDY ABSTRACT Objective To determine whether pregnancy in teenagers is associated with adverse reproductive outcomes. Design Hospital based retrospective cohort study using routine maternity discharge data for a Nepali fiscal year, 2062/63 (2062 Shrawan 1 to 2063 Ashadh 32) Setting Mahendra Adarsha Chikitsalaya, a 170 bedded government hospital in Bharatpur, Chitwan district, Nepal. Main outcome measures Mode of delivery, Post partum haemorrhage, pre‐term delivery, Low APGAR at birth, Small for gestational age, Low birth weight, still birth and Neonatal death. Results Pregnancy in teenagers was associated with significantly (P<0.05) increased risk of delivery of very preterm babies (RR, 3.03; 95% CI, 1.74‐5.29), moderately preterm babies (RR, 1.61; 95% CI, 1.21‐ 2.13), Low Birth Weight babies (RR, 1.65; 95% CI, 1.32‐2.08) and small for gestational age babies (RR, 1.47; 95% CI, 1.03‐2.10). There was no significant difference in risk of having low APGAR score at birth at 1 min and 5 min, still birth, neonatal death and Post partum Hemorrhage. The risk of having delivery by Caesarean section was significantly lower (RR, 0.77; 95% CI, 0.60‐0.98; P<0.05) among teenage mothers. The risks of having deliver by any other method were not statistically significant. Conclusion Pregnant women were more likely to have preterm births, low birth weight babies and small for gestational weight babies. They were less likely to have delivery by Caesarean sections. In other respects, there was no significant differences between teenage and non‐teenage mothers.

1. INTRODUCTION Teenage pregnancy is an important public health problem worldwide as it often occurs in the context of poor social support. It has been associated with maternal complications, premature birth, low birth weight, perinatal mortality, increased infant mortality and maltreatment of children1. It has also been observed that in the developing countries, teenage mothers were at increased risk of maternal anemia, pre‐term birth and Caesarean delivery2. Hence, the United Nations also remarks that early child bearing is a high health risk for both mother and child3. A significant and considerable number of women get married and bear child in their teenage in Nepal but they are not equally distributed across urban and rural areas and exact data are not available4. Adolescents comprise of 23% of 23 millions of Nepalese population5. The median age at first marriage for ever married women in Nepal (age 15‐49) is 16.6 years, which indicates that majority of P a g e | 52

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

newly married couples are teenagers6. Teenage pregnancies (<20 years) with first ANC visit, in Nepal, accounts 15.5% of the total expected pregnancies and this high incidence has been identified as a problem in the safe motherhood program7. Mahendra Adarsha Chikitsalaya, Chitwan ranks third in the country in terms of the number of deliveries being conducted each year. Being a government hospital, it is financially accessible to the majority of the population and hence ideal for this study.

2. MATERIALS AND METHODS 2.1 Data collection and selection criteria Data of women admitted to Mahendra Adarsh Chikitsalaya for maternity care are recorded in a maternity register during the discharge from hospital. We used this register to identify all singleton births in the hospital resulting in a live or still born baby during fiscal year 2062/63 (2062 Shrawan 1 to 2063 Ashadh 32). Inclusion in the study group was restricted to maternal age between 15 and 29, Gravida 1 or 2, birth weight >500 gm and delivery at or after 28 weeks of gestation at birth. Only those cases fulfilling the above criteria and for which data on all variables were available were included for our study.

2.2 Definitions and denominators The age of pregnant woman in completed years at the time of birth of baby was considered as maternal age. The type of delivery was classified as spontaneous, episiotomy, instrumental and caesarean. The denominator for them was the total number of delivery. Spontaneous delivery was defined as vaginal delivery without the use of vacuum, forceps, episiotomy or caesarean section. Episiotomy in a vaginal delivery without the use of vacuum, forceps or caesarean section was defined as episiotomy delivery. Instrumental delivery was vaginal delivery in which vacuum or forceps was used. Caesarean section was defined as the operative procedure whereby fetus at or after 28 weeks of gestation was delivered through an incision on the abdominal and uterine wall. Post partum Haemorrhage (PPH) was defined as blood loss greater than 500 ml following birth of a baby and during the hospital stay of the mother. The denominator was total number of deliveries. Gestational age at birth was the age from the last menstrual period (LMP) in completed weeks. First birth was births to women who had no previous pregnancies or whose previous pregnancies had all ended in abortions. Second birth was defined as births preceded by only one pregnancy that did not result in abortion. Small for gestational age (SGA) baby was a live baby who was less than 10th percentile of birth weight for the given week of gestation derived from Babson growth graphs8 and the denominator was all live births. Birth weight below 2,500 grams at birth irrespective of the gestational age was considered as Low Birth Weight (LBW). The denominator was all live births. Pre‐term delivery was categorized into two groups. Birth of a live baby at 28 to 32 weeks’ gestation was considered as very pre‐term delivery. Live birth at 33 to 36 weeks of gestation was considered as moderately pre‐term delivery. The denominator for both these outcomes was all live births. APGAR score less than 7 was considered as low APGAR score at birth. The denominator was all live births. Still birth was defined as delivery of a dead baby at or after 28 weeks’ gestation, and the denominator was all live births at or after 28 weeks’ gestation. Neonatal death is referred to death of a live born baby during the hospital stay of the mother, and the denominator was all live births.

