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20‐25 September 2017

Welcome


National Annual Review 2073/74

Province 7


Province 7Profile No.

Districts 9Target Estimated Population 2781979A. PalikasUpa Mahanagar Palika 1Nagar Palika 33Gaun Palika 54B. Health FacilitiesHealth Posts 376Primary Health Care Centers 16District level Hospital 4District Hospitals 6Zonal, Sub‐regional and Regional Hospitals 3Private Hospitals 11Government Medical Colleges 1


management

Far West Regional Health Directorate Dipayal

Results

Actions/ Activities

Attitude/ Thoughts

Philosophy

Need to think about these powerful links

Usual Practice

NP= 2, GP= 7No Hospital= 7 GP

NP= 2, GP= 10No Hospital= 1 NP & 10 GP



NP= 2, GP= 5No Hospital= 5 GP




Upa NP= 1, NP=6, GP= 6No Hospital= 4 NP & 6 GP

Map of local bodies vs Health Institutions

RegionLocal Bodies= 88 (1 UpaNP, 33 NP & 54 GP)75 do not have hospitals

4


HUMAN RESOURCE

Category Sanctioned Filled Vacant Vacant Percent

072/73 073/74 072/73 073/74 072/73 073/74

Doctors 142 55 56 87 86 61.3 60.6

Nursing Satffs 851 728 840 123 11 14.5 1.3

Paramedics 1463 1114 1213 349 250 23.9 17.1

Others 721 549 436 172 285 23.9 39.5

Total 3177 2446 2545 731 632 23.0 19.9


Health Service Coverage: National Vs FWDR

Indicator National (NDHS 2016)

FWDR (NDHS 2016)

F WR FWR HMIS 2072-73 HMIS 2073-74

Measles coverage 90.4 95.2 80 83CPR 42.8 48.1 38.1 NAInstitutional delivery 57.4 66.4 57.5 63.2

Delivery by SBA 58 66 58 54.8ANC 4 visit 69.4 77.3 54.55 53.3Adolescent pregnancy 16.7 16.1 NA NA

PNC 3 visits as protocol NA NA 26 32

180 iron compliance 41.5 51.7 52.09 51.8

Treatment success rate NA NA 85.6 85


Immunization

105.0394.31 96.78 95.27

76.27 78.77 80.1885.21 88.24

0.00

20.00

40.00

60.00

80.00

100.00

120.00

FY 2073/74 Province National

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

%


Immunization

101.5894.24

98.9893.52

76.52 76.25 79.7788.72 87.56

0.00

20.00

40.00

60.00

80.00

100.00

120.00


% of children aged 9‐11 months immunized with measles/rubella1

%


Nutrition

171.77

118.83110.92

83.34

38.15

60.89

80.21

95.34102.86

0.00

20.00

40.00

60.00

80.00

100.00

120.00

140.00

160.00

180.00

200.00


% of children aged 0‐23 months registered for growth monitoring


Nutrition

55.2059.07

72.81

54.42

41.8446.37

50.23

62.52

53.17

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00


Percentage of pregnant women received 180 tablets Iron


IMNCI

1.3

2.1

0.5

1.4

0.70.5

0.7 0.70.9

0.0

0.5

1.0

1.5

2.0

2.5


% of severe Pneumonia among new U5 yrs cases


IMNCI

0.87

0.52

0.14

0.29

0.46

0.04 0.03

0.37

0.24

0.000.100.200.300.400.500.600.700.800.901.00

FY 2073/74 Province 7 National

% of children U5 years with diarrhea suffering from Severe dehydration


Safe motherhood

47.71

61.09

72.61

52.5848.26 48.98

61.44 61.66

50.85

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00


% of pregnant women who had four ANC checkups as per protocol


Safe motherhood

69.0475.76 73.69 71.01

76.51

48.16

68.9064.48

59.74

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

90.00


% of institutional deliveries


Family Planning

34.0 33.730.6

38.3

48.7

41.8

34.137.6 37.5

0.0

10.0

20.0

30.0

40.0

50.0

60.0


Current use of family planning as % among MWRA


FCHV Program

103.92

83.6591.52

82.79

100.07

86.1893.83 95.43 94.17

0.00

20.00

40.00

60.00

80.00

100.00

120.00


% of mothers group meeting in FY 2073/74


PHC ORC Program

83.16 86.01

97.20

81.46

93.95 95.22 93.4799.13 96.09

0.00

20.00

40.00

60.00

80.00

100.00

120.00


% ORC conducted among planned ORC in FY 2073/74


TB Programme

84.74 80.8068.07

78.23

133.61

173.34

73.5854.85

85.54

0.0020.0040.0060.0080.00

100.00120.00140.00160.00180.00200.00


Case Notification Rate (all forms)/100000 population


TB Programme

72.34

104.26

69.9078.57 83.21

88.4779.69

93.94 92.31

0.00

20.00

40.00

60.00

80.00

100.00

120.00


TB Programme: Treatment success Rate (New PBC Cases)


