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Annual

R e p o rt
Department of Health Services
2073/74 (2016/17)

Government of Nepal
Ministry of Health and Population
Department of Health Services
Kathmandu, Nepal
CONTENTS
Message from Hon'ble State Minister
Preface from Secretaty of Health and Population
Foreword
Acknowledgement
Executive Summary i
Trend of Health Services Coverage Fact-sheet xi
Abbrreviations and Acronyms xvii
National Health Policy 2071 (2014) xxiii
Chapter 1: INTRODUCTION 
1.1 Background 1
1.2 Department of Health Services (DoHS) 3
1.3 Source of information 5
1.4 Structure of the Report 5
Chapter 2: CHILD HEALTH 6-56
2.1 Immunization 6
2.2 Nutrition 25
2.3 Integrated Management of Neonatal & Childhood Illness (IMNCI) 44
Chapter 3: FAMILY HEALTH 57-116
3.1 Family Planning 57
3.2 Safe Motherhood and Newborn Health 71
3.3 Female Community Health Volunteer (FCHV) 88
3.4 Primary Health Care Outreach (PHC/ORC) 91
3.5 Demography and Reproductive Health Research 93
3.6 Adolescent Sexual and Reproductive Health 105
Chapter 4: DISEASE CONTROL 117 - 213
4.1 Malaria 117
4.2 Kala-azar 134
4.3 Lymphatic Filariasis (LF) 139
4.4 Dengue 143
4.5 Zoonoses 145
4.6 Leprosy 149
4.7 Tuberculosis 163
4.8 HIV/AIDS and STI 175
4.9 Eye Care 193
4.10 Entomology 196
4.11 Epidemiology and Disease Outbreak Management 198
4.12 Disaster Management 201
4.13 Surveillance and Research 205
4.14 Homeopathic Services 208
4.15 Human Organ Transplant Services 210
Chapter 5: CURATIVE SERVICES (Inpatients/OPD services) 214 -235
Chapter 6: SUPPORTING PROGRAMS 236 -303
6.1 Health Training 236
6.2 Vector Borne Disease Research & Training 244
6.3 Health Education, Information and Communication 249
6.4 Logistic Management 255
6.5 Public Health Laboratory Services 262
6.6 Personnel Administration Management 268
6.7 Financial Management 272
6.8 Health Service Management 279
6.9 Primary Health Care Revitalization 290
6.10 Medico-Legal services 299
6.11 Monitoring and Evaluation 301
Chapter7: PROGRESS OF OTHER DEPARTMENTS UNDER MoHP 304 - 314
7.1 Derpartment of Drug Administration 304
7.2 Department of Ayurveda 309
Chapter 8 : HEALTH COUNCILS 315 - 332
8.1 Nepal Nursing Council 315
8.2 Nepal Ayurvedic Medical Council 318
8.3 Nepal Health Research Council 320
8.4 Nepal Medical Council 326
8.5 Nepal Health Professional Council 328
8.6 Nepal Pharmacy Council 331
Chapter 9: HEALTH CARE SOCIAL SECURITY 333 - 337
Chapter 10: DEVELOPMENT PARTNER SUPPORT 338- 354
10.1 Multilateral Non-Government Organization 339
10.2 Bilateral Organization 341
10.3 Internal Non-Government Organization 343
10.4 Non-Government Organization 351
ANNEXES
Annex 1: Activities carried out in FY 2073/74 by programs
Annex 2: Target for 2074/75 by programs
Annex 3: Health Services: Estimated Target Population, Raw & Analyzed data sheets
Annex 4: Human Resource (HR) situation by districts
Executive Summary

Executive Summary

A. INTRODUCTION
The annual report of the Department of Health Services (DoHS) for fiscal year 2073/74 (2016/2017)
is the twenty-third consecutive report of its kind. This report focuses on the objectives, targets and
strategies adopted by Nepal’s health programmes and analyses their major achievements and
highlights trends in service coverage over three fiscal years.

This report also identifies issues, problems and constraints and suggests actions to be taken by
health institutions for further improvements. The main institutions that delivered basic health
services in 2073/74 were the 123 public hospitals including other ministries, the 1,715 non-public
health facilities, the 200 primary health care centres (PHCCs) and the 3,808 health posts. Primary
health care services were also provided by 12,180 primary health care outreach clinic (PHCORC)
sites. A total of 16,022 Expanded Programme of Immunization (EPI) clinics provided immunization
services. These services were supported by 49,001 female community health volunteers (FCHV). The
information on the achievements of the public health system, NGOs, INGOs and private health
facilities were collected by DoHS’s Health Management Information System (HMIS).

B. CHILD HEALTH
Immunization
The National Immunization Program (NIP) formerly Expanded Program on Immunization (EPI) was
started in FY 2034/35 and is a priority 1 program. It is one of the successful public health
interventions of Ministry of Health. It made a large contribution to Nepal's achievement of
Millennium Development Goal 4 and 5 by reducing morbidity and mortality among children and
mothers from vaccine preventable diseases.
Nepal's constitution 2015 ensures access to health care as a fundamental right of the people. The
Immunization Act endorsed (BS 2072 Magh 12) says that every child has the right to access quality
vaccines.
National Immunization Program has included several underused and new vaccines in program and
currently there are eleven antigens–BCG, DPT-HepB-Hib (penta), PCV, OPV (bOPV), Measles and
Rubella (MR) and Japanese Encephalitis provided through 16,000 service delivery points in health
facilities (fixed session), outreach sessions and mobile clinic (sessions). Government of Nepal
procures BCG, OPV, Td , JE, measles/rubella 1st dose and co-finances to GAVI supported vaccines
DPT-HepB-Hib (penta), PCV and measles component of MR2. Aiming to reach every child in country,
some innovative activities have also been carried out in country like Full Immunization declaration
initiative, Immunization Act, rule and immunization fund creation.
The coverage of all antigens increased in 073/74 compare to 072/073. The highest coverage was of
BCG (91%), DPT-HepB-Hib3 (86%), oral polio vaccine 3 (86%), which were all more than the previous
year. The measles rubella second dose was introduced in 2072/73 and had the lowest coverage
(57%) however it is more than previous year.

Nutrition
The national nutrition programme is priority programme of the government. It aims to achieve the
nutritional well-being of all people so as they can maintain a healthy life and contributed to the
country's socioeconomic development. There is high level commitment to improving the nutritional
status especially of women and of young children.

Nutrition is a globally recognized development agenda. Since the year 2000, several global
movements have advocated nutrition for development. The Scaling-Up-Nutrition (SUN) initiative
DoHS, Annual Report 2073/74 (2016/17) i
Executive Summary
calls for multi-sectoral action for improved nutrition during the first 1,000 days of life. The
Government of Nepal as an early member of SUN adopted the Multi-sector Nutrition Plan (MSNP) in
2012 to reduce chronic nutrition. The UN General Assembly declared the 2016–2025 period as the
Decade of Action on Nutrition. Aligning with the MSNP and current global initiatives, CHD – nutrition
section has developed strategies and plans for improving maternal infant and young child nutrition
assisted by experts from the Nutrition Technical Committee. Moreover, as recommended by the
Nepal Nutrition Assessment and Gap Analysis (NAGA) and guided by MSNP, in 2012–2013 MoH
conducted an Organization and Management Survey towards establishing a National Nutrition
Centre for implementing MSNP in the health sector. Recently, MSNP-2 has been approved for
2075/76 – 2079/80.
In 2073/74 an average of 3 growth monitoring visit was carried out by 0-23 month's children at
national level which is slightly decreased as of previous year. Sixty three percent children aged 0-23
months were registered for growth monitoring which is six percent more than 2072/73 and twenty-
five percent of 0-6 months infants registered for growth monitoring who were exclusively breastfed
for their first six months which is 6.65 percent less than 072/073.
Integrated Management of Childhood Illness
In October 2014 the childhood (CB-IMCI) and newborn (CBNCP) care programmes were merged into
the Community Based Integrated Management of Childhood Illness (CB-IMNCI) programme to give a
more integrated approach. It is an integrated package of child-survival interventions and addresses
major newborn care conditions including birth asphyxia, bacterial infection, jaundice, hypothermia,
low birth weight, and encouragement of breastfeeding. It addresses the major illnesses of 2 to 59
month old children — pneumonia, diarrhoea, malaria, measles and malnutrition, in a holistic way.

In fiscal year 2073/74, 25,742 newborns cases (aged 0-28 days) were registered and treated at
health facilities and PHC/ORCs of whom 12,295 were treated for local bacterial infections and 3,713
for possible Severe Bacterial Infections (PSBI). In the same year, 31,098 infants (29-59 day old) were
treated at health facilities and PHC/ORCs of whom 2,765 were treated for PSBI. At the national level
1.0 percent 0-59 day old (among expected number of live births) suffered from PSBI. And 58.4
percent of all PSBI cases were treated with a complete dose of gentamycin.

In 2073/74, 1,184,120 cases of Diarrhoea were reported of which 0.44 percent suffered from severe
dehydration (increased from 0.2 percent the previous year). The national incidence of diarrhoea per
1,000 under-5 year olds decreased from 422/1,000 in 2072/73 to 400/1000 in FY 2073/74. In FY
2073/74, a total of 1,810,722 ARI cases were registered, out of which 10.5% were categorized as
pneumonia cases and 0.29% were severe pneumonia cases. The incidence of pneumonia (both
pneumonia and severe pneumonia at HF and PHC/ORC) at national level was 64 per 1000 under five
children as compared to 147 per 1,000 under-five children in the previous fiscal year (FY 2072/73).

C. FAMILY HEALTH
Family planning
In order to provide the reproductive population with options to limit or space births, various modern
contraceptive methods are made available under the national health services delivery system.
Family planning services are provided through different health institutions at various levels through
static clinics as well as mobile outreach services. The Contraceptive Prevalence Rate (CPR) is one of
the main indicators for monitoring and evaluating the National Family Planning Program. The
contraceptive prevalence rate (CPR) for modern family planning method is 44% at national level in
fiscal year 2073/74. There has been a one percentage point increase in modern CPR at national level
in FY 2073/74 than in FY 2072/73. There is wide variation in CPR at the province level with lowest
35% in Province 4 and highest 49% in Province 2

ii DoHS, Annual Report 2073/74 (2016/17)


Executive Summary
Safe motherhood
During FY 2073/74, the national level ANC 4th visit (as per protocol) as percentage of expected
pregnancy has been increased to 52%. Similarly, the institutional delivery has slightly been increases
to 57% in FY 2073/74 as compare to 55% in FY 2072/73. Percentage of mothers who received first
postnatal care at the health facility among expected live births has also slightly decreased to 51% in
FY 2073/74 from 57% of FY 2072/73. During FY 2073/74, a total of 96417 CAC service has been
provided, out of which, 44% women had received medical abortion service. While about 70%
women had received post abortion family planning services. Contribution of Long Acting FP service
out of total post abortion FP is appeared to be only about 16% (a 2% point increase in FY 2073/74
than in FY 2072/73.

Female community health volunteers


The major role of the Female Community Health Volunteers (FCHVs) is promotion of safe
motherhood, child health, family planning, and other community based health services to promote
health and healthy behavior of mothers and community people with support from health workers
and health facilities. At present there are 51,470 FCHVs (47,328 FCHVs at rural/VDC level and 4,142
at urban/municipality level) actively working all over the country. FCHVs contributed significantly in
the distribution of oral contraceptive Pills, Condoms and Oral Rehydration Solution (ORS) packets
and counseling and referring to mothers in the health facilities for the service utilization. FCHVs have
distributed a total of 9983370 packets of Condom in FY 2073/74. Service statistics also show that
more than one half of the diarrhoea and ARI cases were treated by FCHVs.

Primary health care outreach clinics


Based on the local needs PHC/ORCs are conducted every month at fixed locations of the VDC on
specific dates and time. The clinics are conducted within half an hour's walking distance for the
population residing in that area. Primary health care outreach clinics (PHC/ORC) extend basic health
care services to the community level.

Total number of clinics expected to run in a year 159,764 (13,314 PHC/ORC Clinics x 12 times).
However, only 83% clinics were conducted in FY 2073/74. On an average 19 clients were served per
clinic during the fiscal year 2073/74 and it was slightly increased compared to FY 2072/73 (16%).

Adolescent sexual and reproductive health


The National ASRH program has been gradually scaled up to 70 of the 75 districts covering 1134
health facilities till the end of current fiscal year 2073/74. Different development partners such as
UNFPA, UNICEF, WHO, Save the Children, Ipas, ADRA Nepal and MSI Nepal at national and sub-
national level supported to Family Health Division (FHD) for scaling up and strengthening ASRH
services in the health facilities in order to make those health facilities as adolescent friendly service
sites. The remaining five districts (Manang, Mustang, Dolpa, Rasuwa and Sindhupalchowk) will be
covered in the running FY 2074/75.
Demography and reproductive health research
Planning, monitoring and evaluation of reproductive health (RH) activities are the key functions of
Program, Budget and Demography Section. This section conducts periodic and ad hoc studies and
also coordinates reproductive health related research and studies carried out by other organizations
in Nepal. In addition to the development of annual program and Budget, target population setting,
and guideline/ documents, implementation of Maternal and Perinatal Death Surveillance and
Response (MPDSR) was a major activity conducted in FY 2073/74 through Demography Section.

A total of 1076 persons including health facility personnel and district stakeholders were trained in
MPDSR during FY 2073/74. Furthermore, all FCHVs of Baitadi had also received MPDSR orientation.

DoHS, Annual Report 2073/74 (2016/17) iii


Executive Summary
As per government commitment to count every maternal deaths, community-level MPDSR has been
expanded in 6 districts by the end of FY 2073/74 and Ministry of Health has planned to gradually
expand this to all 75 districts. In addition, facility-based MPDSR has already started in 42 hospitals in
FY 2073/74.

D. DISEASE CONTROL
Malaria
Nepal has surpassed the Millennium Development Goal 6 by reducing malaria morbidity and
mortality rates by more than 50% in 2010 as compared to 2000. Therefore, Government of Nepal
has set a vision of Malaria free Nepal in 2025. Current National Malaria Strategic Plan (NMSP) 2014-
2025 was developed based on the epidemiology of malaria derived from 2012 micro-stratification,
The aim of NMSP is to attain “Malaria Free Nepal by 2026”.

Total positive cases of malaria slightly increased to last fiscal year from 991 in FY 2072/73 to 1128 in
2073/74 where 492 cases are indigenous cases and 636 are imported casesdue to active
surveillance. The proportion of P. falciparum infections is decreasing trend and reached 13.1 % in
current FY2073/74 as compared to the previous year, however still the proportion is high which may
be due to high number of imported P. falciparum cases.The trend of indigenous pf malaria cases are
decreasing while imported cases of pf are in increasing trend. The trend of clinically suspected
malaria case, slide positivity rate, pf and pv malaria cases also decreasing year by year, mainly due to
increased coverage of RDT, microscopic laboratory service at peripheral level, high coverage of LLINs
in endemic districts and increased socio-economic status of community people.

Kala-azar
Kala-azar is a major public health problem in 18 districts of Nepal and to eliminate Kala azar in Nepal
set goal to improving the health status of vulnerable groups and at risk populations living in kala-azar
endemic areas of Nepal by eliminating kala-azar so that it is no longer a public health problem. The
incidence of kala-azar at national and district level has been less than 1/10,000 population since
2013. The trend of KA cases has been decreasing significantly for the last several years. In FY
2073/2074, total 225 native cases and 6 foreign cases were reported. 157 cases were reported from
programme district while other cases were from other nonprogrammer district. The case fatality
rate was 0.3 percent in 2073/2074.

Lymphatic filariasis
Lymphatic Filariasis (LF) is a public health problem in Nepal. The goal of national Lymphatic Filariasis
programme is the people of Nepal no longer suffer from lymphatic filariasis. As of 2073/74, MDA has
been stopped (phased out) in 31 districts, post-MDA surveillance initiated in 20 districts and
morbidity management partially initiated in all endemic districts. All endemic districts will complete
the recommended six rounds of MDA by 2018. The LF elimination programme has also indirectly
contributed to strengthening of health system through trainings and capacity building activities. The
transmission assessment survey in 31 districts in 2016 found that the prevalence of infection had
significantly reduced. Since 2003 more than 100 million doses of lymphatic filariasis drugs have been
administrated to at-risk population. 2172 hydrocele surgeries have been performed in year
2073/074.

Dengue
Dengue, a mosquito-borne disease emerged in Nepal in since 2005. The goal of national Dengue
control program is to reduce the morbidity and mortality due to dengue fever, dengue haemorrhagic
fever (DHF) and dengue shock syndrome (DSS).The number of reported dengue cases has decreased
significantly since 2010 but cases of dengue were increased in 2073/74 fiscal year. The majority of
iv DoHS, Annual Report 2073/74 (2016/17)
Executive Summary
cases have been reported from Chitwan, Jhapa and Rupandehi with more than 46 percent of
2073/74 cases from Chitwan. Total 1527 cases reported from 42 districts.

Zoonoses
Nepal has dual burden of disease and zoonotic diseases of epidemic, endemic and pandemic
potentials are major public health concerns. Globally more than 300 Zoonotic diseases are identified
among which about 60 have been identified in Nepal as emerging and re-emerging diseases. No
Nepalese dies of rabies or poisonous snake bites due to the unavailability of anti-rabies vaccine
(ARV) or anti-snake venom serum or timely health care services and to prevent, control and manage
epidemic and outbreak of zoonoses is the goal of zoonoses program. Around 30,000 cases in pets
and more than 100 human rabies cases occur each year with the highest risk are in the Terai. During
the FY 2073/74, 39,744 dog and other animal bites cases has been reported including 8 deaths
throughout the Nepal and 6121 cases of Snake bite has been reported. 33 deaths due to snake bite
has been reported this year.