P a g e | 53

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

2.3 Statistical analyses Data entry and statistical analysis were performed using commercial statistical software (SPSS Win, SPSS Inc, Chicago, USA). The Chi square test was used for all categoric variables.

3. RESULTS Of the 5,076 deliveries recorded in the maternity register during the fiscal year 062/063 in Mahendra Adarsha Chikitsalaya, 80.79% (n=4,101) satisfied our selection criteria and were included for the study. Of these 19.27% (n=790) were of age group 15 to 19 and 80.73% (n=3,311) were of age group 20 to 29. The study group characteristics are shown in Table 1.

We observed that teeenage mothers had significantly increased incidences of delivery of very preterm babies (RR, 3.03; 95% CI, 1.74‐5.29; P<0.001), moderately preterm babies (RR, 1.61; 95% CI, 1.21‐2.13; P<0.001), Low Birth Weight babies (RR, 1.65; 95% CI, 1.32‐2.08; P<0.001) and small for gestational age babies (RR, 1.47; 95% CI, 1.03‐2.10; P<0.05). The risk of having low APGAR score at birth at 1 min (RR, 1.23; 95% CI, 0.99‐1.53) and 5 min (RR, 1.70; 95% CI, 0.85‐3.42), still birth (RR, 1.62; 95% CI, 0.96‐2.74) and neonatal death(RR, 2.09; 95% CI, 0.78‐5.56) was also higher in the teenage group, although this was not statistically significant. Among the maternal outcomes (Table 3), it was seen that the risk of having delivery by Caesarean section was significantly lower (RR, 0.77; 95% CI, 0.60‐0.98; P<0.05) among teenage mothers. The risks of having delivery by any other method were not statistically significant. The risk of developing Post Partum Hemorrhage was also not significant (RR, 1.09; 95% CI, 0.59‐1.99). Table 1: Study Group Demographics

Total

Women aged 15 ‐19

P‐value

Total

4,101 (100)

790 (19.27)

3,311 (80.73)

Mean age±S.D

21.91±2.76

18.15±0.90

22.81±2.25

<0.001#

Ethnicity

Brahmin/Chhetri 2,328 (56.76)

328 (7.99)

2,000 (48.76)

Newars

255 (06.21)

45 (1.09)

210 (05.12)

Mongolians

680 (16.58)

160 (3.90)

520 (12.68)

Others

838 (20.43)

257 (6.27)

581 (14.17)

Values in the bracket are expressed as percentage of total delivery #

Women aged 20 ‐ 29

Test of variance applied to continuous variables.

P a g e | 54

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

Table 2: Foetal Outcomes

Women aged Women aged 15 ‐19 20 – 29

Relative Risk 95% CI

P‐Value

Weeks of Gestation

Very Preterm

21(0.52)

29(0.72)

3.03(1.74‐5.29)

<0.001

Mod. Preterm

63(1.57)

164(4.08)

1.61(1.21‐2.13)

<0.001

Low Birth Weight

83(2.07)

212(5.28)

1.65 (1.32‐2.08)

<0.001

Small for Gestational Age

35(0.87)

98(2.44)

1.47 (1.03‐2.10)

<0.05

Low APGAR score

1 min

92(2.29)

313(7.80)

1.23(0.99‐1.53)

*NS,0.06

5 min

11(0.27)

27(0.67)

1.70 (0.85‐3.42)

NS,0.12

Still Birth

19(0.47)

49(1.22)

1.62 (0.96‐2.74)

NS,0.06

Neonatal Death

6(0.15)

12(0.30)

2.09 (0.78‐5.56)

NS,0.12

Values in the bracket are expressed as percentage of all live births in the study group. *NS‐ Not significant

Table 3: Maternal Outcomes

Women aged 15 ‐19

Women aged 20 ‐ 29

Relative Risk 95% CI

P‐Value

Type of Delivery

Spontaneous

569 (13.87)

2,338 (57.01) 1.02 (0.97‐1.07)

NS, 0.43

Episiotomy

112 (02.73)

404 (09.85)

1.16 (0.95‐1.41)

NS, 0.12

Instrumental

37 (00.90)

178 (04.34)

0.87 (0.61‐1.23)

NS, 0.43

Caesarean

72 (01.76)

391 (09.53)

0.77 (0.60‐0.98)

<0.05

PPH

13 (00.32)

50 (01.22)

1.09 (0.59‐1.99)