LeprosyLeprosy Prevalence rate /10000 Popn

0 0

0.8

0.2

0.8 0.8

0.2 0.2 0.2

00.10.20.30.40.50.60.70.80.9



LeprosyLeprosy New case detection rate (NCDR) per 100,000 popn

1.40.5

4.3

2.3

11.110

2.61.5

2.1

0

2

4

6

8

10

12



Malaria

0.034.3

356.3

61.9

124.9

175.8

81.3

329.7

121.3

0.0

50.0

100.0

150.0

200.0

250.0

300.0

350.0

400.0


Malaria Blood Slide collection( target vs achieve )


Kalazar Programme

0.00 0.00

0.29

0.00

0.15

0.04

0.00 0.00 0.000.00

0.05

0.10

0.15

0.20

0.25

0.30

0.35


Incidence of Kalazar per 10000


HIV & AIDS Situation

67676238 6481

2313 24672824

516 562 645

0

1000

2000

3000

4000

5000

6000

7000

8000

2071/72 2072/73 2073/74

HIV Positive

Under ART

Death

34% 39%43%


% of population utilizing outpatient (OPD) services

100

69

119

78

54 51

100

70

90

0

20

40

60

80

100

120

140



Average length of stay in hospital

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

2.70

3.20

2.40

2.70 2.70

2.402.60

3.3

2.70

2.40 2.30

1.60

2.70

2.00

2073/74

2073/74


Financial Progress in 2073/74

90.9

74.8

94.8 93.6 89.7

77.5

96.086.1

91.986.9 88.6

96.988.3

0.0

20.0

40.0

60.0

80.0

100.0

120.0


% of Irregularity Clearance in 2073/74

5360

97

65

16 12

84

33

0

83

5652

79

0

20

40

60

80

100

120


Issues Solution Responsibility TimeUntimely acquisition of HR (PSC, Karar, Transfer)

Many fulfilled post are either on study leave or deputation (Kaaj).

Scientific acquisition (population based HR ratio)Mutli year contract policy development and implmentation

MOHPSC

Urgently

Development‐ Inadquateskill based training to health workers

National and international exposure, training.

Initiation of e‐learning.Capacity of RHTC should be built and decentralization of training ; PEN package, RH package

MoHDoHSRHDLocal Bodies

Urgently

Inadequate ulitization of Human resources for health

Right person – right job with right logistics

MoHDoHS

Urgently

Inadequate maintenance of HRH.

Maintenance of all the above MoHDoHSLocal Bodies

Urgently

HUMAN RESOURCE ISSUES

National Annual health Review 2073/74


Issues Action point (Activities) Responsibility Time

Irregularities and clearance.

Continuation of irregularities.

Priority for clearance MoHPSC

Urgently

Transfer of accountant before external aduit

Coordination with Ma. Le. Ni. Ka.

MoHDoHS

Urgently

No well defined budget for health sector in local bodies.

Financial planning should be done in actual basis.

MoHDoHSRHDLocal bodies

Urgently

Inadequate coordination with Health Coordinator in local bodies.

Orientation to local bodies on health program

MoHDoHSLocal Bodies

Urgently

No salary distribution for staffs at local bodies.Less budget for medical and surgical supply in district and regional level

Coordination between MoH & MoFALD

MoHDoHSLocal Bodies

Urgently

FINANCIAL MANAGEMENT ISSUES



Issue Action point (Activities) Responsibility Time

Inadequate acquisition of medicine, medical and surgical equipments,vehicles & commodities.

Adequate and timely flow of commodities.

MoHDoHSLMDLocal Bodies

Urgently

Repair and maintenance of equipments, instruments & vehicles.

Ensure the availability of B‐Met at district level.Servicing & repair‐ment of vehicles.


Urgently

Improper utilization of equipments, instrument & vehicles.

Right person‐ right jobBio‐MET should be appointed


LOGISTICS MANAGEMENT ISSUES




Raw milk consumption, increasing risk to bovine TB.