Leprosy
During the reporting year 2073/74, a total number of 3215 new leprosy cases were detected and put
under Multi Drug Therapy (MDT). 2626 cases were under treatment and receiving MDT at the end of
the fiscal year. Registered prevalence rate of 0.92 cases per 10,000 population at national level was
reported this year which is below the cut-off point of below 1 case per 10,000 population as per the
standard set by WHO. 87 (2.71%) new leprosy cases of Grade 2 Disability (G2D), 220 (6.84%) new
child leprosy cases and 1361 (42.33%) new female leprosy cases were recorded. The increasing trend
of registered prevalence rate after the elimination in 2009 is a serious concern for leprosy control
programme hence early and active case detection activities need to be amplified and
records/reports of local health facility level needs to be verified and validated.
Leprosy Control Division, Disability Focal Unit had recently endorsed Policy, Strategy and 10 Years
Action Plan on Disability Management (Prevention, Treatment and Rehabilitation). The unit is
coordinating with DPOs and related organization for the disability prevention and rehabilitation of
people with disability

Tuberculosis
Tuberculosis (TB) is still a major public health problem in Nepal. Directly Observed Treatment short
course (DOTS) have successfully been implemented throughout the country since April 2001 and a
total of 4344 DOTS treatment centers are providing TB treatment service throughout the country. In
Fiscal Year 2073/74, total of 31,765 cases of TB were registered. Among them, 54.63% were
pulmonary bacteriologically confirmed (PBC). Most cases were reported among the middle-aged
group with the highest among 15-24 year of age (20%). The childhood TB (new and relapse) was
5.7%. The Case Notification Rate (CNR) all forms was 111 per 100,000 population. The Midwest
Region hold highest case (CNR 128) followed by central region (CNR 123), far western region (CNR
109), western region(CNR 106) and eastern region (CNR 83). Whereas in eco-terrain, CNR was
highest in Terai zones followed by hill and mountain zones with rates of 123, 104 and 61 per 100,000
populations respectively.

The overall treatment success rates (all forms) of drug susceptible TB was 92.%. The treatment
success rates of new and re-treatment Pulmonary Bacteriological Confirmed (PBC) was 90%
compared 93 % in new Pulmonary Clinically Diagnosed (PCD) and Extra Pulmonary cases. Failure rate
in new PBC was 1.2% compared to 2.2% in retreatment cases, 0.1% in new PCD cases and 0.16% in
EP cases. National Tuberculosis program, Nepal was able to save 29,027 lives in FY 2073/74
nationally, but still 971 deaths were reported among general TB cases.

DoHS, Annual Report 2073/74 (2016/17) v


Executive Summary
HIV/AIDS and STI
Making up 3.6% of the total estimated people living with HIV (PLHIV) (32,735), there are about 1,197
children aged up to 14 years who are living with HIV in Nepal in 2016, while the adults aged 15 years
and above account for 96.4%. Almost 75% of total estimated infections (31,539) among population
aged 15-49 years. By sex, males account for two-thirds (62%) of the infections and the remaining
more than one-third (38%) of infections are in females. The prevalence of HIV among 15-49 years of
age group is 0.17% in 2016. Total 14,544 PLHIV are on ART treatment by the end of FY 073/74.

Eye care
Nepal’s eye care programme is run by Nepal Netra Jyoti Sangh and is a successful example of an
NGO-run eye care programme. The prevalence of blindness in Nepal has reduced at the current
time. In 2073/74, Nepal’s hospitals, eye care centres and outreach clinics provided 3,873,340
outpatient consultations and performed 317,901 eye surgeries.

Human Organ Transplant services


National Transplant Center's main objectives are to strengthen and expand organ transplantation
services, provide specialized services beyond transplantation along with high quality health care at a
low price/free of cost and produce high level human resources by providing structured training in
various aspects of services to expand the services across the country. During this reporting year a
total number of 22,473 OPD services, 518 minor and 1,101 major surgeries, 132 kidney
transplantation and along with two liver transplantation (which was first of its kinds in the nation)
services were provided.

Entomology
Entomology section/entomology lab is one of the integral parts of Epidemiology and Disease Control
Division. It is accountable to plan, implement, monitor & supervise all entomological activities like
surveillance, risk assessment & operational research of vectors borne diseases as well other
emerging and re-emerging diseases having potential of outbreak and prone to be epidemic in
nature. In FY 2073/74, investigations and an entomological survey was conducted in 12 different
districts of five regions of Nepal. In that survey Anopheles mosquitoes were collected. These are the
common species of anopheles mosquito which were found in that survey.

Epidemiology and outbreak management


In Nepal communicable disease outbreak are common and occur in different district. Forty-one
communicable disease outbreaks were recorded in Nepal in 2073/74, which affected 3,565 people
and resulted in 29 deaths. There were major outbreaks of acute gastroenteritis and diarrhoea,
cholera, leptospirosis, scrub typhus, influenza, food poisoning, mushroom poisoning and dog bite.
The average case fatality rate was 0.81 percent. The Scrub Typhus outbreak had the greatest
morbidity. Mushroom poisoning also had a high case fatality rate (45%). Reported water and food-
borne diseases were more prevalent this year.

Disaster management
This collaborative programme between MoH/DoHS/EDCD and WHO-EHA has been committed to
enhancing health sector emergency preparedness, disaster response and epidemiology and
outbreak management capabilities in close coordination & collaboration with key players in the
country. In the fiscal year 2073/74, no any such disaster event was recorded which affected the
health of people. District health sector contingency planning, Rapid Response training, Emergency
and disaster preparedness planning activities were carried out for disaster preparedness.

vi DoHS, Annual Report 2073/74 (2016/17)


Executive Summary
Surveillance and research
Disease surveillance and research is an integral part of Epidemiology and Disease Control Division.
This section came into existence in August 12, 2013 (Shrawan 28, 2070 BS). The mission of the
communicable diseases Surveillance program is to protect and improve the health of Nepalese
citizens by tracking and responding to the occurrence of disease in the population across the
country. In 2073/74 an additional 4 sentinel sites were trained on EWARS (District hospital Khotang,
District hospital Panchthar, District hospital Manang and Bayalpata hospital, Achham) bringing the
number of EWARS sentinel sites to 64. Similarly Water quality surveillance Central committee
(WQSCC) meeting with stakeholder and organized water quality surveillance workshop at
Arghakhanchi, Baglung and Gorkha districts. Surveillance of reportable diseases is responsible for
collecting, analyzing, interpreting, and reporting information for infectious diseases.

E. CURATIVE SERVICES
In 2073/74, curative health services were provided to outpatients, including emergency patients,
and inpatients including free health services. Inpatient services were provided different level of
hospitals including INGOs/NGOs, Private medical college hospitals, nursing homes, and private
hospitals. In this fiscal year 2073/2074, 72% of the total population received outpatients (OPD)
services, 1,322,816 patients were admitted for hospital services and 1,765,764 patients received
emergency services from hospitals.

F. SUPPORTING PROGRAMMES
Health Training
The National Health Training Centre is the apex body for human resource development in Nepal’s
health sector. The NHTC has five regional training centres, one sub-regional centre, 34 clinical
training sites and 75 district training units. The Training Working Group ensures the efficient running
of national health training programmes, maintains the quality of training and improves the
coordination of all training provided under NHTC. In 2073/74 initiated a number of new training
programmes including on primary trauma care management, on-the-job training for gynaecologists
and obstetric fistula training.

Vector Borne Disease Research & Training


Vector Borne Disease Research & Training Center (VBDRTC) became semi autonomous with the
effect of Development Board Act from 24th January 2000. Now the center is being governed by the
Development Board. Main objective of training center is to fulfill the knowledge and management
gap between vector borne disease and program to the VBD focal persons. Mostly who were not
trained before or newly recruited also enhance the level of knowledge and skills of the participant
pertaining to prevalent and possible vector borne diseases. VBDRTC is responsible for research and
training of VBDS including Malaria, Kala-azar, Dengue, Chikungunaya, Lymphatic Filariasis, Scrub
typhus and Japanese encephalitis.

Health education, information and communication


The National Health Education, Information and Communication Center(NHEICC) is the apex body
under Ministry of Health for planning, implementing, monitoring and evaluating Nepal's health
promotion, education and communication programmes including periodic surveys and research. The
major achievements in 2073/74 at the central level were the development and implementation of
health communication policies, strategies, development and broadcasting of health message
through various methods and media. More over MERO BARSA 2074" Ma Swastha Mero, Desh
Swastha" health promotion campaign was launched and implemented, Tobacco Control
Intervention, Golden 1000 Days Communication Campaign and health information related Mobile
SMS messages were delivered.

DoHS, Annual Report 2073/74 (2016/17) vii


Executive Summary

At the district level, behavior change communication activities were conducted for preventing and
controlling epidemics, broadcasted health message through local FM Radio, developed need based
IEC materials and distributed to health facilities.

Logistics management
The main role of Logistics Management Division is to support in delivering quality health care
services providing by program divisions and centers through logistics supply of essential equipments,
vaccines, family planning commodities and free health drugs to all regional /district stores and
health facilities. The major function of LMD is to forecast, quantify, procure, store and distribute
health commodities, equipments, instruments and repairing & maintaining of the bio-medical
equipments/instruments and transportation vehicles. The quarterly LMIS and monthly Web-based
LMIS have facilitated evidence based logistics decision making and initiatives in annual logistics
planning, quarterly national pipeline review meetings, the consensus forecasting of health
commodities and the implementation of the pull system. LMD carried out Regional Procurement and
Supply Chain Workshop in all regions of the country to address the problems and issues faced by the
districts in procurement and supply chain management of health commodities in the region and
district.

LMD has form a authorized 23 members Logistics Working Group (LWG) under the chaired of LMD
Director with representation of Divisions, Centers, supporting partners and other stakeholders. LWG
address all issues and challenges on procurement and supply chain on health commodities and
materials in center, region and district level.

Health laboratory services


The National Public health laboratory (NPHL) is the Nodal Institute for capacity building and for the
development of public health laboratory sector. There are diagnostic health laboratories in 8 central
hospitals, 3 regional hospitals, 3 sub-regional hospitals, 10 zonal hospitals, 62 district hospitals, 22
other district level hospitals, 204 PHCCs and more than 1,500 private health institutions.
In 2073/74, NPHL provided various types of routine and specialized laboratory services with more
biochemistry, haematology, parasitology, immunology, virology, endocrinology, and microbiology
test carried out more than in the previous year.

Personnel administration
The Personnel Administration Section is responsible for routine and programme administrative
function. Its major functions include upgrading health institutions, the transfer of health workers,
level upgrading of health workers up to 7th level, capacity building as well as internal management
of human resources of personnel. MoH has more than 30,000 employees of whom more than
24,000 are technical personnel and 6,300 are administrative staff across the 196 sanctioned types of
technical and administrative posts.

Financial management
An effective financial support system is imperative for the efficient management of health services.
DoHS’s Finance Section is the focal point for financial management for all programmes under DoHS.
In 2073/74 out of total national budget of Rs. 10,48,92,13,54,000 a sum of Rs. 40,56,30,27,000
(3.86%) was allocated for the health sector during the reporting year. Of the total health sector

viii DoHS, Annual Report 2073/74 (2016/17)


Executive Summary
budget, Rs. 31,45,05,36,111 (77.53%) was allocated for the execution of programs under the
Department of Health Services Network

Health service management


The Management Division is responsible for DoHS’s general management functions. The division’s
major ongoing activities were institutionalizing the use of geographic information systems for health
service planning, developing the Health Infrastructure Information System (HIIS), the construction
and maintenance of health facility buildings and other infrastructure, and health facility upgrading.
Other activities included HMIS training for newly recruited health workers, arranging the supply of
HMIS recording and reporting tools. Managed the provision of free treatment to impoverished
citizens including 5,821 Cancer, 3,291 Heart disease and 5,888 Kidney free treatment services

Primary health care revitalization


The Primary Health Care Revitalization Division is responsible for strengthening Primary Health Care
by increasing access to basic free health services especially for poor, disadvantaged and unreached
population groups. Its main achievements in 2073/74 were related to increasing access to free basic
health services, improving social health protection and strengthening urban health including non
communicable disease services.

Medico-legal services
Medico-legal services include forensic, pathology, autopsy, clinical forensic medicine and toxicology
services. Medico-legal services have been neglected in Nepal’s health system. The report presents
five recommendations for improving medico-legal services in Nepal: recognizing the specific nature
of the forensic/medico-legal service sector, training district medical officers and other health
professionals to provide medico-legal services, providing facilities, providing incentives and
remuneration and improving coordination between investigating authorities.

Monitoring and evaluation


As in previous years the Health Management Information System (HMIS) Section collected, collated
and provided information on the activities undertaken at the district level to all DoHS divisions,
centres, regional directorates, and the 75 district health and district public health offices. Annual
performance review workshops were conducted in all districts and regions / national level. Several
trainings were conducted on programme management to improve the skills of health workers.
Ninety-two percent of targeted activities were carried out in 2073/74.

G. PROGRESS OF OTHER DEPARTMENTS


The Department of Drug Administration (DoA) is responsible for regulating all functions related to
modern, veterinary and traditional medicines. Its manages the delivery of Ayurveda health services.
The department runs two Ayurveda hospitals, 14 zonal Ayurveda dispensaries, 61 district Ayurveda
health centres and 305 Ayurveda dispensaries. In 2072/73, there were 1,034,029 outpatient
consultations and a total of 1.2 million client-visits for Ayurveda treatment at DoA institutions.

H. HEALTH COUNCILS
The six professional health councils (Nepal Medical Council, Nepal Nursing Council, Nepal Ayurvedic
Medical Council, Nepal Health Professional Council, Nepal Pharmacy Council and Nepal Health
Research Council) accredit health-related schools and training centres and regulate care providers.

DoHS, Annual Report 2073/74 (2016/17) ix


Executive Summary
I. HEALTH CARE SOCIAL SECURITY
The Social Health Security Program was initiated in April 2016 in Kailali district and in June 2016 in
Baglung and Ilam districts. As such, the program was rolled out to three districts in FY 2072/73. In
the FY 2073/74, the program was expanded to additional 12 districts. By the end of this year 228,113
people have been enrolled to the program. More than 63 million annual contributions have been
collected.

J. DEVELOPMENT PARTNER SUPPORT


Development partners support the government health system through a sector-wide approach
(SWAp). The SWAp now supports the implementation of the new Nepal Health Sector Strategy
(NHSS, 2016–2021). The Joint Financing Arrangement (JFA) has been signed by various partners and
the government. The JFA describes in detail the arrangement for partners’ financing of the NHSS.
The JFA elaborates the pool funding arrangement and parallel financing mechanism as bilaterally
agreed between the government and the donor partners.

x DoHS, Annual Report 2073/74 (2016/17)


Department of Health Services
Trend of Health Service Coverage Fact Sheet
Fiscal Years 2071/72 to 2073/74 (2014/15 to 2016/17)
Province level, FY 2073/74
National level
PROGRAMME Province No
INDICATORS 2071/72 2072/73 2073/74
(2014/15) (2015/16) (2016/17)
1 2 3 4 5 6 7
REPORTING STATUS
% of public
hospitals
92 89 93 100 85 88 92 99 93 93
reporting to
HMIS
% of primary
health care
centres 99 100 98 97 97 100 94 100 99 100
reporting to
HMIS
% of health posts
reporting to 99 99 100 99 99 100 99 100 99 100
HMIS
% of PHC-ORC
clinics reporting 81 92 89 93 82 88 92 94 85 93
to HMIS
% of EPI clinics
reporting to 92 88 100 97 100 97 98 98 97 97
HMIS
% of female
community
health
volunteers 87 82 90 88 94 88 94 91 85 92
(FCHVs)
reporting to
HMIS
% of private
health facilities
68 80 47 52 20 52 56 35 37 62
reporting to
HMIS
IMMUNIZATION
% of children
under one year
94 87 91 92 103 85 75 92 101 87
immunized with
BCG
% of children
under one year
91 82 86 87 99 76 76 87 97 85
immunized with
DPT-HepB-Hib3
% of children
under one year
90 79 86 86 98 75 76 87 96 85
immunized with
OPV 3
% of one-year-
old children
immunized 85 77 84 84 91 76 75 86 96 85
against
measles/rubella

DoHS, Annual Report 2073/74 (2016/17) xi


Province level, FY 2073/74
National level
PROGRAMME Province No
INDICATORS 2071/72 2072/73 2073/74
1 2 3 4 5 6 7
(2014/15) (2015/16) (2016/17)
% of children 12-
23 months
immunized 53 63 67 73 65 59 71 72 64 71
against Japanese
encephalitis
Immunization
programme:
Dropout rate 3.2 5.0 4.7 3.5 10.8 0.9 1.6 3.7 4.7 2.1
DPT-Hep B-Hib 1
vs 3 coverage
NUTRITION
% of children
aged 0-12
months
97 78 85 83 75 68 84 100 127 91
registered for
growth
monitoring
Average number
of visits among
children aged 0-
24 months 3 3 3 4 2 3 4 3 3 4
registered for
growth
monitoring
% of children
aged 0- 6
months
registered for
growth 29 32 25 21 3 41 14 37 36 26
monitoring,
exclusively
breastfed for the
first six months
% of children
aged 6–8
months
registered for
growth 28 32 31 24 3 65 12 37 40 27
monitoring
received solid,
semi-solid or
soft foods
% of children
aged 6-23
months, who
received 1st
19 21 34 39 9 77 12 40 7 14
dose of Baal Vita
(MNP) in 15
programme
districts
Percentage of
78 64 69 64 63 56 69 79 110 77
children aged 0-

xii DoHS, Annual Report 2073/74 (2016/17)