NS, 0.78

Values in the bracket are expressed as percentage of total delivery

P a g e | 55

2063

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

4. DISCUSSION As in our study, many of the previous studies have shown that teenage pregnancy is associated with Preterm delivery, Low birth weight babies and Small for gestational age babies9‐11. It is said that this is due to the social, economic and behavioural factors rather than the biological effect of young age12‐14. Significant differences in the socioeconomic status between teenage mothers and older mothers have been seen in studies from Nepal too15. Also, it is argued by some western studies that teenage mothers are more likely to be unmarried and smokers which adversely affect the outcomes16‐18. However, we doubt this to be true to our scenario. Also, the physical maturity of Nepalese population is different from western populations where most of these studies were conducted. It is also seen from our study that the risk of having still birth or neonatal death in teenage age group is not statistically significant compared to the non‐teenage women. This is in coherence with some of the recent studies19,20. However, it should also be borne in mind that our study is a hospital based study where most of the complications, that would otherwise have adverse outcomes in a community setting, are well handled. Some studies have shown that the risk of Caesarean section is increased21 in teenage pregnancy while some have shown the opposite16,19. Our study shows that this risk is significantly decreased which could be due to a significantly higher incidence of low birth weight in teenage pregnancies, which would be associated with a higher chance of successful vaginal delivery. Also, our discussion with gynecologists revealed a certain degree of reluctance on their part to perform elective caesarean section on teenagers. Another possibility is that women of teenage age group, identifying teenage pregnancy as a risk, could be coming to hospital early compared to non teenage women who come to hospital in later stages only and hence requiring Caesarean section. Considering that ours is a hospital based study where women from better socioeconomic status form the majority because of their awareness on pregnancy related issues, this is quite likely.

5. LIMITATIONS Our study does not take into account the socioeconomic factors such as maternal education, family income etc. which could be playing a major role on the outcomes. Our study has been conducted in a referral centre, therefore the complications of pregnancy, delivery and fetal outcome may not be true reflection of their prevlaence in the catchment area, as only 11.25% of all deliveries are conducted in institutions in Nepal7. We have also not conducted multivariate analyses among the existing variables. Taking into account of ethnicity may have yielded slightly different results as the outcomes have been known to vary with various ethnic groups in Nepal22. Also we have not taken into consideration the birth order or gravida, which is a known factor for adverse pregnancy related outcomes23. The reliability of data recorded in maternity register is also questionable as it does not undergo any quality analysis tests.

6. CONCLUSION Since we have not taken into account socioeconomic and behavioral factors, we are unable to comment whether the adverse outcomes are due to biological immaturity or socioeconomic factors. A biologic cause could be confirmed or refuted only by access to more detailed socioeconomic information at the individual level. We suggest community based prospective collection of data for this. P a g e | 56

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

Despite all, teenage pregnancy can reduce educational, career and economic prospects and so should be discouraged.

7. REFERENCES 1.

Mapanga KG. The perils of adolescent pregnancy. World Health 1997; 50: 16‐18.

Scholl TO, Hediger ML, Belsky DH. Prenatal care and maternal health during adolescent pregnancy: A review and meta‐analysis. Adolesc Health 1994; 15: 444‐456

United Nations. Adolescent reproductive behavior: evidence from developing countries: volume 2. New York: United Nations; 1989

Ganesh Dangal: An Update on Teenage Pregnancy. The Internet Journal of Gynecology and Obstetrics. 2005. Volume 5 Number1. th http://www.ispub.com/ostia/ index.php?xmlFilePath=journals/ijgo/vol5n1/teenage.xml (Accessed on 18 Jan, 2007)

Central Bureau of Statistics. Population census 2001 national report. Kathmandu: National Planning Commission Secretariat and Central Bureau of Statistics‐ Government of Nepal in collaboration with UNFPA; 2002

Family Health Division‐ Government of Nepal, New ERA and ORC Macro. Nepal demographic and health survey 2001. Maryland, USA: Family Health Division, Government of Nepal, New ERA and ORC Macro; 2002.

Department of Health Services. Annual report 2061/62 (2004/2005). Kathmandu: Department of Health Services, Government of Nepal, 2006.

Babson SG, Benda GI.Growth graphs for the clinical assessment of infants of varying gestational age. J Pediatri 1976;89:814‐820.

Fraser AM, Brockert JE and Ward RH. Association of young maternal age with adverse reproductive outcomes. N Engl J Med 1995;332:1113‐7

10. Friede A, Baldwin W, Rhodes PH, et al. Young Maternal age and infant mortality: the role of low birth weight. Public Health Rep 1987;102:192‐9 11. Brown HL, Fan YD, Gonsoulin WJ. Obstetric complications in young teenagers. South Med J 1991;84:46‐48 12. Hollingsworth DR, Felice M. Teenage Pregnancy: A multiracial sociologic problem. Am J Obstet Gynecol 1986;155:741‐6 13. McAnarney ER. Young Maternal age and adverse neonatal outcome. Am J Dis Child 1987;141:1053‐9 14. Reichman NE, Pagnini DL. Maternal age and birth outcomes: Data from New Jersey. Fam Plann Perspect 1997;29:268‐72,295 15. Sharma AK, Verma K, Khatri S, Kannan AT. Pregnancy in adolescents: A Study of Risks and Outcome in Eastern Nepal. Indian Pediatrics 2001; 38: 1405‐1409 16. Lao TT, Ho LF. Obstetric outcome of teenage pregnancies. Human Reprod 1998;13:3228‐32 17. Olausson PM, Cnattingius S, Goldenberg RL. Determinants of poor pregnancy outcomes among teenagers in Sweden. Obstet Gynecol 1997;89:451‐7 18. Ketterlinus RD, Henderson SH, Lamb ME. Maternal age, sociodemographics, perinatal health and behavior: influences on neonatal risk status. J Adolesc Health Care 1990;11:423‐31 19. Jolly et al. Obstetric riks of pregnancy in women less than 18 years old. Obstet Gynecol 2000;96(6):962‐6. 20. Lao TT, Ho LF. The Obstetric implications of teenage pregnancy. Human Reprod 1997;12(10):2303‐5 21. Bacci A, Manhica GM, Machungo F and et al. Outcome of teenage pregnancy in Maputo. Int J Gynaecol. Obstet 1993;40:19‐23 22. Acharya PP, Alpass F, Birth outcomes across ethnic groups of women in Nepal Health Care Women Int. 2004 Jan;25(1):40‐54. 23. Smith GCS, Pell JP. Teenage Pregnancy and risk of adverse perinatal outcomes associated with first and second births: population based retrospective cohort study. BMJ 2001;323:476‐81