BCC for increasing awareness

MoH, DoHSRHD & local bodies

Urgently

Raw meat consumption‐Zoonotic diseases.

Behavior of eating raw meat in the form of Kachbalishould be bannes


Urgently

Not touching women in post natal period‐ Less PNC visit, increased MMR, NMR, Breast abscess.

Increase awareness among family members


Urgently

Chaupadi Partha‐( Suicide, snakebite, communicable diseases.)Child marriage

Acts formulated for chaupadi partha and child marriage

Urgently

SOCIO‐CULTURAL ISSUES




Selection and availability of land for health facilities

Public and government held land to be allocated for construction

MoH, DoHS, DHO,Local bodies& Line ministries

Urgently

Location of facilities vs. Population settlement

Priority in feasible area forpopulation

HFOMC, HP, PHCC & DHO

Urgently

Duration of building construction (quarter and Health institution building)

Monitoring from DUBC and MoH DUBC Urgently

No handover of RHEOC WHO had completed construction but no handover

WHO Urgently

INFRASTRUCTURE: ISSUES




Insufficient cold chain equipment (refrigerator) and power backup

Old cold chain equipments needs to be raplaced.

LMD, CHD, RMS As soon as possible

Inadequate and irregular supply of vaccine and syringe

Inadequate number of nutrition rehabilitation center (for hilly districts)

Uninterrupted supply

Establish of community based NRH.

LMD, CHD, RMS As soon as possible

IPV shortage ? Ensure the uninterrupted supply. LMD, CHD, RMS As soon as possible

Target setting

Implementation of POKHARA Declaration???

As per actual basis MD As soon as possible

PROGRAM ISSUES: CHILD HEALTH




LowandstagnantCPR(migrationandbetterincentiveinUttarakhanda)

Regularization and increase in no. of satellite clinicsDMT training with IEC materials in every districtCompilation of data from private sectors

FHD, DHO Local bodies

As soon as possible

LowANCandPNCvisitsasprotocol

Regularization of PHC outreach clinicsSafe delivery sites‐ Guideline preparation and implementation


As soon as possible

Inadequateno.oftrainedhealthworkers

Adequate quota for SBA trainingObstetrics management training to paramedicsMulti‐year contract policy for Karar


As soon as possible

Highproportionofteenagepregnancy

Implementation of Child marriage prohibition act

Complication management at health institutions

FHD, Admin. As soon as possible

Pelvicorganprolapsedcamps

Revision of operation guideline FHD As soon as possible

PROGRAM ISSUES: FAMILY HEALTH



Family Health Division: Air Lifting Issues

36

FY 073/741st case Referred by helicopter charter from Kolti,

Bajura to Nepalgunj (Retained placenta with puerperal sepsis)

Mother has been saved Out of 5 lakh budget, 4 lakh expenditure.2nd case Referred by helicopter charter from Kolti,

Bajura to Nepalgunj (Obstructed labor with intra‐uterine fetal death)

Mother has been saved 4.5 lakh NRS has to be paid

• Air lifting fund for general people (Emergency Fund)



IncreaseinDR TB(DOTS????)

Proper implementation of DOTS strategy

Strict monitoring from NTC

NTCHealth institutions

As soon as possible

TBHIVco‐infection Coordination between NTC & NCASC

NTC NCASC

As soon as possible

Crossborderissues Cross border Coordination Bilateral agencies As soon as possible

PROGRAM ISSUES: TB LEPROSY




Low coverage (only implemented at Kailalidistrict)

Blanket coverage of NCD program

PHCRD As soon as possible

No specialized NCD referral or treatment center.

Initiation for establishment of treatment center

MoH As soon as possible

No trauma center Establishment of trauma center


PROGRAM ISSUES: NCD




Less training programs More programs to be addedDecentralization of training (through RHTC)

MoH,NHTC

As soon as possible

RHTC : ISSUES




Untimley and incomplete recording and reporting.

Strengthen recording and reporting Open MRS system implementation

MoH, DOHS Urgently

HRH management‐retention of health workers (esp. doctors)

Timely acquisitionDevelopment and training of HWsUtilization‐ Right person right job

MoH, DoHSHospitals

Urgently

Acquisition, Repair and maintenance of biomedical equipments.

Availability of Bio Med & technical manpower in every hospitalTimely acquisition of equipments & instruments

MoH, DoHSHospitals, HFOMC

Urgently

Power backup and water supply.