Province level, FY 2073/74
National level
PROGRAMME Province No
INDICATORS 2071/72 2072/73 2073/74
1 2 3 4 5 6 7
(2014/15) (2015/16) (2016/17)
23 months
registered for
growth
monitoring
Percentage of
pregnant women
52 49 44 41 43 32 46 58 50 52
received 180
tablets Iron
ACUTE RESPIRATORY INFECTION (ARI)
Incidence of
acute respiratory
infection (ARI)
per 1,000 765 648 612 717 472 439 597 576 927 992
children under
five years (new
visits)
Incidence of
pneumonia
among children
under five years 188 147 *66 89 53 51 52 55 117 86
(per 1,000)
Note*= HFs
reporting only
% of children
under five years
with ARI 25 22 10 12 11 11 9 9 12 8
suffering
pneumonia
Percentage of
severe
Pneumonia 0.4 0.3 0.3 0.3 0.3 0.3 0.1 0.2 1.5 0.3
among new U5
yrs cases
DIARRHOEA
Incidence of
diarrhoea per
1,000 under five 502 422 400 376 335 288 302 411 722 697
years children
(new cases)
% of children
under 5 with
diarrhoea 93 87 92 86 95 92 97 89 96 94
treated with zinc
and ORS
% of children
under five years
with diarrhoea 0.64 0.8 0.7 0.1 0.2 0.1 0.02 0.1 0.1 0.1
treated with IV
fluid
Percentage of
children U5 0.3 0.2 0.4 0.1 0.1 0.1 0.01 0.1 0.1 0.4
years with
DoHS, Annual Report 2073/74 (2016/17) xiii
Province level, FY 2073/74
National level
PROGRAMME Province No
INDICATORS 2071/72 2072/73 2073/74
1 2 3 4 5 6 7
(2014/15) (2015/16) (2016/17)
diarrhea
suffering from
Severe
dehydration
Percentage of
children U5
years with
189 174 156 138 178 141 195 170 145 147
Pneumonia
treated with
antibiotics
SAFE MOTHERHOOD
% of pregnant
women who
52 66 64 61 81 49 57 71 64 65
received Td 2
and 2+
% of pregnant
women
96 97 102 95 103 109 102 103 110 92
attending first
ANC visit
% of pregnant
women
52 51 53 44 37 68 59 58 49 54
attending four
ANC visits
% of pregnant
women receiving
IFA tablets or
52 49 40 32 40 24 32 55 66 56
syrup during
their last
pregnancy
% of postpartum
mothers who
49 51 72 64 87 46 67 84 95 81
received vitamin
A supplements
% of institutional
52 55 55 49 44 53 46 69 60 68
deliveries
% of deliveries
conducted by a
51 54 52 48 45 52 46 65 51 60
skilled birth
attendant
% of postpartum
women received
PNC checkup 48 52 51 42 44 48 65 59 49 67
within 24 hours
of birth
% of women
who had three
20 18 19 9 23 13 14 25 20 35
PNC check-ups
as per protocol
FAMILY PLANNING
FP Methods New
acceptor among 11 11 10 9 7 9 10 14 14 14
as % of MWRA
xiv DoHS, Annual Report 2073/74 (2016/17)
Province level, FY 2073/74
National level
PROGRAMME Province No
INDICATORS 2071/72 2072/73 2073/74
1 2 3 4 5 6 7
(2014/15) (2015/16) (2016/17)
Contraceptive
prevalence rate
43 43 43.6 47.8 49.4 41.1 35.6 43.6 37.4 40.5
(CPR-
unadjusted)
CPR method mix
3.5 3.5 3.6 2.5 2.0 2.4 3.7 5.7 4.9 6.2
– condoms
CPR method mix
3.0 3.0 3.0 3.7 1.6 2.4 2.9 4.5 2.4 3.5
- pills
CPR method mix
6.9 6.7 7.3 12.1 4.3 6.8 4.8 8.0 7.0 7.2
- Depo
CPR method mix
2.6 2.7 2.8 2.3 1.0 5.2 3.0 3.2 2.0 2.0
- IUCD
CPR method mix
2.8 4.0 4.6 4.1 1.3 6.9 3.2 6.0 5.7 5.4
- implants
CPR method mix
23.8 22.5 22.3 23 39 17 18 16 15 16
- sterilization
Sterilization (Tar
62 78 77 87 86 65 73 55 87 72
vs Achiev.)
FEMALE COMMUNITY HEALTH VOLUNTEERS (FCHV)
Total number of
FCHVs 410
51470 51416 49101`* 8578 7073 9016 5767 8718 5747
(Note =*= HMIS 2
source)
% of ARI cases
managed by
FCHVs among
57 41 59 53 55 58 52 57 49 63
ARI cases in
children under
five years
% of mothers
100 94 86 83 91 81 86 88 80 92
group meeting
% of PHC/ ORC
conducted
84 82 89 93 82 88 92 94 85 93
among planned
PHC/ORC
MALARIA AND KALA-AZAR
Malaria Blood
Slide collection(
69 78 77 38 45 38 112 125 83 140
target vs
achieve )
Malaria Slide
examination
126 112 101 100 100 107 102 101 105 100
(collection vs.
exam.)
Annual blood
slide
0.75 0.84 0.79 0.44 0.51 0.42 0.87 1.07 0.70 1.60
examination rate
(ABER) per 100
Annual parasite
incidence (API) 0.10 0.07 0.08 0.02 0.04 0.03 0.03 0.08 0.13 0.03
per 1,000

DoHS, Annual Report 2073/74 (2016/17) xv


Province level, FY 2073/74
National level
PROGRAMME Province No
INDICATORS 2071/72 2072/73 2073/74
1 2 3 4 5 6 7
(2014/15) (2015/16) (2016/17)
population at
risk
Clinical malaria
20861 10642 3904 987 1377 421 62 723 39 295
cases
Incidence of
kala-azar per
10,000 0.25 0.12 0.11
population at
risk
TUBERCULOSIS
Case notification
rate (all forms of 123 113 111 84 109 128 81 135 98 110
TB)
Treatment
92 90 91 90 93 91 91 92 92 87
success rate
LEPROSY
New case
detection rate
(NCDR) per 11 11 11 11 20 4 5 19 7 8
100,000
population
Prevalence rate
0.9 0.9 0.9 0.8 1.5 0.3 0.5 1.6 0.6 0.7
(PR) per 10,000
HIV/AIDS AND STI
Number of HIV
264081 122888 176228 31780 14245 39043 4530 45104 682 40844
testing
Number of new
1480 2163 1781 207 273 630 108 134 9 208
positive cases
% of positivity
0.6 1.8 1.0 0.7 1.9 1.6 2.4 0.3 1.3 0.5
yield
CURATIVE SERVICES
% of population
utilizing
73 66 72 78 47 82 96 69 78 71
outpatient (OPD)
services
Average length
3 4 3 3 2 4 3 3 3 3
of stay
Source: HMIS/DoHS

xvi DoHS, Annual Report 2073/74 (2016/17)


ABBREVIATIONS AND ACRONYMS

AA anaesthesiologist assistant
AAHW auxiliary Ayurveda health worker
ADRA Adventist Development and Relief Agency
AEFI adverse event following immunization
AES acute encephalitis syndrome
AFP acute flaccid paralysis
AFS adolescent‐friendly services
AGE acute gastroenteritis
AHA Ayurveda Health Assistant
AHW auxiliary health worker
AIDS acquired immuno‐deficiency syndrome
AMDA Association of Medical Doctors of Asia
AMR antimicrobial resistance
ANC antenatal care
ANM auxiliary nurse-midwife
API annual parasite incidence
ARI acute respiratory infection
ART antiretroviral therapy
ARV anti-rabies vaccine and antiretroviral
ASBA advanced skilled birth attendant
ASRH adolescent sexual and reproductive health
ASVS anti-snake venom serum
BAMMS Bachelor of Ayurveda and Modern Medicine and Surgery
BAMS Bachelor of Ayurveda Medicine and Surgery,
BC birthing centre
BCC behaviour change communication
BDS bachelor of dental science
BMEAT biomedical equipment assistant training
BMET biomedical equipment training
BOPV bivalent oral polio vaccine
BPKIHS BP Koirala Institute of Health Sciences
BS Bikram Sambat (Nepali era)
BTSC blood transfusion service centre
CB-IMCI Community-Based Integrated Management of Childhood Illness programme
CB-IMNCI Community Based Integrated Management of Neonatal and Childhood Illness
CB-NCP Community Based Integrated Management of Newborn Care Programme
CBO community-based organisation
CB-PMTCT Community-Based Prevention of Mother to Children Transmission
CCE comprehensive centres of excellence
CDD control of diarrheal disease
CDR Central Development region
CEONC comprehensive emergency obstetric and neonatal care
CHD Child Health Department

DoHS, Annual Report 2073/74 (2016/17) xvii


CHX chlorhexidine
cMYPoA Comprehensive Multi-Year Plan of Action
CNR case notification rate
CoFP Comprehensive family planning
CPR contraceptive prevalence rate
CRS congenital rubella syndrome
CTEVT Council for Technical Education and Vocational Training
DAMA discharged against medical advice
DDA Department of Drug Administration
DHF dengue haemorrhagic fever
DHIS District Health Information System
DHO district health office
DoA Department of Ayurveda
DoHS Department of Health Services
DOTS Directly Observed Treatment Short Course
DPHO district public health office
DPT diphtheria, pertussis, tetanus
DQSA data quality self-assessment
DSS dengue shock syndrome
DTLO district TB and leprosy officer
DUDBC Department of Urban Development and Building Construction
ECC eye care centres
EDCD Epidemiology and Disease Control Division
EDP external development partners
EDR Eastern Development Region
EHCS essential health care services
EID early infant diagnosis
EmOC emergency obstetric care
EOC essential obstetric care
EPI Expanded Programme on Immunization
EQA external quality assurance
EWARS Early Warning and Reporting System
FCHV female community health volunteer
FHD Family Health Division
FSW female sex worker
FWDR Far Western Development Region
FY fiscal year
G2D grade 2 disability
GIS geographic information system
GIZ German Society for International Cooperation (Deutsche Gesellschaft für Internationale
Zusammenarbeit)
GMP good manufacturing practice
GoN Government of Nepal
HA health assistant
HFOMC health facility operation and management committee

xviii DoHS, Annual Report 2073/74 (2016/17)


HIIS Health Infrastructure Information System
HIV human immunodeficiency virus
HMIS Health Management Information System
HURIS Human Resources Management Information System
ICD International Classification of Diseases
ICT immunochromatographic test
IDA iron deficiency anaemia
IDD iodine deficiency disorder
IEC information, education and communication
IFA supplementary iron folic acid
IMAM Integrated Management of Acute Malnutrition
IMCI integrated management of childhood illness
INGO international non-governmental organizations
Ipas International Pregnancy Advisory Services
IPV inactivated polio vaccine
IRS indoor residual spraying
ISMAC iodized salt social marketing campaign
IT information technology
IT information technology
IUCD intrauterine contraceptive device
JE Japanese encephalitis
Kfw Kreditanstalt für Wiederaufbau (German Development Bank).
LAMA left against medical advice
LAPM long acting and permanent methods
LARC Long acting reversible contraceptive
LCD Leprosy Control Division
LCD Leprosy Control Division
LLIN long lasting insecticidal (bed) nets
LMD Logistics Management Division
LMIS Logistics Management Information System
LTF lost to follow-up
M&E monitoring and supervision
MA medical abortion
MAM Management of Acute Malnutrition
MB multibacillary leprosy
MBBS Bachelor of Medicine, Bachelor of Surgery
MCH maternal and child health
mCPR modern contraceptive prevalence rate
MCV measles-containing vaccine
MD Management Division
MDA mass drug administration
MDG Millennium Development Goal
MDGP Doctor of Medicine in General Practice
MDIS Malaria Disease Information System
MDR multi-drug resistant

DoHS, Annual Report 2073/74 (2016/17) xix


MDT multi-drug therapy
MDVP multi-dose vaccine vials
MIYCN Maternal, Infant, and Young Children Nutrition programme
MNCH maternal, newborn and child health
MNH maternal and newborn health
MNP Micro-Nutrient Powder
MoE Ministry of Education
MoF Ministry of Finance
MoFALD Ministry of Federal Affair and Local Development
MoH Ministry of Health
MPDSR maternal and perinatal death surveillance and response
MR measles/rubella
MSM men who have sex with men
MSNP Multi-sector Nutrition Plan
MVA manual vacuum aspiration
MWDR Mid-Western Development Region
NAHD National Adolescent Health and Development (Strategy)
NAMC Nepal Ayurvedic Medical Council
NAMS National Academy for Medical Sciences
NCASC National Centre for AIDS and STD Control;
NCD non-communicable disease
NCDR new case detection rate
NDHS Nepal Demographic and Health Survey
NEQAS National External Quality Assurance Scheme
NGO non-governmental organizations
NHCP National Health Communication Policy
NHEICC National Health Education, Information and Communication Centre
NHIP National Health Insurance Programme and Nepal HIV Investment Plan
NHSP-IP Nepal Health Sector Programme-Implementation Plan
NHSS Nepal Health Sector Strategy (2015-20),
NHSSP Nepal health Sector Support Programme
NHTC National Health Training Centre
NIP National Immunization Programme
NMC Nepal Medical Council
NMICS Nepal Multiple Indicator Cluster Survey
NNJS Nepal Netra Jyoti Sangh
NPHL National Public Health Laboratory
NTC National Tuberculosis Centre
NTP National Tuberculosis Programme
OPD outpatient
OPV oral polio vaccine
ORS oral rehydration solution
OTTM operation theatre technique and management
PAM physical assets management
PB paucibacillary leprosy

xx DoHS, Annual Report 2073/74 (2016/17)


PBC pulmonary bacteriologically confirmed
PCD pulmonary clinically diagnosed
PCV pneumococcal conjugate vaccine
PDR perinatal death review
PEM protein energy malnutrition
PEN Package of Essential Non-communicable Diseases
Pf Plasmodiumfalciparum
PHCC primary health care centre
PHC-ORC primary health care outreach clinics
PHCRD Primary Health Care Revitalisation Division
PLHIV people living with HIV
PMTCT prevention of mother to child transmission
PNC postnatal care
POP pelvic organ prolapse
PPH postpartum haemorrhage
PSBI possible severe bacterial infection
Pv Plasmodium vivax
PWID people who inject drugs
QI quality improvement
RDT rapid diagnostic tests
RHD regional health directorate
RMS regional medical stores
RTI reproductive tract infection
RTQCC regional TB quality control centres
SAHW senior auxiliary health worker
SARC short acting reversible contraceptive
SARI severe acute respiratory infection
SBA skilled birth attendant/attendance
SHSDC Social Health Security Development Committee
SRH sexual and reproductive health
SS+ smear positive
STI sexually transmitted infections
SUN Scaling-Up-Nutrition
TABUCS Transaction Accounting and Budget Control System
Td tetanus and diphtheria
TIMS Training Information Management System
TSLC technical school leaving certificate
TT tetanus toxoid
TTI transfusion transmissible infection
TUTH Tribhuvan University Teaching Hospital
UNFPA United Nations Population Fund
UNICEF United Nations Children Fund
USG ultrasonogram
VA verbal autopsy and visual acuity
VAD vitamin A deficiency

DoHS, Annual Report 2073/74 (2016/17) xxi


VBDTRC Vector-Borne Disease Training and Research Centre
VDC village development committee
VPD vaccine-preventable disease
VSC voluntary surgical contraception
WASH water, sanitation and hygiene
WDR Western Development Region
WHO World Health Organisation
WHO/IPD WHO Immunization Preventable Diseases
WPV wild poliovirus
WRA women of reproductive age

xxii DoHS, Annual Report 2073/74 (2016/17)


NATIONAL HEALTH POLICY, 2071 (2014)
1. Background
The relationship between health of general population and overall development of country is
intertwined. Progresses made in the health sector are considered the main indicators of
development. Despite poverty and conflict in past decades, Nepal has achieved remarkable success
in the health sector.
In the context of health as a fundamental right of the people established by Nepal’s constitution, it is
the responsibility of the nation to maintain the achievement made in controlling communicable
diseases, to reduce infant and maternal mortality rate to the desired level, to control the ever
increasing prevalence of non-communicable diseases and timely management of unpredictable
health disasters, and to provide quality health services to senior citizens, physically and mentally
impaired people, single women especially poor and marginalized and vulnerable communities.
This national health policy 2071, a complete revision of the national health policy 2048, has been
introduced to promote, preserve, improve and rehabilitate the health of the people by preserving
the earlier achievement, appropriately addressing the existing and newly emerging challenges and
by optimally mobilizing all necessary resources through a publicly accountable efficient
management.

2. Past Attempts
In Nepal, only limited people had access to ayurvedic and modern health care services at
Singhadarbar Vaidyakhana established nearly 300 years ago, and Bir Hospital established in 1947;
most ordinary people had to rely on traditional healers such as dhamijhakri, jharphuke, guvaju etc.
After the introduction of the periodic developmental plan in the country from B.S. 2013, a planned
development process began also in the health sector. In this process the first 15 year long-term
health plan and the second 20 year long-term health plan were introduced in B.S.2032 and 2054
respectively.
People actively and remarkably participated in health programs such as Smallpox Eradication,
Malaria Control, Tuberculosis Control, Polio Eradication, Filariasis Elimination, Leprosy Elimination,
as well as regular administration of vitamin ‘A’ to the children. Female Community Health Volunteer
program started from B.S. 2045 in Nepal has been a model program for the whole world.
Meanwhile, a policy for integrating vertical health programs from the perspective of cost
effectiveness and ease of implementation was adopted and the integration of malaria, leprosy,
tuberculosis, smallpox, and family planning / maternal child health programs was completed by B.S.
2047.
After the opening for private-sector investment in the health sector through the enactment of The
National Health Policy 2048, Institutes for the study of health sciences as well as private health
facilities were established in massive scale. The involvement of private sector in health has been
mainly in curative services, production of medicines and equipment, and they are concentrated in
urban areas. At the same time, Nepal Health Sector Program-1 (2060-2065) and Nepal Health Sector
Program-2 (2066-2071) have been formulated and implemented in order to enhance the
effectiveness of the investment of Government, Non-Government and Donor agencies.