P a g e | 57

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

1. BACKGROUND Nepal, a known leprosy endemic country remains so even today and is one of the five countries in the world that have not yet achieved elimination. Leprosy has been recognized as a public health problem since time immemorial and efforts were made to combat it in all earnestness. To isolate and provide treatment to leprosy patients the Khokhana leprosarium was established in the year 1857. With an estimated number of 100,000 leprosy cases in the year 1966, leprosy control program using Dapsone monotherapy was started as a pilot project in the country. This project gradually expanded as a vertical program and remained so until 1987 when it was integrated into the general health services. Multi drug Therapy (MDT) was introduced for the first time in Nepal in the year 1982/83 in selected few areas and hospitals. There was a gradual and steady expansion of MDT services and by the year 1996 coverage was extended to all 75 districts of the country. Being a signatory to the World Health Assembly resolution of May 1991, and the World Health Organization (WHO) Regional Committee resolution on leprosy of September 1992, Nepal had revised programme activities towards attainment of the goal of leprosy elimination as a public health problem by the year 2000, i.e., to curtail the prevalence rate (PR) to less than 1 case per 10,000 population. However this target could not be achieved. 1.1 Rupandehi district Rupandehi is one of the 31 districts within Nepal and one of the five districts in Western Development Region (WDR) which is yet to achieve leprosy elimination. It has the highest PR among the districts of WDR. The trend of different indicators of the leprosy control program in Rupandehi for the last three fiscal years are as follows: Indicators New Case Detection Rate (NCDR) Defaulter Rate P a g e | 58

MB PB MB PB

060/061 061/062 062/063 National 062/063 2.40 1.80 1.50 1.00 2.06 1.60 1.30 0.96 5.00 0.4 0.7 4.00 0 2.5

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

Ratio of grade II disability in New Caases

MB PB Prevalencce Rate per 10 0,000 populattion MB PB MB+P PB Child prop portion amon ng New Casess MB+P PB Female Prroportion among New Patients MB+P PB

0.5 0 0 2.8 1.7 4 4.5

1.1 0 1.9 0.7 2.6 6.82 43.56

2.4 0 1.6 0.5 2.1 10.06 62.89

4.81

6.61 41.25

MB: Multi‐‐Bacillary PB: Pauci‐B Bacillary

1.1.1 Prevvalence Rate per 10,000 Po opulation

5 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0

MB PR M PB PR P MB+PB PR M

060/061

061/062

0 062/063

2. RATTIONALE 1. Rupandehi disstrict has the highest prrevalence of leprosy amo ong the disttricts of WDR. Although the p prevalence raate is decreasing, the rate o of decline is n now slowing. 2. Th he trend of p proportion of Grade II disability among new cases is increasing. TThis shows that pe eople are pre esenting late ffor treatmentt.

G Grade II di sability am mong new cases 3 2.5 2 1.5

Grade II disability am mong new caases

1 0.5 0 060//061

061/062

0 062/063

P a g e | 59

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

3. The trend of child proportion among new patients is also increasing. This shows that the disease is active and spreading in the district.

Child Proportion among new patients 12 10 8 6

Child Proportion among new patients

4 2 0 060/061

061/062

062/063

4. In general, leprosy is seen more commonly in male. But, in Rupandehi, the female proportion among new patients has increased from last year’s 43 to 62. This could be because the female patients, who were unwilling to present to health facilities earlier, are now doing so.

Female Proportion among new patients 70 60 50 40 30 20 10 0

Female Proportion among new patients

060/061

061/062

062/063

5. The defaulter rate has also increased compared to last year’s.

P a g e | 60

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

Defaulter Rate

5 4 3

1 0 060/061

061/062

062/063

6. Nepal remains one of the five leprosy endemic countries in the world. It is essential that district level elimination be targeted so as to achieve national elimination. Even if national elimination is achieved first, district level elimination will have to be eventually achieved to ensure that leprosy no longer remains a public health problem in any part of the country. 7. After elimination, a post‐elimination strategy will be needed at national and sub‐national level for continuation of leprosy services and further reduction of cases.

P a g e | 61

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

3. PROBLEM TREE

Leprosy is endemic in Rupandehi

High grade II disability rate

High proportion of child cases among New Patients

Increasing trend of defaulter rate

Leprosy Cases are not being diagnosed and treated early and effectively

Lack of refresher training for health workers

Questionable quality of diagnostic services

Interruption in course of treatment

Late presentation

E F F E C T S

FOCAL PROBLEM

People not coming for the services.