Permanent power backup planRemote areas‐ solar back upRain harvesting for water supply

MoH, DoHSHospitals, HFOMC

Urgently

Health care waste management

Proper guidelines for health care waste managementImplementation of existing protocals

MoH, DoHSHospitals

Urgently

HOSPITAL RELATED ISSUES




Ill defined hospital budget allocated in Palika

Clarification of budget expenditure areas and modality

MoH Urgently

Hospital infrastructure in each local bodies vsmaster plan.

Infrastructure development plan

MoH Urgently

Dual Pharmacy: Government and private at same place.

Well management of hospital pharmacy.

MoH, DoHS, Hospital

Urgently

Continuation of OCMC. Incorporate the local bodies in committee.Adequate budgeting

MoH Urgently

HOSPITAL RELATED ISSUES CONTD ….




No budget for Malakhetihospital , Gokuleshworhospital in respective local bodies

Allocation of budget MoH Urgently

Drugs, epuipments and instruments

Right logistics in right place with right human resource

MoH, DoHS Urgently

Budget allocation of Bajhang not acc to remoteness

Should be modified from GHA to KA

MoH, DoHS Urgently

Social service unit not established in Tikapurhospital

Should be formulated MoH Urgently

HOSPITAL RELATED ISSUES CONTD ….




No package of orientation health program for elected local level bodies

A minimum of 1 lakh per local body to be allocated for newly elected representatives to orient about the health services of the country.


Hospitalsvs masterplan

Infrastructure development


Budget shiftingtootherpalikaesp.(UHCBajura,Malakheti,Gokule,Saphe NP)

?????????????? MoH As soon as possible

PROGRAM ISSUES: HEALTH GOVERNANCE




Low coverage:Noorientation

Quality of service at entry pointOrientation upto grass root level

Increase coverage and incorporate the beneficiaries

MoHDHOLocal bodies

Urgently

Referralmechanism Establishment of proper referral mechanismGuidelines preparation

Health institutions

Urgently

Coordiantion withRHD

DHOs should coordinate with RHD about program implementation

DHOs Urgently

PROGRAM ISSUES: SOCIAL HEALTH INSURANCE




HR mobilization in federal structure

Clear act and plans for HR mobilization

MoH & line ministries

Urgently

SDG indicators are directly not assessed by HMIS

SDG indicators to be incorporated in HMIS

MoHDoHSMD

Urgently

Existence of Ministry of Health at province level.

?????????? MoH

Karmachari Samayojanof Health services

????????? MoH

POLICY RELATED ISSUES



Activities Proposed for the District to Continue

Key Activities Why How Long

Strategy to strengthen Palika

Full immunization program

To sustain and maintain the NIP

continue

Full institutional delivery initiative

To improve the maternal and neonatal health

2018

Child marriage free district

To improve maternal and neonatal health

2019

Malnutrition free district Improvement of health status

2020

Model health district QoL improved 2021


Activities Proposed for the District to Continue

Key Activities Why How Long

Strategy to strengthen Palika

All programs are crucial


Key Areas to Focus on Orientation to Palika

Health as a fundamental Right and commitment

Universal Health Coverage with GESI aspect

Programatic importance and issues

HRH, logistic and infrastructure management

Socio‐cultural barrier in health


Major Issues by District Issues Doti Aacha

m Baitadi Dadeldhura Bhajhang Bajura Darchul

a Kailali Kanchanpur

Family health

No guideline for no more home delivery campiagn

SBA Training

Inadequate infrastructure,untrained HRH, Shortage of equipments and medicine

Home visit for PNC

No home delivery campiagnby palika

Low and stagnentCPR

Low ANC visit

Low ANC visit

Inadequatecommodities

Child health

EPI training Cold chain center at Palikalevel

Shortage of BCG syringe and IPV

Regular GM

Malnutrition free palikacampaign

Malnutrition

Low GM Irregularsupply of key commodities

Shortage of vaccines


Major Issues by District contd ….