DoHS, Annual Report 2073/74 (2016/17) xxiii


3. Current Situation
Due to concerted efforts of past sixty years, significant achievements have been made in the health
sector. Network of health facilities providing primary health care services have been accessible to all
people. Though concentrated in urban centers and confined to curative services only, the
participation of private sector has been increased. Human resources required for almost all levels of
health care are being produced within the county. Country is increasingly becoming capable to
producing high and medium level human resources. About four dozens of pharmaceutical companies
currently operating in the country have developed the capacity of producing 40 percent of medicine
required by the country.
Likewise, though the services are not widely available, a number of specialized care facilities relating
to eye, cancer, heart, kidney, neurology, orthopedic, and plastic surgery have been established
under Government and Non-Government sector. Diagnostic centers and lab services have been
strengthened and expanded. The major health problems of past decades that have been Malaria,
Tuberculosis, Diarrhea, respiratory diseases, Typhoid, Chickenpox, Whopping Cough, Diphtheria,
Tetanus, Filariasis, Kala Ajar, Trachoma, HIV, are in control and burden of these diseases are in
descending trend. Smallpox has been eradicated and polio is down to zero in Nepal. Leprosy is in
state of elimination. Maternal and neonatal tetanus has been eliminated and trachoma is in process
of elimination. Campaign for control of filarial disease is ongoing.
Various regulatory bodies (Medical Council, Nursing Council, Pharmacy Council, Health Council,
Ayurvedic Council, National Health Research Council) responsible for ensuring quality of production
of human resource for health, health care, drug supply and researches, several institutions have
been established and are operational.
Collaboration and partnership with health related international organizations, donor communities,
and countries have been developed. Health awareness in general public has been increased.
Considerable development in education, communication, agriculture, and food supply has
contributed to the development of health.
As the result of above efforts, remarkable progress has been made in the health sector which is
justified by the indicators in table below.

Indicator Decade of B.S. B.S. 2048 B.S. 2068 Source


2007 (A.D. (A.D. 1991) (A.D. 2011)
1950)
a) Infant mortality rate 200 107 46 Nepal Health and Demographic
(per thousand live births) Survey, 2011
b) Maternal mortality rate 1800 850 170 Millennium Development Goal
(Per 100,000 live births) Progress Report, 2011
c)Average life expectancy 32 53 68.8 (A.D. Nepal Human Development Index
(year) 2011) Report, 2014
d) Under 5 children 280 197 54 Nepal Health and Demographic
mortality (per thousand) Survey, 2011
e)Total fertility rate 7 5.8 2.6 Nepal Health and Demographic
Survey, 2011
f) Fully immunized 70 88/87 Nepal Health and Demographic
children (Percentage) Survey, 2011

xxiv DoHS, Annual Report 2073/74 (2016/17)


4. Issues and Challenges
In spite of considerable achievement in the health sector and country progressing towards positive
direction, there are still many problems and challenges that need to be addressed. Some major
problems and challenges are as follows:

Major Issues:
 Citizens of all localities, levels, classes, groups and communities do not have yet easy and
affordable access to health care as aspired by the constitution.
 Despite the continuous effort of the state, about a half of under 5 children and women of
reproductive age are undernourished whereas the problem of obesity is growing among urban
population.
 Health problems created by the situations like climate change, raising food insecurity and
natural disasters are on the rise.
 Prevalence of cancer, hypertension, diabetes, and illnesses related to heart, kidneys, liver,
lungs, along with other non communicable diseases like mental illnesses, dental problems are
on the rise. Likewise, deaths due to road and injuries are increasing day after day.
 State has not been able to provide adequate priority on primary health care programs in urban
areas, health of senior citizens, mental disorders, genetic and congenital diseases,
environmental health, occupational hazard, sexual and reproductive health of adolescents and
health promotion on school-age children, etc.
 Access to quality medicine for people, right use of medicine, production and distribution of
essential drugs and medical equipments within the country are not effective and people
oriented.

 Laboratory services and medical equipments are not yet up to the quality standard.

 The issues such as complexities seen in rational production of various skilled health
professionals that take social responsibility, brain drain of health professionals, transfer of
health and other personnel, continuous presence of health personnel in health facilities,
security of health personnel, etc., have not yet been addressed in a planned way.
 Not been able to mobilize private-sector investment in health for the benefit of the people and
divert their investment to appropriate areas.
 Not been able to effectively regulate health sector according to law and rules. There is a lack of
sufficient harmony between the organizations producing health personnel and the
organizations utilizing them.

Major Challenges:
 There is a need for appropriate implementation of a two way referral system in order to
improve the quality standard of health care services.
 There is a need for immediate management of highly infectious diseases (like Bird-flu) or
potential new diseases, controlling of epidemic, emergency preparedness for minimizing human
casualty due to earthquake and other natural disasters and retrofitting of hospitals and other
health institutions.
 In order to reduce new born, child and maternal mortality rate, there is a need for maximizing
the effectiveness of controlling Diarrhea, acute respiratory infection, Malaria, Kala Azar,

DoHS, Annual Report 2073/74 (2016/17) xxv


Encephalitis, Filariasis, Dengue, Tuberculosis, Leprosy, HIV, and other diseases that can be
prevented through immunization.
 It has been difficult to control the spread of human and animal related diseases due to the open
border with neighboring countries.
 There is a need for creating opportunities by strengthening health institutions down to the grass
root level and establishment of a social health insurance system so that health services, health
education and information are equally available for all citizens.
 There is a need for increasing state’s investment to the health sector in proportion to
population growth.
 There is a need for urgently addressing regional disparity in health indicators.
 There is a need for implementing health-related acts, rules, policies, strategies and action plan
in a comprehensive and integrated manner. Likewise, country is committed to the international
treaties and agreements, and therefore, it should continue actively participating for their
successful implementation.
 The nation being a party to a convention on the Rights of Persons with Disabilities, it needs to
increase investment for providing all necessary health services to the people with blindness,
visual impairment, hearing impairment, mental impairment, and physical impairment.
 There is a need for empowering local government and holding them accountable for health
services along with improving people participation in rural health programs.

5. Need for new policy, guiding principles and vision


As the existing health policy 2048 is insufficient to ensure citizen’s right to quality health care
through appropriate response to the above problems and challenges, this new national health policy
had to be promulgated. While preparing this policy, a few guiding principles were formulated and
based on those guiding principles, policies, and strategies have been proposed. The National Health
Policy 2071 will be implemented based on the guiding principles presented below:

 As a fundamental right of citizens, provision for obtaining quality health care will be ensured.
 Right to information related to the health services provisioned for citizens will be ensured.
 In order to ensure the health services provisioned by the state is accessible to poor,
marginalized, and vulnerable communities; based on equality and social justice, programs will
be designed and implemented accordingly.
 People will be participated in every kind and level of health services.
 Policies and programs related to health promotion, protection, improvement, and rehabilitation
will be gradually incorporated into state’s other policies.
 Participation of private sector will be promoted ensuring citizen’s easy access to quality health
services at fair price.
 Resources obtained from internal and external agencies will be mobilized for effective
implementation of this policy and the programs formulated under this policy.
 All health services, provided by government or organized differently through a network of
government and private sector, will be regulated.
 Flow of health services will be made fully accountable.
This policy has been deemed necessary for successful implementation of the above guiding
principles.

xxvi DoHS, Annual Report 2073/74 (2016/17)


5.1 Vision
All Nepalese citizens would be able to live productive and quality life; being physically, mentally,
socially, and emotionally healthy.

5.2 Mission
Ensure the fundamental right of citizens to remain healthy through a strategic collaboration among
service provider, beneficiaries, and stakeholders and optimum utilization of available resources.

5.3 Goal
To ensure health for all citizens as a fundamental human right by increasing access to quality health
services through a provision of just and accountable health system.

5.4 Objectives
1. To make available free the basic health services that existed as citizen’s fundamental right.
2. To establish an effective and accountable health system with required medicines, equipments,
technologies and qualified health professional for easy access to acquire quality health services
by each citizen.
3. To promote people’s participation in extending health services. For this, promote ownership of
the private and cooperative sector by augmenting and managing their involvement.

6. Policies
1. To make available in an effective manner the quality health services, established as a
fundamental right, ensuring easy access within the reach of all citizens (universal health
coverage) and provision of basic health services at free of cost.
2. To plan produce, acquire, develop, and utilize necessary human resources to make health
services affordable and effective.
3. To develop the ayurvedic medicine system through the systematic management and utilization
of available herbs in the country as well as safeguarding and systematic development of other
existing complementary medicine systems.
4. To aim at becoming self-sufficient in quality medicine and medical equipment through effortless
and effective importation and utilization with emphasis on internal production.
5. To utilize in policy formulation, program planning, medical and treatment system, the proven
behaviors or practices obtained from researchers by enhancing the quality of research to
international standard.
6. To promote public health by giving high priority to education, information, and communication
programs for transforming into practice the access to information and messages about health as
a right to information.
7. To reduce prevalence of malnutrition through promotion and usage of quality healthy foods.
8. To ensure availability of quality health services through competent and accountable mechanism
and system for coordination, monitoring and regulation.
9. To ensure professional and quality service standard by making health related professional
councils capable, professional, and accountable.
10. To mainstreaming health in every policy of state by reinforcing collaboration with health-related
various stakeholders.

DoHS, Annual Report 2073/74 (2016/17) xxvii


11. To ensure the right of citizens to live in healthy environment through effective control of
environmental pollution for protection and promotion of health.
12. To maintain good governance in the health sector through necessary policy, structure and
management for delivery of quality health services.
13. To promote public and private sectors partnership for systematic and quality development of
health sector.
14. To increase the investment in the health sector by state to ensure quality and accessible health
services and to provide financial security to citizens for medical cost and as well as effectively
utilize and manage financial resources obtained from private and non government sector.

7. Strategies
1. Following strategies (related to policy 1) will be adopted to make available in an effective
manner the quality health services, established as a fundamental right, ensuring easy access
within the reach of all citizens (universal health coverage) and provision of basic health
services at free of cost.
1.1. Basic health service will be provided at free of cost by making acts relating to basic health
service.
1.2. As Nepal is the signatory of international convention on Rights of Persons with Disabilities,
all necessary health services needed for people who are blinds, visually impaired, hearing
impaired as well as mentally, cognitively and physically disabled will be included in urgent
health service category.
1.3. National health guidelines and protocols will be prepared and implemented to ensure all
citizens have received standard quality health care by reforming basic health program of
state for fulfilling basic health needs of citizens.
1.4. Impartial service will be delivered on the basis of equality by strengthening programs
delivering health services in rural areas as well as including marginalized groups in urban
areas.
1.5. Quality health treatment care of national standard will be catered by keeping priority on
preventive and promotive service and by using proper medicine and technology.
1.6. Nepal will be developed as regional hub for health tourism and medical science studies by
confirming areas delivering highly specialized and international standard services and
developing those areas.
1.7. Integrated program of health service, care and support will be formulated and
implemented according to the need of senior citizens.
1.8. Current situation of managing infectious diseases will be modified and implemented under
periodic plan on timely basis with essential additional immunization service. Respective
services are implemented effectively on the basis of policies related to prevention and
control of non communicable diseases, prevention and treatment of accidents and injury,
and mental health.
1.9. Affordable health services will be made available all over the country through telemedicine
(ehealth).
1.10. Arrangement of a doctor and a nurse along with other health technicians will be made
available in every VDC and one nurse midwife in every ward according to population.
Necessary number of health promotion and monitoring officer will be mobilized in every

xxviii DoHS, Annual Report 2073/74 (2016/17)


constituency to monitor quality of health service and make promotive health service
available widely in local level.
1.11. Laboratory and x-ray service will be expanded respectively in VDC level health institutions.
1.12. Blood transfusion service will be made systematic in coordination with non-government
sector by regulating through government sector.
1.13. Institutions providing specialized and highly specialized service will be established and
expanded gradually for providing services accessible to the residents of all regions in
country. Intensive care facility with specialists will be expanded to district level hospitals
gradually on the basis of criteria. Effective two-way communication system will be arranged
between health institutions at community level to highly specialized service providers to
make treatment service systematic.
1.14. Arrangements will be made to provide pharmacy service owned itself by hospital and to
distribute medicines to patients through qualified pharmacy personnel.
1.15. Periodic health related programs and action plans will be implemented by stating target
based on important health and development indicators such as maternal mortality rate,
infant mortality rate, under-five child mortality rate, average age. Reports from health
institutions will be made more scientific, timely, reliable and periodic.
1.16. Primary Health care service will be decentralized gradually by making local government
authorized and accountable for health services by increasing technical capability of local
government.
1.17. Arrangement will be made to contact ambulance service using one symbol number
throughout the country. Arrangement of service with essential medicines, oxygen, and
skilled health personnel will be ensured in ambulance. Air ambulance service will be
operated by making certain criteria for providing medical care by rescuing those in crisis.
1.18. Network of health personnel capable of making first aid treatment with essential drugs and
equipment will be arranged within the distance of one hour maximum in major highways
for treating injured people quickly.
1.19. At least one-village-one-health-institution will be established in the distance of 30 minutes
maximum on the basis of geographical location and population ratio. Programs in periodic
plans will be included to establish one primary health care center in every 20 thousand
population and one 25-bed-hospital for every one hundred thousand population. Likewise
one primary health care center will be established in every industrial area.
1.20. Mental health care service from the level of community to hospitals providing specialized
service will be implemented gradually by including in periodic plan.
1.21. Family planning including sexual and reproductive health will be included as integrated
form of service. Concept of Youth and adolescent friendly health service will be
incorporated in all organizations delivering health services. Reproductive health act will be
introduced.
1.22. Integrated child health program managing diseases relating to child will be implemented
continuously through strengthening on timely basis.
1.23. Flow of health service related to oral, eye and ear care will be actively implemented
throughout the country.
1.24. Establishment of referral hospitals on various subjects of medicines including dental and
ear, nose, throat will be done.

DoHS, Annual Report 2073/74 (2016/17) xxix


1.25. Development of international standard referral laboratory will be done by increasing
capacity of national public health laboratory and national drug laboratory.
1.26. Country being signatory to International treaty, agreements and commitments including
treaty related to controlling tobacco will be implemented actively.
2. Following strategies (related to policy 2) will be adopted to plan, produce, acquire, develop,
and utilize necessary human resources to make health services affordable and effective.
2.1 Master plan will be implemented for managing and developing human resources in
health sector along with projection of necessary workforce required within and outside
the country. Expenditure in human resources will be considered an investment.

2.2 Minimum integrated national curriculum will be implemented to produce human


resources of various kinds at various levels in health sector having appropriate skills and
knowledge capable of taking social responsibility according to national need. Educational
institutions operating under private and government investment will be supported and
regulated by creating high level mechanism with authority for monitoring educational
institutions and quality of human resources produced there.
2.3 Active and continuous presence of human resource in health sector will be ensured by
creating an environment to make them work compulsorily in assigned duty. Special
facility and opportunity will be created for health workers and their dependent families
working in remote areas.

2.4 Quality health services will be ensured by creating new positions of human resources by
having skills mixed on the basis of population.

2.5 Arrangement of one doctor along with 23 health workers will be ensured for every 10
thousand population gradually. Special arrangement will be made for remote and
mountainous areas.

2.6 Arrangements for encouragement of health workers including doctor will be done for
enhancing their capacity by creating opportunity of higher education, in-service training,
and participating them in research and study.

2.7 Regional and zonal hospitals are included in specialization course provided by
government academy.

2.8 Brain drain of human resources is discouraged by taking effective measures such as
career development and various kinds of financial and non-financial incentives to stop
currently visible brain drain and to create conducive working environment.

2.9 Skilled human resource will be produced for safe motherhood by initiating midwifery
education. Opportunity of midwifery education will be provided for enhancing capacity
of working nurses.

2.10 Transparent and scientific rotation transfer system will be developed and implemented
to systematize transfer of health workers and staffs.

2.11 Policy will be adopted for utilizing skilled private sector workers into government
service according to need. Likewise arrangement will be made for utilizing health
workers produced in private sectors into governmental entities according to need.

2.12 Study, research and training center of international standard will be set up by utilizing
outstanding achievements obtained in Nepal’s health sector.

xxx DoHS, Annual Report 2073/74 (2016/17)


2.13 Capacity of female community health volunteers will be developed with necessary
incentives to improve their quality of services.

3 Following strategies (related to policy 3) will be adopted to develop the ayurvedic medicine
system through the systematic management and utilization of available herbs in the country
as well as safeguarding and systematic development of other existing complementary
medicine systems.

3.1 Ayurveda will be developed gradually. Development and reformation will be done by
assessing quality of service in this area from research. Long term plan will be developed and
implemented for the safeguard, development, and expansion of homeopathy, unani (Greek),
and other complimentary medicine system.
3.2 Development and expansion of appropriate structure will be done gradually for
implementation of ayurveda system effectively.
3.3 Emphasis is given for production and commercialization by ensuring quality of herbal
medicine produced by government and private ayurveda medicine manufacturer with
special plan and programs for the safeguard and proper use of locally available herbs.
3.4 Study and research of ayurveda, and development of skilled human resources related to
research will be operated as a priority program by arranging and developing appropriate
human resources for national ayurveda research and training center.
3.5 Special focus will be given to enhance the quality of ayurveda health service by regulating
inappropriate activities in the name of ayurveda and herbs.
4. Following strategies (related to policy 4) will be adopted to aim at becoming self-sufficient in
quality medicine and medical equipment through effortless and effective importation and
utilization with emphasis on internal production.

4.1 Country will be made self sufficient in production of medicine. Arrangement will be made for
production and supply of all essential medicines.
4.2 Supplied to private and government sector, manufactured either within country or
imported, system will be developed according to the criteria for ensuring quality of
medicines, medical tools, equipments, and items used in laboratory.
4.3 Special arrangement will be done for controlling misuse of freely distributed drugs and will
increase gradually the types and numbers of freely distributed essential drugs from every
health institutions.
4.4 Making estimates, purchases, and distribution of drugs more effective and making current
arrangement of purchase and supply system strong, procedural reform including
participation of skilled pharmacist will be done in this process.
5. Following strategies (related to policy 5) will be adopted to utilize in policy formulation,
program planning, medical and treatment system, the proven behaviors or practices obtained
from researchers by enhancing the quality of research to international standard.