C A U S

Lack of Counselling

P a g e | 62

Drug delivery policy not flexible

Lack of knowledge

Social stigma

E S

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

4. OBJECTIVES To eliminate leprosy (prevalence less than 1 per 10000) from Rupandehi district and to ensure, following elimination, further reduction of cases of leprosy and good quality of leprosy sevices. 4.1 Specific objectives 1. To eliminate leprosy form Rupandehi district (prevalence less than 1 per 10000 cases). 2. To minimize social stigma of the disease. 3. To minimize the disability rate due to the disease. 4. To rehabilitate people with disabilities due to the disease. 5. To sustain good quality of leprosy services following elimination. 6. To further reduce cases of leprosy following elimination.

5. METHODOLOGY 5.1 Document and literature review i. ii.

Annual Report of District Public Health Office (DPHO), Rupandehi. Monthly monitoring and Annual performance review worksheet of Rupandehi district for last three fiscal years. Records file available with District Tuberculosis and Leprosy Assistant (DTLA). Annual Report of Leprosy Control Division (LCD). Planning methods: handouts for log frame from orientation classes.

iii. iv. v.

5.2 Interview with key persons

We conducted semi‐structured interviews with: i. ii. iii.

District Public Health Officer District Tuberculosis and Leprosy Assistant. Statistician.

6. DEFINITIONS AND DENOMINATORS 6.1 Prevalence Rate The prevalence rate is the total number of leprosy cases registered for chemotherapy at the end of the reporting year divided by the total population of the area; expressed as a rate per 10,000 population.

P a g e | 63

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

6.2 New Case Detection Rate (NCDR) The case detection rate is the total number of new leprosy cases detected during the reporting year divided by the total population of the area expressed as a rate per 10,000 population. 6.3 MB proportion The percentage of MB cases among the total number of new leprosy cases detected during the reporting year. 6.4 Defaulter Rate A defaulter is a patient who started MDT but who has not received treatment for 12 consecutive months despite all attempts to trace the patient 6.5 Female Proportion among New Patients The proportion of females among the newly detected cases. 6.6 Child Proportion among New Patients The percentage of children among all new cases detected during the reporting year. 6.7 Treatment completion Rate The percentage of total cases diagnosed during a given period of time who complete their treatment correctly. 6.8 Grade II disability proportion The percentages of people with WHO disability grade 2 among the new leprosy cases detected during the reporting year Grade II disability Proportion: 6.9 Leprosy Elimination Monitoring (LEM ) indicators Group I: Elimination indicators

P a g e | 64

1. Case finding activities 1.1 Proportion of new cases with disabilities 1.2 Proportion of children among new cases (or age specific detection) 1.3 Proportion of MB cases among new cases 1.4 Proportion of female among new cases (or sex specific detection) 2. Prevalence: absolute numbers and rate 2.1 Prevalence rate 2.3 Prevalence trend over the last 5 years

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

Group II: Integration of MDT services within General Health Services

Group III: Quality of MDT services:

3. Detection trend: absolute numbers and rate 3.1 Detection trend over the last 5 years 3.2 MB detection trend 3.3 Child detection trend 1. Proportion of existing health facilities providing MDT 2. Accessibility to MDT Service Centre 3. Availability of MDT drugs 1. Proportion of patients treated with MDT 2. Case holding 2.1 Cure rate 2.2 Defaulter rate 3 . Quality of MDT blister‐packs

7. THE FIVE YEAR PLAN In order to eliminate Leprosy from Rupandehi District, the five year plan shall be implemented in two phases: PHASE I: PHASE OF ELIMINATION: 3 YEARS. PHASE II: POST‐ELIMINATION PHASE: 2 YEARS. 7.1 Phase of elimination The phase of elimination will be of the first three years where activites will target reducing the Prevalence Rate of leprosy per 10,000 population to below 1. The major activities in this phase will include active case detection and early and effective management of the diagnosed cases. 7.2 Post‐elimination phase Since, the elimination of leprosy as a public health problem is only an interim goal to reduce the disease burden, it is expected that new cases of leprosy will continue to occur at low levels of transmission. There will still be pockets of endemicity within the district following elimination. At the same time, because elimination has left very few cases in the community, general awareness and diagnostic expertise are likely to decline and the new cases may, therefore, occur without being detected and treated in time. So, the activities of this phase will focus on maintaining good quality of leprosy services, further reduction in cases and strengthened surveillance system following elimination. This phase will be of two years.

8. EXPLANATION OF MAJOR ACTIVITIES TO BE CARRIED OUT DURING THE PROGRAM 8.1 MDT service delivery upto Sub Health Post (SHP) level P a g e | 65