Issues Doti Aacham Baitadi Dadeldhura

Bhajhang Bajura Darchula Kailali Kanchan

pur

Disease control

Inadequate RDTs

No post for ART counsellor at dispensing site

Inadequate training

Regular screening

Hidden HIV and AIDS cases

Increasing Malaria cases

Malariaand Kalaazarcases

Sicklecell anaemia

Sicklecell anaemia

Disaster management

CRRT at Palikalevel

No Ambulance

Lessawareness

Strengthenpreparedness, mitigarion and response

Management ofmedicines, equipments and vechicles

Land slides

Delay in informationsharing

Nobudget for emergency management

Flood





pur

Information management

Inconsistency betweenrecording and reporting

Irregularrecording and reporting

Less priority

Strenthening HMIS

Powerback up problem

No post for Medicalrecorder

Inadequatetrained HR

No clear guideline for information flow through palika

Data qualityassessment

Procurement & supplychain management

Vaccine and syringe shortage

No store buildingat Palikalevel

Gap betweendemand and supply

No storeatpalika

untimely supply

Irregular supply

Inadequatecommodities

Inadequatebudget and guideline

Irregular supply





pur

Hospital services

Expansion of IPD

Vacantposts

Lessawareness

HDC Rules need to be drafted

Inadequateinfrastructure and HRH

Noappropriate OT

Vacant posts

Hand over of hospital building (Malakheti)

Vacant posts

Otherissues

HRHmanagement

Socio‐cultural

poverty

Orientation onhealth system to local bodies

Watersupply

SHI Inadequatebudget for hospital

Socio‐culturalbarriers

Management of hospital pharmacy


EMERGENCY AND RESPONSE BY DISTRICT

• Field visit of flood affected area by Regional Director.

• RRT team lead by MO has been sent to Kailali.


Milestones Reached

• Renovation budget has been added.

• Chaupadi Pratha Prohibition act has been formulated.

• Child marriage prohibition act has been formulated.

• Increasing coverage of Social health Insurance (Kailali, Acham, Baitadi)

• Fully immunized declared District (Acham, Baitadi, Darchula, Bhajang, Dadeldhura, Kanchanpur)


Best Practices/Innovations by District

Baitadi

Sustainability of Fully Immunized districtFully institutional declared 9 VDCs.Child Marriage prohibitionMalnutrition free 1 VDCsModel Health DistrictLocal bodies have allocated NRs. 60 millions.

Achham

PPP model (Bayalpata Hospital)Verbal autopsy of each maternal death and watch groups were strengthened at such places. Audio citizen charterElectronic central billing system in hospitale‐ attendance in DHO

Bajhang No home delivery Initiative for FCHVs for finding out SAM and MAM cases.


Best Practices/Innovations by District

Kanchanpur Electronic Immunization Recording System

Kailali Social Health Insurance Program specially focus to Badghar and Valmansa100 percent GM by Pavera HP

Doti Community Health Score Board, PD (Positive Devince) Hearth/concept of Community rehabilitation center

Darchula Emergency Blood Transfusion Service

BajuraCurative services extended by monthly camps at one health posts from the doctors of DH.No home Delivery.


Way Forward• Availability of tools to negotiate with local bodies• Political commitment and accountability• Newly elected representatives to be oriented about the health services

• Raw meat eating behavior to be changed using various BCC methods.

• Boil milk before consumption as preventive measure to be safe from various communicable diseases.

• Child marriage• Timely acquisition of HR (PSC, Karar)• Timely release of budget and akthayari to districts.• TOR of health coordinators and members



Way Forward contd ….

• Reformation of the Hospital management committee‐orientation on their roles and responsibility as per the new federal system

• Restructuring the organogram of the hospital as per the service provision and fulfill the HR as per the recommendation of WHO and ILO.

• Strengthening recording and reporting

• Availability of Bio Met in every hospital

• Adequate number and sanitary toilets for public.



Way Forward contd ….

• Hospital infrastructure according master plan in local

bodies.

• Protocol and guidelines for utilization of OCMC budget in

the hospital.

• Dietitian position should be created

• Upgrading District Hospital Aacham into 50 beded



Development Partners

CARE Nepal Netherland

s Leprosy Relief (NLR)

Save the children

FAO

SUAAHARA

UNICEF

World Vision

International Nepal

UNFPA

WHO‐IPD

20‐25 September 2017Far West Regional Health Directorate

Dipayal 61

MOH Regular Activities

Multi Sector Nutrition Plan

Golden 1000 Days

ODF

Disable and Disaster Management

Fully Immunization

SDGSLTHPNHSS‐III

HOW?

Logistic and Infrastructure Management

PHC Approach

•Equitable distribution•Intersectoralcoordination•Community participation•Appropriate technology•Multisectoral approach

Financial and Human Resource Management

SDG Indicators•Maternal mortality ratio •Under five mortality rate •Neonatal mortality rate•Total Fertility Rate•Percentage of under five children, who are stunted•Life lost due to road traffic accidents (RTA) per 100,000 population •Suicide rate per 100,000 population

Social Health Insurance


Photos


Store Management Achham


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