5.1 Current organizational, institutional and procedural state of affair of Nepal health research
council will be improved timely to increase quality of health research to international
standard. Special programs will be launched to enhance the capacity of council for the
promotion and facilitation of health research.
5.2 Health research will be regulated for providing new findings and suggestions for promoting,
safeguarding, improving and rehabilitating health of citizens and arrangement will be made

DoHS, Annual Report 2073/74 (2016/17) xxxi


for using suggestions from research more effectively in policy making, planning and
implementation.
5.3 Report and conclusion obtained from research will be made further accessible to all.

5.4 Encouragement will be done to include health in research of other sectors.


5.5 Health researcher and scientist will be encouraged to do research in various subjects of
health and environment will be created to respect their expertise.
5.6 Network of national and international organizations related to study and research will be
established.
5.7 Universities related to health and governmental and nongovernmental educational
institutions will be encouraged and facilitated to participate in research.
5.8 Special priority will be given for scientific exploration and research of herbs available in
country.
6. Following strategies (related to policy 6) will be adopted to promote public health by giving
high priority to education, information, and communication programs for transforming into
practice the access to information and messages about health as a right to information.
6.1 National health information system will be developed to provide information of works done
in health sector in simple and easy manner to the access of all citizens.
6.2 Wide use of health education information and communication will be put in high priority to
promote health by increasing awareness of individual or community, to control diseases, to
obtain health gain in time and to change behavior.
6.3 Advertisement and promotion of items having adverse effect on health of citizens such as
tobacco, substance with tobacco, alcohol, and other alcoholic beverages will be banned.
Likewise any kind of medium of communication that affects the sexual life of citizens directly
or indirectly will be banned.
6.4 Governmental and nongovernmental sectors will be mobilized to disseminate user friendly
and acceptable information in local languages that are informative, promotive and able to
raise awareness among public.
6.5 All citizens will be encouraged to obtain health information using all medium of
communication including electronic in optimum manner.
6.6 School health program that is recognized as effective and capable of providing high return
will be implemented in all schools of country in coordination with ministry of education. For
this, action plan with detail working procedure will be developed for all programs ongoing
currently in schools by unifying them and health programs will be carried out by arranging
one health worker at least in secondary school.
6.7 Arrangement will be done to provide all kinds of information of health service particularly
related to the treatment of patient for establishing a right to information to the respective
consumer.
7. Following strategies (related to policy 7) will be adopted to reduce prevalence of malnutrition
through promotion and usage of quality healthy foods.
7.1 Necessary arrangement will be made to free from the condition of malnutrition in the long
run by emphasizing promotion, production, and usage of food items available and could be
produced locally through the means of educational program in nutrition based in
community.

xxxii DoHS, Annual Report 2073/74 (2016/17)


7.2 Current multi-sector policy and programs related to nutrition including food security will be
implemented with high priority by updating them to improve the situation of malnutrition.
7.3 Regular feedback will be given to agriculture development and other ministries to increase
the self-sufficiency in food as there is direct relationship between food security and
nutrition, under the community health program backyard garden will be promoted with the
involvement of local body, and daily consumption of green vegetable and fruits will be
increased up to 400 grams.
7.4 Necessary act, procedure, and human resources will be arranged to discourage the usage of
processed and readymade food (junk food) that damage the body, alcohol and beverages,
and to monitor the quality of food distributed and sold from hotels and restaurants.
7.5 Coordinate with respective stakeholders will be done to eliminate chemical substances and
poisons used in food and meat items which have adverse effect on human health.
7.6 Appropriate life style will be promoted to control food related diseases and overweight.
7.7 Arrangement will be made to bring within legal domain to control food adulteration that has
adverse effect on health.
8. Following strategies (related to policy 8) will be adopted to ensure availability of quality health
services through competent and accountable mechanism and system for coordination,
monitoring and regulation.
8.1 Receipt of quality health services will be ensured provided by government and private
sectors by arranging legal institution for regulating all health services.
8.2 Current legal arrangement will be amended to regulate drugs used in modern, ayurveda, and
alternative method of treatment used in human and animals to make it more effective.
Arrangement of drug inspectors in right numbers will be placed in every district by
restructuring department of drug administration.
8.3 National directives and protocols will be prepared for ensuring receipt of quality health
services. Arrangement will be made to implement protocols according to the local need of
hospitals for treating diseases.
8.4 Regular monitoring and regulation will be done to ensure delivery of high quality health
service to citizens with criteria to keep the quality of human resources providing services,
technologies used, medicines, equipments including supplies.
8.5 Laboratory/blood transfusion centers along with services provided by such
laboratory/centers will be regulated for standardization according to criteria. Arrangement
of legal provision will be made for laboratories to function only after the accreditation.
8.6 Provision of punishment and penalty will be done on regular basis by monitoring and
evaluating health services provided by government and non-government sector in any
geographical region of the country.
8.7 Necessary organizational structure will be arranged to listen grievances and complaints of
patients or health service user for providing legal remedy. Consultation will be provisioned
for using technology to the availability in the process of treatment.
8.8 Necessary strategy will be adopted to make investment of private sector to the benefit of
public by legal arrangement and to increase investment in appropriate place.
8.9 Legal arrangement will be made under the Infectious disease act 2020 to compulsorily
inform the designated entity in specified time for the diseases likely to become pandemic.
Infectious disease act, 2020 will be amended.

DoHS, Annual Report 2073/74 (2016/17) xxxiii


8.10 Arrangement will be made for mentioning generic name of medicine by doctor to be
understandable clearly by all.
9. Following strategies (related to policy 9) will be adopted to ensure professional and quality
service standard by making health related professional councils capable, professional, and
accountable.
9.1 Work of various established councils will be made effective, transparent and accountable to
ensure the quality of varieties of education related to health and health services provided.
9.2 Current act and rules will be implemented through amendment to bring uniformity on the
services provided by health institutions and councils.
9.3 Health institutions and councils will be strengthened more through legal and physical means.
9.4 Collaboration will be promoted with professional association /organizations established in
private and non government sector to deliver health services and doing study and research.
10. Following strategies (related to policy 10) will be adopted to mainstreaming health in every
policy of state by reinforcing collaboration with health-related various stakeholders.
10.1 Current multilateral cooperation will be made stronger by accepting health as a main
agenda of development. Issues of health will be included in all associated acts.

10.2 Action plans will be implemented in coordination with multi sector as various aspects such
as safe drinking water, hygiene, energy, food security, climate, environment, education,
accommodation, road including physical development impact the receipt of health services.

10.3 Sustaining the progress made in millennium development goal set for 2015 by Nepal, goal
set thereafter will be addressed effectively.

10.4 Coordination with all the stakeholder entities will be done for making multi sectoral action
plan by utilizing national network and mechanism and opportunities for addressing negative
effect on health due to climate change for overall management.

10.5 Proper arrangement will be done for effective coordination and collaboration with
stakeholders entities for managing diseases communicated through animals and insects.

11. Following strategies (related to policy 11) will be adopted to ensure the right of citizens to live
in healthy environment through effective control of environmental pollution for protection
and promotion of health.
11.1 Collaboration for leadership will be taken for regulation by developing mechanism for
controlling adverse effect of environmental pollution and climate change for health
safeguarding and promotion.

11.2 Effective arrangement will be done for managing waste generated from the entities
providing health services in scientific manner. Current legal system for managing waste will
be implemented strictly.

11.3 Act will be implemented to manage radioactive materials used in health sector according to
national and international standards.
12. Following strategies (related to policy 12) will be adopted to maintain good governance in the
health sector through necessary policy, structure and management for delivery of quality
health services.
12.1 Changes will be made to acts and rules according to need after reviewing them to make
health services in operation more effective and trustworthy. Integrated public health service

xxxiv DoHS, Annual Report 2073/74 (2016/17)


act will be implemented by integrating health related acts and rules according to need by
timely revising them.

12.2 System of result oriented utilization and management will be adopted for effectively
mobilizing foreign aid in health sector by integrating all partner entities.

12.3 All physical infrastructure constructed will be made friendly to disable people, children, and
will be made earthquake resistant. Infrastructures that are being used currently but at risks
will be strengthened using available technology to make earthquake resistant. To provide
service to all physical infrastructures additional necessary infrastructure like store etc will be
added and systematized.

12.4 Health institutions are constructed according to the prevailing building standard on the
basis of physical location and population.

12.5 Modern information technology will be used at maximum for health management.

12.6 Multi-sectoral action plan will prepared and implemented to address emergency health
issues instantly arising from natural disaster and other causes.

12.7 Individuals having social prestige and respect, and individuals regarding health service as
charity, professionals, and local community will be involved in forming development
committees of various hospitals and operations and management committees of health
institutions. Community involvement is encouraged in management of health service, easy
access and continuation.

12.8 Act will be implemented for management and regulation of hospital management
committee including other committees.

12.9 Good governance action plan will be prepared and implemented for ensuring qualitative
service by incorporating government, private, community and cooperative in health service
delivery. Local cooperatives having many consumers will be participated in management of
local level health institutions by developing criteria for delivering health service.

12.10 Health good-governance action plan will be prepared and implemented for making health
service delivery transparent, responsive and publicly accountable.

12.11 Action of withdrawing tissues or blood related substance, or transplanting or action of


human organ transplanting will be systematized by law.

12.12 Action of organ donation will be eased by defining brain dead in scientific and professional
manner, in relation to selecting appropriate organ recipient with the goal of providing
organs for transplanting will be systematized by law.

12.13 Arrangement will be made to have only one official professional trade union in relation to
current situation of many trade unions present in one health institution.

12.14 Infertility is systematized by the law of surrogacy.

13. Following strategies (related to policy 13) will be adopted to promote public and private
sectors partnership for systematic and quality development of health sector.
13.1 Public and private partnership will be developed complimenting each other to promote
further the concept of public and private partnership.

DoHS, Annual Report 2073/74 (2016/17) xxxv


13.2 Arrangement of legal system will be made to encourage and manage the concept of
cooperative needed for health sector.

13.3 Grant will be providing to health institutions in nongovernmental sector by making clear
criteria.
14. Following strategies (related to policy 14) will be adopted to increase the investment in the
health sector by state to ensure quality and accessible health services and to provide financial
security to citizens for medical cost and as well as effectively utilize and manage financial
resources obtained from private and non government sector.
14.1 Arrangement will be done for allocating budget on the basis of population by determining
per capita investment in health sector by acknowledging spending made in health is not
expenditure but an investment. Per capita investment will be increased gradually.

14.2 As current personal expenditure of individual is 55 percent of gross expenditure made in


health, such percentage will be reduced gradually.

14.3 Amount appropriated for health sector will be distributed equitably by making criteria.

14.4 Nationwide insurance plan will be rolled out by making law and directives for ensuring
delivery of affordable health service by making financial management sustainable.
Arrangement will be made to provide discount for Incapable and financially poor.

14.5 Vaccine fund set up with the aim of preventing fund scarcity will be systematized through
law to conduct immunization program without interruption.
14.6 Action will be encouraged to find or help others to find new ways to manage finance of
health sector. Other funds of health sector will be made systematic and effective.

14.7 Arrangement will be made to use local level program and fund for health service and
infrastructures.

14.8 Production and sales and distribution of substance with tobacco and other substance
harmful to health will be discouraged with high taxes. Sources of fund obtained this way are
spent in health service.

15. Miscellaneous
15.1 Current sectoral policy and newly made such policies will be helpful and complementary to
implement provisions contained in this national policy.

15.2 Partnership and collaboration will be done with private, commercial groups, cooperatives,
communities and development partner organizations and not for profit service providers
with the aim of providing quality, sufficient, relevant, timely service of appropriate kind.

8. Structural arrangements
For effective implementation of this policy, departments, divisions, branches, subdivision etc of
current organizational structure from central to rural level along with additional regulating bodies,
and employee positions according to these levels will be added or reduced according to need under
the ministry of health and population by taking care of state restructuring.

9. Financial resources
Government sources, foreign loans and assistance, and investments of private sector in this sector in
totality will be the sources of implementation of this national health policy.

xxxvi DoHS, Annual Report 2073/74 (2016/17)


10. Monitoring and evaluation
1. Responsive and effective mechanism will be arranged to monitor and evaluate health programs at
every level regularly. For this, effective monitoring and evaluation system will be developed by
taking into account of the result based monitoring and evaluation model formulated and practiced
by national planning commission as well as monitoring and evaluation system implemented by the
ministry of local development.

2. Health management information system will be amended timely and will be upgraded to
complete computerized system.

11. Risks
1. In the absence of overall resource mobilization strategy in health sector, chances of difficulty in
resource mobilization will be present.

2. Health policy may need to be readjusted by segregating programs to be included in the domain of
center and federation after the country is transformed into the federal structure.

12. Revocation
National health policy 2048 has been revoked.

DoHS, Annual Report 2073/74 (2016/17) xxxvii


Chapter 1
Introduction

INTRODUCTION

1.1 Background
This is the twenty-third annual report of the Department of Health Services (DoHS). This report
analyses the performance and achievements of DoHS in fiscal year 2073/74 (2016/2017). It focuses
on performance in 2073/74 and the following areas that provide the basis improving performance in
subsequent years:
• Programme’s policy statements, including goals, objectives, strategies, major activities and
achievements.
• Programme’s indicators.
• Problems, issues, constraints and recommendations on improving performance and achieving
targets.

This report also provides information on the contributions of the Department of Ayurveda and
Department of Drug Administration, the health councils, partners and stakeholders on
contemporary issues in the health sector as well as the progress of major programmes implemented
by DoHS and its regional health directorates (RHDs), district health offices (DHOs), district public
health offices (DPHOs) and health facilities.

The preparation of this report follows the seven province level workshop in parallel sessions on the
first two days that culminated in the National Annual Performance Review Workshop date on 20 –25
September 2017 which was held in Kathmandu..These workshops were attended by senior
personnel from the regional directorates, divisions, centres and sections, central level hospitals, and
by representatives of external development partners (EDPs) and non-governmental organizations
(NGOs and INGOs).

Workshop participants reviewed the policy statements of each programme and analysed data
generated by the Health Management Information System (HMIS and from other sources on
selected indicators. These data were interpreted during the presentations and discussions.

The objectives of National Annual Performance Review Workshop:


• Review the program implemented in fiscal year 2073/74 and draw lessons learned
• Develop action plan to be implemented in coordination with Municipalities (Palika), Province
and Federal Government in:
• FY 2074/75 (running fiscal year), and
• FY 2075/76 (next fiscal year)

• Orient district managers on policy/management issues and new programmes

The Ministry of Health delivers promotional, preventive, diagnostic, curative, and palliative health
care services and carries out related policy, planning, human resource, financial management and
monitoring and evaluation functions. MoH has five divisions: the Curative Services Division; the

DoHS, Annual Report 2073/74 (2016/17) 1


Introduction

Policy, Planning and International Cooperation Division (PPICD); the Public Health, Monitoring and
Evaluation Division; the Human Resources and Financial Management Division and the
Administration Division.

Nepal’s public health system has the following six centres that have a degree of autonomy in
personnel and financial management: National Health Education, Information and Communication
Centre (NHEICC); National Health Training Centre (NHTC); National Centre for AIDS and STD Control
(NCASC); National Tuberculosis Centre (NTC); National Public Health Laboratory (NPHL) and Vector-
Borne Disease Training and Research Centre (VBDTRC). The NHTC coordinates all training
programmes of the divisions and implements training by sharing common inputs and reducing the
travelling time of care providers. All information, education and communication (IEC) and behaviour
change communication (BCC) activities are coordinated by NHIECC. The centres support the delivery
of essential health care services (EHCS) and work in coordination with the respective divisions. In
addition, the six professional councils (Nepal Medical Council, Nepal Nursing Council, Nepal
Ayurvedic Medical Council, Nepal Health Professional Council, Nepal Pharmacy Council and Nepal
Health Research Council) accredit health-related schools and training centres and regulate care
providers.

DoHS, the Department of Ayurveda (DoA) and the Department of Drug Administration (DDA) come
under MoH. These three departments are responsible for formulating and implementing
programmes, the use of financial resources and accountability, and monitoring and evaluation. DDA
is the regulatory authority for assuring the quality and regulating the import, export, production,
sale and distribution of drugs. The Department of Ayurveda offers Ayurvedic care and implements
health promotional activities.

1.2 Department of Health Services


The DoHS is responsible for delivering preventive, promotive, diagnostic and curative health
services. The director general is the organisational head. The DoHS has seven divisions (Table 1.1 and
Figure 1.1.).

Table 1.1: The responsibilities of DoHS’s seven divisions


Division Areas of responsibility
1 Child Health Division (CHD) The Expanded Programme on Immunization (EPI), Nutrition and
Community-Based Integrated Management of Childhood Illness
programme (CB-IMCI) and newborn care.
2 Family Health Division (FHD) Reproductive health care (including safe motherhood and neonatal
health), family planning and female community health volunteers
(FCHVs)
3 Epidemiology and Disease The control of epidemics, pandemic and endemic diseases and the
Control Division (EDCD) treatment of animal bites.
4 Leprosy Control Division (LCD) The prevention, early detection, treatment, referral, rehabilitation,
management and follow-up through the community-based
rehabilitation of all types of disability including leprosy.

2 DoHS, Annual Report 2073/74 (2016/17)


Introduction

Division Areas of responsibility


5 Management Division Infrastructure, budgeting and planning, monitoring and supervision
(M&E), quality of care, management information system, information
technology (IT), nursing services, oral and mental health, physical assets
management (PAM), and free medication and treatment for
impoverished citizens.
6 Logistics Management Division The procurement, supply and management of logistics, equipment and
(LMD) services required by DoHS and below levels.
7 Primary Health Care Expanding the coverage of primary health services in an equitable way
Revitalization Division (PHCRD) particularly by addressing the needs of disadvantaged and unreached
population groups.