C O M M U N I T Y E X P E R I E N C E

R E S E A R C H A N D M A N A G E M E N T F I E L D W O R K

2063

For effective treatment of the leprosy patients, it is essential that Multi Drug Therapy is easily available. During the first phase, drug delivery will be undertaken at the SHP level within the district. In the post elimination phase, drug delivery will be continued from SHP in high endemic areas while in other areas it will be available at health post (HP) level. Also, the district will maintain an adequate supply of MDT drugs and anti reaction drugs within the district throughout the program duration. Secondary and tertiary care will be provided to the needy leprosy patients throughout the program duration through the existing network of referral centres. 8.2 Human Resource Development Comprehensive leprosy training (CLT) will be provided to Basic health workers who have not undergone training before and refresher training to those who have undergone CLT in the past. In order to ensure that the diagnostic capabilities of the staffs do not decline during the post elimination phase, the training and capacity building process will be conducted in both phases. 8.3 Information Education and Communication (IEC) To enhance awareness among community members, to facilitate passive case detection and to reduce stigma, IEC activities will be undertaken on regular basis using electronic and print media. In addition, school health education, house to house awareness and various activities will be conducted on world leprosy day. 8.4 Case Validation Exercise To assess the quality of leprosy diagnostic services provided at peripheral health facilities in the district, case validation exercises will be conducted twice in the first phase(first and third year) and once in the second phase (fifth year). It will essentially be an observational study where findings of two independent examinations by two evaluators on each of the registered patients will be compared with that of the findings recorded in patients’ care cards to measure the proportion of cases inappropriately registered as new leprosy cases. 8.5 Leprosy Elimination Monitoring Leprosy Elimination Monitoring (LEM) exercises will be carried out twice in the first phase of the program, in the first year and third year and once in the post elimination phase in the final year. A set of indicators will be calculated as mentioned above according to WHO guidelines for monitors. Monitors will visit health facilities within the district and evaluate for completeness and update of the records by a cohort analysis.

P a g e | 66

COMMUNITY EXPERIENCE, RESEARCH AND MANAGEMENT FIELD WORK 2063

9. LOG FRAME MATRIX 9.1 Phase I

Intervention logic

Development objectives/Goal Project objective/ Purpose

To eliminate Leprosy from Rupandehi District

Results/ Outputs

P a g e | 67

Objectively measurable and verifiable indicators Prevalence Rate <1 per 10,000 population

1. ‐An initial rise in New Case detection rate followed by decline ‐Decrease in MB proportion among new cases. ‐Decrease in Grade II disability among new cases. 2. ‐Increase in treatment completion rate. ‐Decrease in defaulter rate 3. ‐Decrease in child proportion among new cases. 1. An initial increase in 1. Active Case detection in all areas with NCDR PR>2.5 per 10,000 population. 2. All registered cases received MDT services 2. ‐Treatment completion rate. promptly. 1.To diagnose cases of leprosy early. 2.To treat the diagnosed leprosy cases effectively. 3. To reduce the rate of transmission of leprosy.

Sources of verifications Reports from the health institutions within the district Reports from the health institutions within the district

1. Reports from Leprosy Elimination Campaign (LEC) and school surveys. 2,3. Report from DPHO.

Important assumptions

Wrong diagnosis is avoided All active cases identified.

1.Pocket areas correctly identified.

COMMUNITY EXPERIENCE, RESEARCH AND MANAGEMENT FIELD WORK 2063

3. Target population received information about leprosy. 4.Health workers able to diagnose cases effectively. 5. Rehabilitation of all cases with disabilities. 6. Assurance of quality of diagnostic services. 7. Monitoring and assessment of performance of Leprosy control program.

P a g e | 68

‐No of patients Removed from treatment. 3.‐ An initial increase in NCDR. ‐Decrease in MB and Grade II disability Proportion among new cases. 4. Decrease in percentage of wrong diagnosis. 5. Percentage of cases with disability rehabilitated. 6. Percentage of wrong diagnosis. 7. Trends of Leprosy elimination monitoring (LEM) indicators.

4. Report from case validation exercise. 5.Report from DPHO 6. Report from case validation exercise. 7. Report form LEM exercise.

3.Accessibility of community to electronic media. 4. Avoidance of over and under diagnosis. 7. Monitoring and supervision by trained staffs.

COMMUNITY EXPERIENCE, RESEARCH AND MANAGEMENT FIELD WORK 2063

Activities

P a g e | 69

1. Identify leprosy pocket areas . 2. Active case detection: 2.1 Leprosy Elimination Campaigns (LEC) Conduct LECs in high endemic areas two times in a year for the first two years and once in high endemic areas for the third year. 2.2 School Surveys. 3. Effective Treatment of the registered cases 3.1 Ensure the adequacy of drugs required for MDT in health institutions. 3.2 Adequate stock of drugs required for supportive therapy and treatment of adverse effects. 3.3 Delivery of MDT services up to SHP level. 3.4 Flexible patient friendly drug delivery policy 4. Enhance community awareness on different aspects of leprosy including elimination of the disease: 4.1 Broadcasting messages through local FMs, local cable TV networks. 4.2 Conducting school health education.

1.‐No of V.D.Cs with PR > 2.5 per 10,000 population 2. An initial increase in NCDR. 3. 3.1,3.2 Drug stock level throughout the year. 3.3 Percentage of SHPs delivering MDT services. 3.4 Percentage of health institutions implementing flexible drug delivery policy. 4.1. No of times message broadcasted. 4.2. No of schools where health education

1. Previous year reports from the SHPs, HPs and PHCs within the district. 2. Reports from the LEC and school surveys. 3.1,3.2 LMIS report from heatlh institutions 3.3. Records/Reports from SHPs 3.4 Records/Reports from health institutions 4.1.Contract Record with the electronic media. 4.2.Records from DTLA.