Figure 1.1: Organogram of the Department of Health Services (DoHS)


MINISTRY OF HEALTH AND POPULATION

DEPARTMENT OF HEALTH SERVICES

DIVISION (7) CENTRE (6)

VBDRTC
NHEICC
PHCRD

NCSAC
NHTC
EDCD

NPHL
LMD
CHD

FHD

NTC
LCD
MD

CENTRAL HOSPITALS - 6

REGIONAL HEALTH DIRECTORATE - 5


MEDICAL STORE - 5
TRAINING CENTRE
SUB-REGIONAL

REGIONAL TB
HOSPITAL – 2

HOSPITAL - 3

CENTRE - 1
REGIONAL

REGIONAL

REGIONAL
-5

ZONAL HOSPITAL – 10

DISTRICT PUBLIC HEALTH DISTRICT/OTHERS DISTRICT HEALTH


OFFICE – 29 HOSPITAL – 85 OFFICE – 48

PRIMARY HEALTH CARE


CENTRE/HEALTH CENTRE –200

HEALTH POST – 3,808

FCHV 51,470 PHC/ORC CLINIC 12,180 EPI OUTREACH CLINIC 16,022


Source: HMIS, DoHS

DoHS, Annual Report 2073/74 (2016/17) 3


Introduction

DoHS’s main functions are as follows:


a) Advise the Government of Nepal (GoN) on formulating health related policies and developing
and expanding health institutions in line with these policies.
b) Determine the required human resource for health institutions and developing them by
preparing and implementing short and long term plans.
c) Manage the procurement and supply of drugs, equipment, instruments and other logistics at
regional, district and below levels.
d) Coordinate activities and mobilize resources for the implementation of approved programmes.
e) Manage the immediate solution of problems arising from natural disasters and epidemics.
f) Establish relations with foreign countries and international institutions to enhance and develop
health services and assist MoH in receiving and mobilizing foreign resources by identifying areas
of cooperation.
g) Encourage the private sector and non-government and foreign institutions to participate in
health services, maintain relations and coordination, and control the quality of health services by
regular supervision and monitoring.
h) Manage free medication and treatment for severe diseases (cancer, heart disease, Alzheimer’s,
Parkinson’s disease, head injuries, spinal injuries, renal failure and sickle-cell anaemia) for
impoverished citizens.
i) Manage information systems related to health facilities, health services, logistics, training and
finance to support the planning, monitoring, and evaluation of health programmes.
j) Maintain data, statements and information on health services and update and publish them.
k) The financial management of DoHS, RHDs, DHOs and DPHOs and the settlement of irregularities.

The five RHDs provide technical backstopping and programme monitoring to district health systems
and come directly under MoH. The regional, sub-regional and zonal hospitals have decentralised
authority through their hospital development boards. There are also training centres, laboratories,
TB centres (in some regions) and medical stores at the regional level.

Each of Nepal’s districts has either a DHO or DPHO. The DPHOs and DHOs are responsible for
implementing EHCS and monitoring activities and outputs of district hospitals, primary health care
centres (PHCCs) and health posts. The public health care service delivery outlets include health
posts, PHCCs, health centres, district and other hospitals, zonal hospitals, sub-regional hospitals,
regional hospitals, and central level hospitals.

Health posts are the first institutional contact point for basic health services. These lowest level
health facilities monitor the activities of FCHVs and the community-based activities of primary health
care outreach clinics (PHC-ORCs) and EPI clinics. In addition, they are the referral centres of FCHVs as
well as venues for community based activities such as PHC-ORC and EPI clinics. Each level above the
health post level is a referral point in a network from PHCCs on to district, zonal sub-regional and
regional hospitals, and finally to tertiary level hospitals. This hierarchy is designed to ensure that
most of the population can receive public health and minor treatment in accessible places. Inversely,
the system works as a supporting mechanism for lower levels by providing logistical, financial,
monitory supervisory and technical support from the centre to the periphery.

4 DoHS, Annual Report 2073/74 (2016/17)


Introduction

1.3 Sources of Information


The Health Management Information System (HMIS) provided the main source of information for
this report. The report also uses information from other management information systems (MISs),
disease surveillance systems, vital registration, censuses, sentinel reporting, surveys, rapid
assessments and research. The main health sector MISs include the HMIS, the Logistics Management
Information System (LMIS), the Financial Management Information System (FMIS), the Health
Infrastructure Information System (HIIS), the Planning and Management of Assets in Health Care
System (PLAMAHS),the Human Resource Information System (HuRIS), the Training Information
Management System (TIMS), the Ayurveda Reporting System (ARS) and the Drug Information
Network (DIN).

1.4 Structure of the Report


This report has ten chapters. Chapter 1 covers the background to annual report preparation, the
structure of DoHS, and sources of information on Nepal’s health sector. Chapters 2 to 6 cover DoHS’s
different health care related programmes; Chapter 7 presents the health sector M&E, Chapter 8
presents the programmes of the DDA and DoA; Chapter 8 presents the programmes of the health
sector councils, Chapter 9 the progress on health insurance while Chapter 11 gives details of the
health sector development partners.

Annex 1 presents the achievement of targets of DoHS’s programmes, Annex 2 gives the programme
targets for the next fiscal year (2074/75), Annex 3 gives the human resource situation of all districts,
while Annex 4 presents the target populations for FY 2073/74 and 2074/75 and health services raw
and analysed data by the indicators of different programmes disaggregated by ecological,
development regions and districts.

DoHS, Annual Report 2073/74 (2016/17) 5


Measles vaccination & coverage
Fiscal Year 2073-74 (2016/2017)
No. of infants immunized Coverage (%)

Source: HMIS
Chapter 2
Child Health: Immunization

CHILD HEALTH

2.1 National Immunization Programme


1 BACKGROUND

National Immunization Program (NIP) formerly Expanded Program on Immunization (EPI) was
started in 2034 and is a priority 1 program. It is one of the successful public health interventions of
Ministry of Health and has achieved several milestones and contributed in reduction of morbidity,
mortality and disability associated with vaccine preventable diseases.
National Immunization Program works closely with other divisions of Department of Health Services,
centres of Ministry of Health and different partners supporting routine immunization. EPI section is
one of the sections among the three sections of Child Health Division which plans, executes and
monitors several activities of immunization. Vaccine and cold chain section of Logistics Management
Division procures, stores and distributes vaccine throughout the country as planned by EPI section of
CHD, while NHEICC develops routine and supplementary immunization's IEC and social mobilization
materials and conducts activities in close coordination with the EPI section. Capacity building of
health staffs on routine immunization in close coordination with EPI section is executed through
National Health and Regional Health Training Centres. Immunization related information is collected
through HMIS section of Management Division and is shared quarterly for review and feedback. EPI
section of Child Health Division coordinates several stakeholders of immunization to execute
activities of the annual work plan.
National Immunization Program has included several underused and new vaccines in program and
currently there are eleven antigens–BCG, DPTHepBHib (penta), PCV, OPV (bOPV), Measles and
Rubella (MR) and Japanese Encephalitis provided through 16,000 service delivery points in health
facilities (fixed session), outreach sessions and mobile clinic (sessions). Inactivated Polio Vaccine
(IPV) which was introduced in routine immunization in 2014 has stock out globally and has stopped
temporarily but is in plan to be introduced in 2018 as fractional IPV (fIPV). Government of Nepal
procures BCG, OPV, Td, JE, measles/rubella 1st dose and co-finances to GAVI supported vaccines
DPTHepBHib, PCV and measles component of MR2.
National Immunization Program has cMYP 2017-2021 aligned with global, regional and national
guidelines, policies and recommendation to guide the program for five years. All the activities
outlined in cMYP have been costed as well as have developed strategies for implementation.
National Immunization Program has a very good record to meet the eradication, elimination and
control of vaccine preventable disease targets. Small pox eradication has become the history, MNT
elimination status is sustained from 2005, polio free status is maintained since 2010, measles
elimination and rubella, congenital rubella syndrome control is targeted by 2019. Japanese
encephalitis and other vaccine preventable diseases like pertussis are in state of control however 10
cases of Diphtheria were reported from various parts of the country.
National Immunization Program produces evidences on burden of diseases which can be prevented
from vaccines like rotavirus diarrhoea, invasive bacterial disease etc. in collaboration of academia
and research institutes within the country. National Immunization Program with the support of WHO
works with various committees functions as advisory, quality monitoring of immunization program
like National committee for immunization practice, Adverse Events Following Immunization

DoHS, Annual Report 2073/74 (2016/2017) 7


Child Health: Immunization
Committee, National Verification Committee for Measles Elimination and also committees related
with polio eradication like National Certification Committee for Polio Eradication, National Task
Force for Laboratory Containment etc. It also carries feasibility study on introduction of new vaccines
e.g. Human Papilloma Virus vaccine demonstration study completed in two districts.
Aiming to reach every child in country, some innovative activities have also been carried out in
country like Full Immunization declaration initiative, Immunization law, rule and immunization fund
creation.
2. GUIDING DOCUMENTS OF NATIONAL IMMUNIZATION PROGRAM
There are several Global, Regional and National guiding documents for National Immunization
Program. The main documents which have been taken in account and are incorporated in cMYP
2017-21 are–Global Vaccine Action Plan, SEARO Vaccine Action Plan, and Nepal Health Sector
Support Program – NHSSP.
2.1 Comprehensive Multi Year Plan of Action
The Comprehensive Multi Year Plan (cMYP) 2012-16 ended in 2016 and new cMYP 2017-21 is in
place. The comprehensive multiyear plan is prepared based on the global, regional and national
policies, strategies on immunization. The previous cMYP 2012-16 has the goals and objectives as
follows:
2.1.1 GOALS: To reduce child mortality, morbidity and disability associated with vaccine
preventable diseases.
2.1.2 Objectives and strategies
Objective 1: Achieve and maintain at least 90% vaccination coverage for all antigens at national and
district level by 2016
Objective 2: Ensure access to vaccines of assured quality and with appropriate waste management
Objective 3: Achieve and maintain polio free status
Objective 4: Maintain maternal and neonatal tetanus elimination status
Objective 5: Initiate measles elimination
Objective 6: Accelerate control of vaccine-preventable diseases through introduction of new and
underused vaccines
Objective 7: Strengthen and expand VPD surveillance
Objective 8: Continue to expand immunization beyond infancy

Most of the activities in past years were identified and carried out as per goal and objectives
spelled in cMYP 2012-16 and have been either met or near to be met and that will be discussed
in subsequent chapters. However, booster dose of currently used antigen based on evidence and
protection of adult from potential VPDs have not been met.
3. TARGET POPULATION
3.1 Under 1 year children for BCG, DPT-HepB-Hib, OPV, IPV, PCV and Measles/ Rubella1 (MR1)
vaccine.
3.2 Twelve months children for JE
3.3 15 months children for MRSD
8 DoHS, Annual Report 2073/74 (2016/2017)
Child Health: Immunization
3.4 Pregnant women for Tetanus Toxoid containing (Td) vaccine.

4. NATIONAL IMMUNIZATION SCHEDULE.

TABLE 2.1.1: National Immunization Schedule


SN Number of
Type of Vaccine Recommended Age
Doses
1 BCG 1 At birth or on first contact with health institution
2 OPV 3 6, 10, and 14 weeks of age
3 DPT-Hep B-Hib 3 6, 10, and 14 weeks of age
4 IPV 1 14 week of age
5 PCV 3 6,10 weeks and 9 month of age
6 Measles-Rubella 2 MR1 at 9 months and MR2 at 15 months of age
7 Td 2 Pregnant women (2 doses of Td)
8 JE 1 12 months of age

5. ANALYSIS OF ACHIEVEMENTS BY MAJOR ACTIVITIES

5.1 Major activities carried out in FY 2073/74


1. Hiring of 415 health workers to deliver immunization services in 75 districts
2. 3 days capacity building on immunization and vaccine management of 1600 health workers
3. 2 days microplanning workshop of district level -75 districts
4. Demonstration study of 2 doses (6 months interval) of Human Papilloma Virus vaccine in 2 districts
(Kaski and Chitwan) for 15000 female child of 6th grade
5. In-country visit for 25 health workers, through RHDS
6. Data Quality Training to 15 districts (3 from each RHDS)
7. Procurement of 6 refrigerator vans for RMS
8. Review and update on Micro planning of routine immunization in 5 RHDS
9. Training to 100 health workers of private/NGOs and Urban health clinics
10. 2 times Interaction with medias on routine immunization
11. Advocacy meeting, interaction with private, corporate house and industrialists, bankers, Red cross
and Lions club to raise immunization fund
12. 2 days workshop with LDOs and planning officers and EPI officers for resource mobilization to
sustain routine immunization
13. JE campaign coverage survey after JE supplementary immunization in 75 districts
14. Post HPV feasibility study, coverage survey in 2 districts – Kaski and Chitwan
15. Fund submission in Immunization fund
16. Piloting of revised Home Based record (Child Health card)
17. National workshop on routine immunization-2 times
18. Procurement and distribution of vaccine and cold chain equipment
19. Supervision and monitoring of routine immunization program

DoHS, Annual Report 2073/74 (2016/2017) 9


Child Health: Immunization

5.2 TARGET vs. ACHIEVEMENT, FY 2073/74


The cMYP 2012-16 has set the goal to reduce child mortality, morbidity and disability associated with
vaccine preventable diseases. The NDHS survey 2016 reveals the significant reduction in childhood
mortality. A big portion of childhood mortality is contributed by immunization against deadly vaccine
preventable diseases.

Figure 2.1.1 Trends in Childhood mortality

5.3 Achievements against objective no. 1: Achieve and maintain at least 90% vaccination coverage
for all antigens at national and district level by 2016.
The table and map presented below shows the achievement status against objective no. 1:

TABLE 2.1.2: Immunization coverage by antigens doses FY 2073/74


SN Antigens Target population Targets Achievement % Achieved
1 BCG under 1 Year 623929 569751 91.34
2 DPT-Hep B Hib 1 under 1 year 623929 566098 90.73
3 DPT-Hep B Hib 2 under 1 year 623929 552190 88.50
4 DPT-Hep B Hib 3 under 1 year 623929 539698 86.49
5 Polio1 under 1 year 623929 562452 90.14
6 Polio2 under 1 year 623929 550544 88.23
7 Polio3 under 1 year 623929 536191 85.93
8 IPV under 1 year 623929 100815 16.15
9 PCV1 under 1 year 623929 550364 88.20

10 DoHS, Annual Report 2073/74 (2016/2017)


Child Health: Immunization
SN Antigens Target population Targets Achievement % Achieved
10 PCV2 under 1 year 623929 534158 85.61
11 PCV3 under 1 year 623929 484993 77.73
st
12 Measles/Rubella 1 dose under 1 year 623929 524332 84.03
13 JE 12 months 623929 420494 67.39
nd
14 Measles/Rubella 2 dose 15 Months 626022 356878 57.00
3 dozes completion of
15 DPT-HepB-Hib & OPV Completed after 1 year 32081 5.14
after 1 year
16 Td 2 & Td2 + Pregnant women 756976 486466 64.26
Source: HMIS/MD and EPI/CHD, DoHS

Figure 2.1.2 : Antigens wise national coverage for FY 2071/72 to 2073/74

Source: HMIS/MD and EPI/CHD, DoHS

Above table 2.1.2 shows antigens wise coverage at national level during FY 2073/74 and figure 2.1.2
shows the three years trends of immunization coverage. Immunization coverage of all antigens
except IPV was found increased in FY 2073/74 as compared to FY 2072/73. The highest coverage was
91.34% for BCG, 90.73% and 90.14% for DPTHepBHIb1 and OPV1 respectively. Similarly, the
coverage of DPTHepBHib3 and OPV3 were 86.79% and 85.93 respectively. The children who have
completed the 3rd dose of DPT-HepB-Hib and OPV after their first birthday is accounted 5.14% of
the national coverage. If this coverage of 5.14% aggregated to DPTHepBHib3 and OPV3, the
coverage reaches to above 90% for both antigens. The coverage of 1st, 2nd and 3rd dose of
DPTHepBHib and OPV is different; since these doses are administered in same settings should be the
same. The coverage of PCV1 was 88.20% and that of PCV3 was 77.73%. The IPV coverage is only 16%
because there is shortage (globally and nationally) of IPV vaccine since October 2016. Measles

DoHS, Annual Report 2073/74 (2016/2017) 11


Child Health: Immunization
rubella1 and MR2 coverage was 84.03% and 57% respectively. Since the 3rd dose of PCV and MR1 are
given in same setting at the age of 9 months, the coverage should be the same.
The dropout rate of 1st vs 3rd dose of DPTHepBHib and OPV antigens were 4 and 5% respectively.

5.3.1 EQUITY IN IMMUNIZATION COVERAGE:

Figure 2.1.3: Districts with > 90% for all antigens (BCG, DPTHepBHib, OPV, PCV and MR1)

The above map 2.1.3 shows that only 8 districts have achieved ≥90% coverage with BCG,
DPTHepBHIb3, OPV3, PCV3 and MR1. Since PCV and MR2 were not introduced during the
development of cMYP 2012-16 and JE vaccine was only introduced in all 75 districts in 2016, if we
exclude PCV and JE from the objective 1, there will be 30 districts achieving ≥90% coverage.

Figure 2.1.4 and Figure 2.1.4a. : 3 years trend of DPTHepHib3 coverage by region and 1 year
coverage by province

Source: HMIS/MD/DoHS Source: HMIS/MD/DoHS

Figure 2.1.4 shows that DPTHepBHib3 coverage during Fy 2073/074 remained between 82% to 92%
in all development regions and highest being in MWDR (92%) whereas lowest in WDR (82%). Figure

12 DoHS, Annual Report 2073/74 (2016/2017)


Child Health: Immunization
2.1.4a shows the coverage of DPTHepBHib3 at provincial level in Fy 2073/74 which varied from 76%
to 99% and the highest coverage of 99% was in province no. 2 and lowest coverage of 76% was in
province no. 3 and 4.