1. Reliability of old records. 2.Staffs properly trained for LEC and school surveys. 3.Patient counseled before treatment. 4. 1.Accessibility of community to electronic media 4.2 School teachers have enough

COMMUNITY EXPERIENCE, RESEARCH AND MANAGEMENT FIELD WORK 2063

4.3 House to house community awareness program. 4.4 Organizing various activities on World Leprosy Day. 5. Human Resource Development. 5.1 Comprehensive leprosy training (CLT) to the Basic health workers posted in endemic areas who have not undergone the training before. 5.2 Refresher training to those who have undergone CLT in the past. 5.3 Orientation training to the FCHVs. 6. Reduce disabilities and rehabilitate those with disabilities. 6.1 Enabling or empowering affected persons to take on responsibility for preventing worsening of impairments and disabilities by suitably training them, their family members and local community volunteers. 6.2 Provide treatment locally for conditions such as palmar and plantar ulcers. 6.3 Provide orthopaedic devices, prosthesis and corrective surgeries by involving government hospitals and medical college within the district.

P a g e | 70

conducted. 4.3 No. of household visited by FCHVs 4.4.No. of activities conducted. 5.1. Percentage of health worker receiving CLT. 5.2. Percentage of health worker receiving refresher training 5.3. Percentage of FCHVs receiving orientation. 6.1. No. of persons trained. 6.2. Number of institutions providing treatment. 6.3. ‐Number of cases receiving prosthesis. ‐Number of institutions within the district

4.3.,4.4. Records from DPHO. 5. Records from DPHO. 6.Records from DPHO.

knowledge on the subject. 4.3.FCHVs are properly trained. 5. Training properly attended by the trainees. 6. 1 Target group’s readiness to take responsibility 6.2.Availability of resource and properly trained staff.

COMMUNITY EXPERIENCE, RESEARCH AND MANAGEMENT FIELD WORK 2063

7. Assurance of quality of diagnostic services provided 7.1 Case validation exercises. 8. Monitoring and supervision of the program 8.1 Supervision and monitoring of patient services at peripheral level by program managers. 8.2 Quarterly review workshops at PHC and HP level. 9. Assess the performance and progress made by the program. The performance and progress of the program will be made by Leprosy Elimination Monitoring (LEM) exercises which will be conducted at the end of first and third year.

P a g e | 71

7. Report from case validation exercise 7.1‐ Percentage of cases wrongly diagnosed ‐ Percentage of cases wrongly grouped. ‐Percentage of cases with wrong address ‐Percentage of cases erroneously re‐registered as new cases. 8.1 No.of times peripheral 8. 1. Supervision reports. health institutions (PHC,HP and SHP) supervised by program managers. 8.2. Review workshop 8.2 No. of review workshops in a year at PHC reports. and HP level. 9.Reports from LEM 9. Indicators of LEM exercises. exercises. providing these services.

7. Sample should be representative of the total number of cases. 8. Monitoring staff properly trained. 9. WHO guideline for monitors properly followed.

COMMUNITY EXPERIENCE, RESEARCH AND MANAGEMENT FIELD WORK 2063

9.2 Phase II

Sources of verifications To maintain the elimination status of Reports from the Development health institutions objectives/Goal leprosy in Rupandehi district. within the district 1. To sustain good quality of leprosy 1. Percentage of wrongly 1. Reports from case Project validation exercise. diagnosed cases. services following elimination. objective/ 2. To further reduce cases of leprosy 2. PR Purpose 2. Reports from DPHO following elimination. 3. To rehabilitate people with 3.Percentage of people 3. Reports from DPHO rehabilitated. disabilities due to the disease. 1. Decreasing trend of PR 1,2,3.Report from Results/ 1. Reduction in number of cases. and NCDR. DPHO Outputs 2. Decreased MB and 2. Early and Effective detection of new Grade II disability cases. Proportion among new cases. 3. Prompt MDT services to all registered 3. –Treatment cases and rehabilitation for those in need. completion rate. ‐ Defaulter rate. ‐ Percentage of people with disability rehabilitated. 4.Records from the 4. Elimination at VDC level. 4. PR<1 per 10,000 population at VDC level. health institution in the concerned VDCs.

P a g e | 72

Intervention logic

Objectively measurable and verifiable indicators PR < 1.0 per 10,000 population.

Important assumptions

1. Diagnostic capability of staffs is maintained.

1. Diagnostic capability of staffs is maintained. 2.Priority to the program is maintained. 4.Reliablitity of records maintained.

COMMUNITY EXPERIENCE, RESEARCH AND MANAGEMENT FIELD WORK 2063

Activities

P a g e | 73

5. Effective strengthened surveillance system for disease established. 6. Establishment of a network of INGOs, NGOs, Private practioners and traditional healers. 1. Increased information, education and communication (IEC) activities. 2. Involvement of private practioners and traditional healers. 3. Identify pockets of high endemicity and cluster cases so as to focus control measures where they are most needed. 4. Delivery of MDT services in high endemic VDCs through SHPs and in other areas through HP. 5. Adequate supply of MDT drugs at appropriate levels. 6. Continue rehabilitative services to cases with disability within the district. 7. Capacity building of the staff and development of proper referral system within the district. 8. Strengthen the surveillance system.