5.3.2 ACCESS AND UTILIZATION OF IMMUNIZATION SERVICES:


National Immunization Program evaluates the status of the districts by accessibility and utilization of
immunization services. Districts are categorized by CAT 1 to 4 on the basis of DPT-HepB-Hib1
coverage and dropout rate of DPT-HepB-Hib1 VS DPT-HepB-Hib3 to know the accessibility and
utilization (whether service has reached to all and has been utilized by all) of immunization services.

Table 2.1.3: Districts categorized based on the 80% coverage of DPT-HepB-Hib1 (Access) and drop
out less than 10% of DPT-HepB-Hib1 VS DPT-HepB-Hib3 (Utilization) 2073/74

Category 1 Category 2 Category 3 Category 4


(less Problem) (Problem) (Problem) (Problem)
Low Drop-Out (<10%) High Drop-out (10%) Low Drop-out (<10%) High Drop-out (10%)
High Coverage (80%) High Coverage (80%) Low Coverage (<80%) Low Coverage (<80%)

Mugu, Kalikot, Siraha, Humla, Dhanusa, Kailali,


Bajura, Rukum, Bara, Kapilbastu, Mahottari, Jajarkot, Kanchanpur,
Parsa, Doti, Dolpa, Rukum west, Rautahat and Dhankuta,
Rolpa, Banke, Rasuwa, Dailekh, Sarlahi Gorkha, Bardiya,
Jumla, Achham, Pyuthan, Bajhang, Lamjung,
Sankhuwasabha, Makwanpur, Sindhupalchok,
Saptari, Panchthar, Jhapa, Ilam, Parbat,
Taplejung, Khotang, Morang, Dolakha,
Sunsari, Salyan, Udayapur, Bhaktapur,
Rupandehi, Surkhet, Baitadi, Dang, Tanahu, Kaski,
Bhojpur, Sindhuli, Darchaula, Lalitpur,
Nuwakot, Kavre, Nawalpur, Myagdi, Kathmandu,
Gulmi, Terhathum, Nawalparasi, Mustang,
Arghakhanchi, Chitawan, Syangja, Ramechhap and
Okhaldhunga, Baglung, Dhading, Manang
Palpa, Dadeldhura and Solukhumbu

(54 districts) (5 Districts) (18 Districts) (0 Districts)

Table 2.1.3 shows that 54 CAT1 districts have good accessibility as well as utilization of immunization
services i.e. more than 80% children have sufficient immunization service delivery points to utilize
the immunization services, thus the dropout rate is less than 10%. The 5 districts under CAT 2 have
problems of utilizing immunization services, thus have high dropout rate. The 18 districts under CAT
3 have problems of accessibility for the immunization service delivery i.e. either there are not
sufficient sessions or all sessions have not delivered their immunization services throughout the
year. There are no districts under CAT 4.

DoHS, Annual Report 2073/74 (2016/2017) 13


Child Health: Immunization
5.3.3 NUMBER OF UN-IMMUNIZED CHILDREN IN FISCAL YEAR 2073/74:

The un-immunized children are calculated against DPTHepBHib3 i.e. total targeted children of under
1 year minus children who received 3rd dose of DPTHepBHib. The number of unimmunized children
with DPTHepBHib3 was 84,231 in 2073/74 which was 122,168 in 2072/73, and 56,513 in 2071/72.
Though the number of unimmunized children in 2073/74 is less than previous year yet it remains
high. If the number of children who completed their 3rd dose of DPTHepbHib3 after their first
birthday are subtracted in this number, the unimmunized children will be 52,150.

5.3.4 MEASLES-RUBELLA FIRST DOSE COVERAGE:

Measles elimination and rubella and congenital rubella syndrome control is targeted by 2019. To
achieve this target, the coverage of MR1 and MR2 should be minimum of 95% universally.
Figure 2.1.5 shows region wise 3 years measles rubella 1st dose coverage and figure 2.1.5a shows
province wise coverage of MR1 and MR2 during 2073/74. MR1 coverage has increased by 7% at
national level compared to previous year of 77%. Similarly, the MR1 coverage has increased in EDR,
CDR, WDR, MWDR and FWDR by 5%, 12%, 1%, 9% and 3% respectively compared to the previous
year. None of the regions have reached to 95% in Fy 2073/74. The highest of 92% was in MWDR and
lowest of 80% in WDR. The MR2 coverage in Fy 2073/74 was found 57% and is far lower than
expected.
Province wise coverage of MR1 (figure 2.1.5b) shows highest coverage of 96% in province 6 and
lowest of 75% in province no. 4 during Fy 2073/74. Similarly, MR2 coverage was only 57% at national
level which was found highest of 67% in province no. 5 and lowest of 49% each in province no. 2 & 3.

Source: HMIS/MD/DoHS Source: HMIS/MD/DoHS

5.3.5 Td2+ COVERAGE:

Td vaccine is given to pregnant women. Previously unimmunized pregnant woman receives 2 doses
of Td vaccine. Those who have completed their 2 or more doses of Td vaccines during their past
pregnancies receive 1 dose Td vaccine.

14 DoHS, Annual Report 2073/74 (2016/2017)


Child Health: Immunization

Source: HMIS/MD/DoHS Source: HMIS/MD/DoHS

Above figures 2.1.6 and 2.1.6a show the Td2 and Td2+ coverage trend for 3 years by region and Td2
and Td2+ coverage during 2073/74 by province respectively. Td2+ includes cumulative doses of Td or
tetanus toxoid containing vaccine doses received during the present and past pregnancies. Td2 and
Td2+ coverage has decreased by 2% at national level as compared to previous year 2072/73. Highest
declining of Td2+ coverage by 6% has found in WDR and found decreased by 3% in EDR, 1% in each
MWDR and FWDR. The coverage Td2+ of CDR is 1% higher than previous year. In provinces, the
highest coverage of 81% is reported in province no. 2 and lowest of 49% in province no. 3 during FY
2073/74.

5.3.6 DROP-OUT RATES:


Figure 2.1.7 shows the dropout rate for BCG vs
MR1, DPTHepHib1 vs DPTHepBHib3 and
DPTHepBHib1 vs MR1. The dropout rate must not
increase than 10%. The dropout rate has been
found decreased. The dropout rate of BCG vs
MR1 has lowered than the previous year by 3%
whereas that for DPT-HepB-Hib1 vs 3 and DPT-
HepB-Hib1 vs MR1 has lower by 0.5% and 1%
respectively.

5.3.7 VACCINE WASTAGE RATE:


Figure 2.1.8 : Vaccine wastage rate of MDVP like
DPTHepHib and is still higher than accepted rate
of 15%. The wastage rate of DPTHepBHib, OPV
and PCV has increased by 1% than previous year.
The wastage rate of MR vaccine which was
supposed to drop drastically after the
introduction of 2nd dose still remains high which
indicates that 2nd dose is still not given in all
sessions.

DoHS, Annual Report 2073/74 (2016/2017) 15


Child Health: Immunization
6. SUPPLEMENTARY IMMUNIZATION ACTIVITIES

6.1 Polio Supplementary immunization: Nepal is polio free since 2010. Nepal falls in tier3 country
among globally targeted country for supplementary immunization activities and GPEI did not plan
for polio SIA, however NIP decided to conduct supplementary immunization in limited geographical
areas based on the immunity gap. Thus one dose of OPV was administered in selected 15 districts on
4-5 March 2017 (21-22 Falgun 2073). Total children under 5 children received OPV were 1,462,863
against 1,585,612 targeted (108%).

Figure 2.1.9: Map showing the districts of Polio SIA in FY 2073/74

Source: CHD/DoHS

6.2 FULLY IMMUNIZED DISTRICT DECLARATION:


Fully immunization VDC, district and then the country declaration is one of the new and innovative
initiatives which started with the objective to reach every child and take ownership of immunization
by local political body. The program targeted to declare the country as fully immunized by 2074/75
and until 2073/74, 23 districts were declared as fully immunized. Total 1839 VDCs and 91
municipalities were declared as fully immunized. This process is continuing and every month, some
VDCs and districts are declaring as fully immunized.
Figure2.1.10: Map showing the FID districts until Poush 2074:

16 DoHS, Annual Report 2073/74 (2016/2017)


Child Health: Immunization

7. In objective 2, cMYP 2012-16 has set the objective to ensure access to vaccines of assured quality
and with appropriate waste management and the NIP has strictly followed the objective as the
vaccines used in routine immunization are WHO prequalified. All vaccines received had expiry date
more than 18 months and attached with appropriate vaccine vial monitors (VVM). Vaccine
transported with appropriately conditioned icepacks both at store and sessions level. Auto Disable
(AD) syringes are used to administer each dose of vaccine and one syringe for one vial is used to
reconstitute the vaccine vial. Injection safety and multi-dose vial policy are in place. In case of
adverse events following immunization, cases are thoroughly investigated and causal association is
established by expert AEFI committee members. Surveillance of Adverse Events Following
Immunization (AEFI) is one of the functional surveillance systems.

8. In objective 3, cMYP 2012-16 has set the objective to achieve and maintain polio free status. The
standard indicators for polio eradication program have been discussed in successive chapters.
Nepal is polio free since August 2010. Officially SEAR (South East Asian Region) region was declared
polio free on 27 March 2014. Nepal has been able to sustain polio free status. The non AFP rate as
well as adequate stool collection rate has been maintained above the global surveillance standard.

8.1 ACUTE FLACCID PARALYSIS SURVEILLANCE:


Acute Flaccid Paralysis Surveillance which was initiated in 1998 in Nepal is conducted in all 75
districts. There are 735 routine weekly Zero reporting sites and 79 active surveillance sites. The AFP
cases have been calculated from July to June to align with government fiscal year. For sensitive
surveillance, there are 2 main indicators–non AFP rate which should be at least 2 per 1,00,000 from
<15 population and adequate stool collection rate which should be more than 80%.

Figure 2.1.11: Map showing reported Acute Flaccid Paralysis (AFP) in FY 2073/74

DoHS, Annual Report 2073/74 (2016/2017) 17


Child Health: Immunization
The above map (figure 2.1.11) shows total reported AFP cases for F/Y 2073/74 totalling 389 cases
from 70 districts. There are 5 districts which have not reported AFP cases during this period and
mostly these districts are sparsely populated.

Figure 2.1.12: Map showing Non-Polio AFP Rate by districts

The map (figure 2.1.12) shows non polio AFP rate by districts. National non polio AFP rate is 4.5
(more than 2/1,00,000 under 15 populations). There are 61 districts which have reported non polio
AFP rate more than 2 and 11 districts have non polio AFP rate between 1 to 1.9, and 1 district has
reported less than 1 non polio AFP rate. There are 5 districts which have not reported AFP cases and
these districts have very sparse population.

The table below shows province wise non polio AFP and adequate stool collection rate. All the
provinces have met the standard indicators of non-AFP rate more than 2 and adequate stool
collection more than 80%.
Table 2.1.4: NPAFP and Adequate Stool collection Rate by Province, FY 2073/74
Province NPAFP Cases NPAFP Rate Stool Adq

Province 1 76 5.36 100


Province 2 92 5.12 97
Province 3 56 3.06 98
Province 4 33 3.86 100
Province 5 68 5.05 99
Province 6 31 6.10 100
Province 7 31 3.68 81
Total 387 4.50 97
Source: CHD/WHO/IPD Nepal
Note: the non-polio AFP and adequate stool collection rate of Nawalparasi and Rukum have been
calculated as for previous structure

18 DoHS, Annual Report 2073/74 (2016/2017)


Child Health: Immunization
Figure 2.1.13 : Adequate stool collection rate

Note: the non-polio AFP and adequate stool collection rate of Nawalparasi and Rukum have been
calculated as old structure
The map (Figure 2.1.13) shows adequate stool collection rate which is 97% nationally (Adequate
stool collection rate should be more than 80%). Nationally, the adequate stool collection rate is
above the surveillance standard while in 5 districts, no AFP were reported and in most of the district
the adequate stool collection rate is more than 80%.

9. In objective no. 4, cMYP 2012-16 has set the objective to maintain maternal and neonatal tetanus
elimination status. The status is as follows:

NEONATAL TETANUS SURVEILLANCE:


Neo-natal tetanus elimination has remained sustained since 2005. The table below shows the
districts which have reported NT cases through VPD surveillance network. Neonatal cases reported
through HMIS are also verified regularly through this network.
Figure 2.1.14: Neo-natal tetanus cases 2073/74

DoHS, Annual Report 2073/74 (2016/2017) 19


Child Health: Immunization
Figure 2.1.14 shows neonatal tetanus cases distribution by the districts. Total of 3 NT cases were
reported from 2 districts in 2073/74. Nepal has sustained MNT elimination status validated in 2005
(less than 1 case per 1000 live births).

10. In objective no. 5, the cMYP 2012-16 has set the objectives to initiate measles elimination.
Measles elimination is a flagship program of SEAR. Nepal has targeted measles elimination by 2019
while SEAR has targeted elimination by 2020. There are 520 case based measles surveillance sites.
The case based measles surveillance sites are in expansion phase throughout the country. The
sensitivity of measles surveillance is evaluated against non-measles and non- rubella (NMNR) cases
and that should be more then 2 /1,00,000 populations. Currently the non-measles and non- rubella
rate is 2.9/1,00,000 i.e. meet the surveillance standard nationally.

MEASLES LIKE ILLNESS SURVEILLANCE:


Figure 2.1.15: Confirmed Measles & Rubella Cases, Nepal 2003-2017 (July)

Figure 2.1.15 shows laboratory confirmed measles, rubella cases from 2003 to 2014. There is a
drastic reduction in measles and rubella cases. There were 203 suspected measles cases reported
from 16 suspected measles outbreak. Among them, twelve were confirmed measles outbreaks and
total 100 measles cases were laboratories confirmed and EPI linked measles cases detected during
the period.

The table below shows the province wise non-measles and non-rubella cases and rate. All the
provinces have met NMNR standard of more than 2. The highest NMNR was 5.47 in province no. 6
and lowest in 0.52 in province no. 2.

20 DoHS, Annual Report 2073/74 (2016/2017)


Child Health: Immunization
Table 2.1.5: Reported Measles/Rubella cases by Province
Province NMNR Cases NMNR Rate Measles Cases Rubella Cases
Province 1 170 3.63 6 1
Province 2 31 0.52 30 2
Province 3 187 3.23 26 3
Province 4 123 4.35 2 4
Province 5 154 3.66 57 8
Province 6 68 5.47 6 0
Province 7 57 2.22 10 1
Total 790 2.90 137 19
Source: CHD/WHO/IPD Nepal

11. The objective no. 6 of cMYP 2012- 16 has set the objectives to accelerate control of vaccine
preventable diseases through introduction of new and underused vaccines. Japanese Encephalitis
has remained endemic in country. Periodically the disease outbreak has been recorded especially in
southern part of Nepal. To control the disease, National Immunization Program decided to introduce
JE vaccine (SA-14-14-2) in high burdened districts first, in phased manner from 2006 until 2011 and
thus it was expanded in 31 districts until 2015. In 2016, the vaccine has been introduced in all 75
districts in routine after mass campaign of JE vaccine.
ACUTE ENCEPHALITIS SYNDROME SURVEILLANCE: Acute encephalitis syndrome surveillance was
initiated in 2003/04 built on AFP network to know the burden of disease of Japanese Encephalitis
throughout the country. The status of JE disease is as follows:

Figure 2.1.16: Trend of reported AES and Lab confirmed JE cases


The diagram below shows seasonality and number of AES as well as laboratory confirmed JE cases:

Figure 2.1.16 shows the trend of reported AES and laboratory JE cases since 2004 to 2016. In
2073/74 total of 85 cases of confirmed JE detected from 33 districts.

DoHS, Annual Report 2073/74 (2016/2017) 21


Child Health: Immunization

Figure 2.1.17: Reported AES and laboratory confirmed JE cases by districts in FY 2073/2074

Figure 2.1.17 shows that 72 districts have reported AES cases and only 38 districts have 127
laboratory confirmed JE cases.

Table 2.1.6: province wise AES and JE cases:


Province AES cases JE Cases
Province 1 259 18
Province 2 296 23
Province 3 211 14
Province 4 97 5
Province 5 117 17
Province 6 52 4
Province 7 23 4
Total 1055 85
Source: CHD/WHO/IPD Nepal

Province wise data shows that highest JE cases were reported from province no. 2 followed by 1 and
5 and no provinces remained free of disease.

12. The objective 7 of cMYP 2012-16 has set the objective to strengthen and expand VPD
surveillance. National program with the technical and financial support of WHO, Surveillance on
Invasive Bacterial disease (IBD) and Rota Virus Diarrhoea is ongoing in 2 sentinel sites.
13. The objective 8 of cMYP 2012-16 has set the objective to continue to expand immunization
beyond infancy. National Immunization Program has completed feasibility study for the introduction
of Human papilloma Virus vaccine in 2 districts (Chitwan and Kaski). National Committee for
Immunization practice has recommended for the introduction of HPV in routine immunization.

22 DoHS, Annual Report 2073/74 (2016/2017)


Child Health: Immunization
9. PROBLEMS/CONSTRAINTS AND ACTIONS TO BE TAKEN
Regional performance review meeting in 2073/74 identified the following problems and constraints
and recommended action to be taken at different levels of immunization delivery system.