5. No. of sentinel sites establshed. 6. ‐No of cases reported by them. ‐ No of IEC activities conducted by them. 1. No of times IEC activities are conducted. No. of IEC materials produced and distributed. 2. No of cases reported by private practitioners and traditional healers. 3.No. of VDCs with PR>1 per 10,000 population. 4.No. of SHPs providing MDT services. 5. Drug stock level throughout the year. 6 Percentage of people with disability receiving reahabilitative services. 7.‐No. of staffs receiving refresher training. ‐ No of sites delivering MDT within the district. 8. ‐No. of sentinel sites

5. Evaluation of the surveillance system by DPHO. 6.Reports from INGOs, NGOs, and DPHO.

6. Co‐ordination is maintained despite having different goals.

1. Contract report with media. Report from DPHO 2.Monthly performance monitoring and review sheet, DPHO 3. Records from health institutions at VDC level. 4. Records at SHP 5. LMIS report from health institutions. 6. Reports from DPHO and rehabilitation centres. 7. Reports from DPHO. 8.HMIS report from

1. Accessibility of community to media and posters. 2.Traditional healers willing to refer cases to health institutions. 3.Reliability of records from those areas. 4.Drug supply maintained according to the need. 6. Availability of resource and properly trained staff. 7. Motivation among staffs to take training even in low prevalence situation. 8.Availability of resources

COMMUNITY EXPERIENCE, RESEARCH AND MANAGEMENT FIELD WORK 2063

10.

11.

12.

Monitor and supervise the activities regularly. Case Validation exercise Evaluate the program. Promotion of partnership with other NGOs and INGOs working in the district.

P a g e | 74

‐New cases reported promptly to DPHO. 9.No. of times of monitoring and supervision. 10. Percentage of cases wrongly diagnosed ‐ Percentage of cases wrongly grouped. ‐Percentage of cases with wrong address ‐Percentage of cases erroneously re‐ registered as new cases. 11. LEM Indicators 12. No. of coordination meeting of NGOs and INGOs with DPHO

health institution to DPHO. 9.Records at DPHO 10. Report from Case validation exercise. 11. Report from LEM exercise 12.Minute register at DPHO.

to establish sentinel sites. 9. Staffs monitoring and supervising are trained. 10. Sample should be representative of the total number of cases 11. WHO guideline for monitors properly followed. 12. Co‐ordination is maintained despite having different goals.

COMMUNITY EXPERIENCE, RESEARCH AND MANAGEMENT FIELD WORK 2063

10. BUDGETING PHASE

ACTIVITIES

AMOUNT (in NRs) 8,00,000 Phase I Leprosy Elimination Campaigns (LEC) 5,00,000 School Surveys 1,50,000 Information, education and communication (IEC) activities. 1,50,000 School health education. 4,50,000 House to house community awareness program. 5,00,000 Organizing various activities on World Leprosy Day. Comprehensive leprosy training (CLT) to the Basic health workers. 1,25,000 1,25,000 Refresher training. 85,000 Orientation training to the FCHVs. 1,20,000 Case validation exercises. 90,000 Supervision and monitoring. 1,60,000 Quarterly review workshops. 5,00,000 Leprosy Elimination Monitoring (LEM) exercises 1,00,000 Phase II Information, education and communication (IEC) activities. 50,000 Capacity building of the staff 60,000 Monitor and supervise the activities regularly. 60,000 Case Validation exercise 2,50,000 Leprosy Elimination Monitoring (LEM) exercises 60,000 Meeting with other NGOs and INGOs working in the district TOTAL EXPENDITURE 43,35,000

11. CONCLUSION Since, Leprosy elimination has been achieved in many districts within Nepal, it is quite possible that this target can be achieved in Rupandehi district too. The above plan aims to do this in next three years but more importantly, also focuses on post elimination strategies which are vital for sustaining the elimination. Elimination of leprosy from Rupandehi district, will not only benefit the people of the district but can also be a role model for other endemic districts trying to achieve elimination.

P a g e | 75

COMMUNITY EXPERIENCE, RESEARCH AND MANAGEMENT FIELD WORK 2063

LEARNING REFLECTIONS From our Community and Clinical Experience and Field Management, we learnt the following: 1. Broad outline of the Health Care Delivery System in the districts of Nepal in terms of a. accessibility b. effectiveness c. limitations d. costs and e. availability 2. Level and quality of health system in the districts. 3. Knowledge on various aspects of National Immunization Program. 4. Effective management makes a difference. 5. Process of information flow from periphery to central level and vice versa. 6. How grass root level health workers delivers services at periphery. 7. Logistic management and budgeting. 8. What is expected of a Medical Officer in PHC, District hospital and specialized centre. 9. Process of conducting an epidemiological study. 10. Use of statistical tools in epidemiological study. 11. Use of commercial statistical software in analysis of study. 12. Process of proper referencing. 13. Application of the log frame analysis in planning process. 14. Process of planning; cycle of planning. 15. Group Dynamics. 16. Interaction and rapport building. 17. Adjustment to the local culture P a g e | 76

COMMUNITY EXPERIENCE, RESEARCH AND MANAGEMENT FIELD WORK 2063

P a g e | 77

Annexes

LETTER FROM M.A.H. BHARATPUR HOSPITAL, CHITWAN

LETTER FROM DISTRICT HEALTH OFFICE, GORKHA