Problems/Constraints Action to be taken Responsibility


Inadequate HRH especially in Provision for sufficient vaccinators for the MoH/DoHS/DHO,
Metro/Sub - Metropolitan, Metro / Sub - Metropolitan, MCH / Local Government
MCH / Institutional clinics and Institutional Clinics
ill-defined JD of AHW & ANM Incorporate responsibility of delivering
(for vaccinations) immunization service in Job Description of
all HA, SAHW, AHW/ANM to conduct
immunization sessions
Poor quality immunization Joint supportive supervision of Immunization HF/DHO/RHD/
data: Under and over as per HMIS. CHD/HMIS
reporting Strengthen supportive supervision at all
levels
Quarterly review of performance of data at
HF/DHO level as –HMIS 9.2, 9.3 and 2.5
Provision of DQSA to the RHDS and districts
Poor Inventory keeping and Update inventory of cold chain equipment RMS/District Cold
distribution system with their cold chain capacity and vaccine, Store
syringes, diluents etc. and use of stock
control register. Maintain maximum and
minimum stock level. Always make vaccine
requisition by deducting the stock at hand
from maximum stock level of
vaccine/syringes/diluents at all levels
Unplanned immunization Utilize immunization month as an Districts
month celebration opportunity to intensify routine
immunization activities especially to ensure
full immunization
Give more emphasis to reach the unreached
based on prioritization.
Increase the access and utilization in Cat 2
and 3 VDCs/municipalities and reduce the
dropout rate in Cat 2 VDCs
Report the immunization month’s
achievement separately to see the
additionally of immunization performance of
immunization month
Low achievement of FID Orientation, Capacity building and MoH, MoFALD,
according to national target empowerment of local government DoHS/CHD,
Accelerate of Full Immunization declaration Province, municipal
at all levels
Coordination with intersectoral stakeholders

DoHS, Annual Report 2073/74 (2016/2017) 23


Child Health: Immunization
Problems/Constraints Action to be taken Responsibility
Poor Cold Chain and Vaccine Effective implementation of EVM training at LMD/CHD/NHTC/
management all level DHO
Supportive supervision and onsite coaching
at all levels
Strengthen bundling
Inadequate CC Equipment Provision of engineer and refrigerator DoHS/ LMD/CHD
and inadequate repair, technician at regional / provincial level
maintenance and Supply of cold chain spare parts
replacement, lack of Replacement of ageing equipment
technician regular repair of cold chain equipment
Inadequate Vaccine Store Strengthen the vaccine stores with new MoH, DoHS, LMD,
Capacity specially central buildings in central store CHD
level Establishment of new vaccine store at
Province No.6.

24 DoHS, Annual Report 2073/74 (2016/2017)


Child Health
Growth Monitoring Status
Fiscal Year 2073
2073-74
74 (2016/2017)
% of Children aged 0-11
0 11 months % of Children aged 0
0-11
11 m registered % of Children aged 12-23
12 23 m registered
registered for Growth Monitoring for GM who were underweight for GM who were underweight

Source:
ource: HMIS/MD/DoHS

DoHS, Annual Report 2073/74


207 (201
(2016/2017) 25
Child Health

2.2 Nutrition
2.2.1 Background
Nutrition section under Child Health Division is responsible for national nutrition program for
improving the nutritional status of children, pregnant women and adolescents. Its goal is to
achieve nutritional well-being of all people to maintain a healthy life to contribute in the
socio-economic development of the country, through improved nutrition program implementation in
collaboration with relevant sectors. Nutrition interventions are cost effective investments for
attaining many of the Sustainable Development Goals. In alignment with international and national
declarations and national health policies, the Government of Nepal is committed to ensuring that its
citizens have adequate food, health and nutrition. The Constitution (2015) ensures the right to food,
health and nutrition to all citizens. Hunger and under-nutrition often results in the vicious cycle of
malnutrition and infections that leads to poor cognitive and intellectual development, less
productivity and compromised socioeconomic development.

Focus on nutrition — Nutrition is a globally recognized development agenda. Since the year 2000,
several global movements have advocated nutrition for development. The Scaling-Up-Nutrition (SUN)
initiative calls for multi-sectoral action for improved nutrition during the first 1,000 days of life. The
Government of Nepal as an early member of SUN adopted the Multi-sector Nutrition Plan (MSNP) in
2012 to reduce chronic nutrition. Recently, the UN General Assembly declared the 2016–2025 period
as the Decade of Action on Nutrition.

Policy initiatives — The National Nutrition Policy and Strategy was officially endorsed in 2004 to
address all forms of malnutrition including under-nutrition and over-nutrition. This policy provides
the strategic and programmatic directions in the health sector while the MSNP provides a broader
policy framework within and beyond the health sector under a Food and Nutrition Security
Secretariat of the National Planning Commission that coordinates its implementation. The National
Health Policy, 2071 highlights improved nutrition via the use and promotion of quality and nutritious
foods generated locally to fight malnutrition. The Nutrition Technical Committee was established in
CHD in 2011 to support multi-sectoral coordination for developing nutrition programmes.

Aligning with the MSNP and current global initiatives, CHD – nutrition section has developed
strategies and plans for improving maternal infant and young child nutrition assisted by experts from
the Nutrition Technical Committee. Moreover, as recommended by the Nepal Nutrition Assessment
and Gap Analysis (NAGA) and guided by MSNP, in 2012–2013 MoH conducted an Organization and
Management Survey towards establishing a National Nutrition Centre for implementing MSNP in the
health sector. Recently, MSNP -2 has been approved for 2075/76 – 2079/80.

2.2.2 Malnutrition in Nepal


Despite a steady decline in recent years, child under-nutrition is still unacceptable in Nepal. Maternal
malnutrition is also a problem with 17 per-cent of mothers suffering chronic energy deficiency
alongside the increasing trend of overweight mothers (22 per cent). Although Nepal's effort in
micronutrient supplementation such as the National Vitamin A Programme have been globally
recognized as a successful programme, nutritional anaemia remains a serious public health issue
among women, adolescents and children. Forty-one percent of women of reproductive age and 46
per cent of pregnant women are anaemic. About 68 per cent of children aged 6-23 months are
26 DoHS, Annual Report 2073/74 (2016/2017)
Child Health
anaemic while the prevalence of that among adolescent women ( 15-19) has been increased from
38.5 per cent in 2011 to 43.6 percent in 2016 (NDHS).

2.2.3 Efforts to address under-nutrition


MoH has implemented several programmes to counter malnutrition. This began with growth
monitoring and breastfeeding promotion followed by community-based micronutrient
supplementation. Most recent national nutrition programmes have taken a food-based approach to
promote improved dietary behaviour among vulnerable groups. CHD’s Nutrition Section has
implemented the programmes in Box 2.2.1.

Box 2.2.1: Nutrition programmes implemented by CHD’s Nutrition Section (1993–2016)

Nationwide programmes: Scale-up programmes:


 Growth monitoring and counselling  Maternal, Infant, and Young Children
 Prevention and control of iron deficiency Nutrition (MIYCN) programme
anaemia (IDA)  Integrated Management of Acute
 Prevention, control and treatment of Malnutrition (IMAM)
vitamin A deficiency (VAD)  Micronutrient Powder (MNP) distribution
 Prevention of iodine deficiency disorders linked with infant and young child
(IDD) feeding(IYCF)
 Control of parasitic infestation by  School Health and Nutrition Programme
deworming  Vitamin A supplementation to address the
 Mandatory flour fortification in large roller low coverage in 6–11 month olds
mills.  Multi-sector Nutrition Plan (MSNP)
 Infant and young child feeding(IYCF)

The overall objective of the national nutrition programme undertaken by nutrition section is to
enhance nutritional well-being, reduce child and maternal mortality and contribute to equitable
human development.

The specific objectives of the programme are as follows:


 To reduce protein-energy malnutrition in children under 5 years of age and women of
reproductive age
 To improve maternal nutrition
 To reduce the prevalence of anaemia among adolescent girls, women and children
 To eliminate iodine deficiency disorders and vitamin A deficiency and sustain elimination
 To reduce the infestation of intestinal worms among children and pregnant women
 To reduce the prevalence of low birth weight
 To improve household food security to ensure that all people can have adequate access,
availability and use of food needed for a healthy life
 To promote the practice of good dietary habits to improve the nutritional status of all people
 To prevent and control infectious diseases to improve nutritional status and reduce child
mortality

DoHS, Annual Report 2073/74 (2016/2017) 27


Child Health
 To control lifestyle related diseases including coronary disease, hypertension, tobacco related
diseases, cancer and diabetes
 To improve the health and nutritional status of schoolchildren
 To reduce the critical risk of malnutrition and life during very difficult circumstances
 To strengthen the system for analysing, monitoring and evaluating the nutrition situation
 Behaviour change communication and nutrition education at community levels
 To align health sector programmes on nutrition with the Multi-Sectoral Nutrition Initiative.

2.2.4 Targets

2.2.4.1 Current Global Nutrition Targets


a. Sustainable Development Goal
Goal 2 — End hunger, achieve food security and improved nutrition and promote sustainable
agriculture
 By 2030, end hunger and ensure access by all people, in particular the poor and people in
vulnerable situations, including infants, to safe, nutritious and sufficient food all year round;
 By 2030, end all forms of malnutrition, including achieving, by 2025, the internationally agreed
targets on stunting and wasting in children under 5 years of age, and address the nutritional
needs of adolescent girls, pregnant and lactating women and older persons;
 By 2030, double the agricultural productivity and incomes of small-scale food producers, in
particular women, indigenous peoples, family farmers, pastoralists and fishers, including
through secure and equal access to land, other productive resources and inputs, knowledge,
financial services, markets and opportunities for value addition and non-farm employment;
b. Global Nutrition Target by 2025 (World Health Assembly [WHA])
 Reduce the global number of children under five who are stunted by 40 percent
 Reduce anaemia in women of reproductive age by 50 percent
 Reduce low birth weight by 30 percent
 No increase in childhood overweight
 Increase the rate of exclusive breastfeeding in the first six months up to at least 50 percent
 Reduce and maintain childhood wasting to less than 5 percent.

2.2.4.2 National Nutritional Status and Targets

Table 2.2.1: Nepal’s progress against the MSNP 2 targets (2001–2016)


Status (%) Target (%)
Indicators NDHS NDHS NDHS NDHS MSNP WHA SDG
2001 2006 2011 2016 2022 2025 2030
Stunting among U5 children 57 49 41 36 28 24 15
Wasting among U5 children 11 13 11 10 7 <5 4
Underweight among U5
43 39 29 27 20 15 10
children
Percentage of LBW - 14 12 24 10 <1.4 <1.4

28 DoHS, Annual Report 2073/74 (2016/2017)


Child Health
Status (%) Target (%)
Indicators NDHS NDHS NDHS NDHS MSNP WHA SDG
2001 2006 2011 2016 2022 2025 2030
Exclusive breastfed - 53 70 66 80 85 90
Fed according to
- - 24 36 60 70 80
recommended IYCF practices
Over-weight and obesity
- - - 2.1 1.4 1 <1
among U5 children
Anaemia among U5 children - 48 46 53 28 20 <15
Anaemia among children
- 78 69 68 - 60 <50
under 6-23 months
Anaemia among women (15-
- 36 35 41 24 20 <15
49)
Anaemia among pregnant
- 42 48 46 - 35 <25
women
Anaemia in adolescent 25 (for
- 39 38.5 43.6 35 <25
women (15-19) 10-19)
Body mass index
26 24 18.2 17 12 8 <5
(<18.5kg/m2) among women
overweight or obese among
- 9 14 22 18 15 <12
women

2.2.5 Programme strategies


The main overall strategies for improving nutrition are i) the promotion of a food based-approach, ii)
food fortification, iii) the supplementation of foods and iv) the promotion of public health measures.
The specific nutrition strategies are listed in Box 2.2.2.

Box 2.2.2: Specific strategies to improve nutrition in Nepal

Control of protein energy malnutrition (PEM) Household food security


 Promote breastfeeding within one hour of birth  Promote kitchen garden and agricultural
and avoid pre-lacteal feeding. skills.
 Promote exclusive breastfeeding for first six  Promote the raising of poultry, fish and
months and the timely introduction of livestock for household consumption.
complementary food.  Inform community people how to store and
 Ensure continuation of breastfeeding for at least 2 preserve food.
years and the introduction of appropriate  Improve technical knowledge of food
complementary feeding after 6 months. processing and preservation.
 Strengthen the capacity of health workers and  Promote women’s group income generation
medical professionals for nutrition and activities.
breastfeeding management and counselling.
Improved dietary practices
 Improve skills and knowledge of health workers on
growth monitoring and nutrition counselling  Conduct a study to clarify the problems of
 Strengthen the system of growth monitoring and culturally-related dietary habits
 Promote nutrition education and advocate

DoHS, Annual Report 2073/74 (2016/2017) 29


Child Health
its supervision and monitoring. for good diets and dietary habits.
 Promote the use of appropriate locally available  Develop and strengthen programmes for
complementary foods such as jaulo and Sarbottam behaviour change to improve dietary habits.
Pitho.  Strengthen nutritional education and
 Increase awareness on the importance of advocacy activities to eliminate food taboos
appropriate and adequate nutrition for children that affect nutritional status.
and pregnant and lactating mothers.  Promote the household food security
 Strengthen the knowledge of health personnel on programme.
the dietary and clinical management of severely
Infectious disease prevention and control
malnourished children.
 Distribute fortified foods to pregnant and lactating  Promote knowledge, attitudes and practices
women and children aged 6 to 23 months in food that will prevent infectious diseases.
deficient areas.  Ensure access to appropriate health services.
 Improve maternal and adolescent nutrition and  Improve nutritional status to increase
low birth weight through improved maternal resistance against infectious disease
nutrition.  Improve safe water supplies, sanitation and
 Create awareness of the importance of additional housing conditions.
dietary intake during pregnancy and lactation.  Improve food hygiene.
 Strengthen nutrition education and nutrition
School Health and Nutrition Programme
counselling.
 Build capacity of policy and working level
Control of iron deficiency anaemia (IDA) stakeholders.
 Advocate to policy makers to promote dietary  The biannual distribution of deworming
diversity. tablets to grade 1 to 10 school children.
 Iron folic acid supplementation for pregnant and  Celebrate School Health and Nutrition (SHN)
post-partum mothers. week each June to raise awareness on
 Iron fortification of wheat flour at roller mills. malnutrition at the community level through
 Intermittent iron folic acid supplementation for school children and health workers.
adolescent girls.  Distribute first aid kits to public schools.
 Multiple micronutrient supplementation for  Introduce child-to-child and child-to-parent
children aged 6-23 months. approaches.
 Create awareness of importance of iron in
Integrated management of acute malnutrition
nutrition, promote consumption of iron rich foods
 Build capacity of health workers on managing
and promote diverse daily diets.
acute malnutrition and of other community
 Control parasitic infestation among nutritionally
workers on screening and the referral of
vulnerable groups through deworming pregnant
cases.
women and children aged 12-23 months.
 Establish and implement the key parts of the
Control of iodine deficiency disorders IMAM programme: community mobilization,
 The universal iodization of salt. inpatient therapeutic care, outpatient
 Strengthen implementation of the Iodized Salt Act, therapeutic care and management of MAM.
2055 to ensure that all edible salt is iodized.  Implement the IMAM programme based on
 The social marketing of certified two-child logo maximum coverage & access, timeliness of
iodized salt. service provision, appropriate care and care
 Ensure the systematic monitoring of iodized salt. as long as it is needed.
 Increase the accessibility and market share of  Integrate the management of acute
iodized packet salt with the two-child logo. malnutrition across sectors to ensure that
 Create awareness about the importance of using treatment is linked to support for
iodized salt to control iodine deficiency disorder rehabilitating cases and to wider malnutrition

30 DoHS, Annual Report 2073/74 (2016/2017)


Child Health
(IDD) through social marketing campaign. prevention programme and services.
 Support and promote IYCF, water, sanitation
Control of vitamin A deficiency
and hygiene (WASH), early childhood
 The biannual supplementation of high dose development, social protection and child
vitamin A capsules to 6-59 month olds. health and care along with the management
 Post-partum vitamin A supplementation for of acute malnutrition.
mothers within 42 days of delivery.  Promote the IMAM programme as the bridge
 Strengthen implementation of vitamin A between emergency and development
treatment protocol for severe malnutrition, programmes.
persistent diarrhoea, measles and xerophthalmia.  The supportive supervision and monitoring of
 Nutrition education to promote dietary IMAM programme activities.
diversification and consumption of vitamin A rich  Harmonize the community and facility-based
foods. management of acute malnutrition.
 Ensuring the availability of vitamin A capsules at  Strengthen the coordination and capacity of
health facilities. nutrition rehabilitation homes.
 Increase awareness of importance of vitamin A
supplementation. Nutrition in emergencies
 The biannual distribution of vitamin A capsules to  Develop adequate capacity and predictable
6 and 59 month olds through FCHVs. leadership in the nutrition sector for
 Advocate for increased home production, managing humanitarian responses.
consumption and preservation of vitamin A rich  Formulate an emergency nutrition in
foods. emergency preparedness and response
 Strengthen the use of the vitamin A Treatment contingency plans.
protocol.  Establish and strengthen stronger
 Promote the consumption of vitamin A rich foods partnerships and coordination mechanisms
and a balanced diet through nutrition education. between government, UN and non-UN
 Provide vitamin A capsules (200,000 IU) to agencies.
postpartum mothers through healthcare facilities  Agencies to respond in emergencies through
and community volunteers. the activated nutrition cluster.

Low birth weight Lifestyle related diseases


 Reduce maternal malnutrition by preventing PEM,  Create awareness among adults about the
VAD, IDD and IDA. importance of maintaining good dietary
 Reduce the workloads of pregnant women. habits.
 Increase awareness of the risks of smoking and  Develop the capacity for nutritional
alcohol to pregnant women. counselling at health facilities.
 Increase awareness of risks of early pregnancy to  Create awareness among adolescents and
infant and maternal health. adults about the importance of controlling
 Promote activities for nutrition monitoring and smoking and body weight.
counselling at antenatal clinics.  Create awareness to increase physical activity
and improve stress management.

DoHS, Annual Report 2073/74 (2016/2017) 31


Child Health
2.2.6 Major achievements
2.2.6.1 Growth monitoring and promotion
Monitoring the growth of children less than two years of age helps prevent and control protein-
energy malnutrition and provides the opportunity for taking preventive and curative actions. Health
workers at all public health facilities monitor the growth of children once a month using the growth
monitoring card that is based on WHO’s new growth standards.

In FY 2073/74, the percentage of newborns with low birth weight (<2.5 kg) was increased to 11% at
national level from that as 9% in FY 2072/73. It was similar across the provinces with the highest rate
in the province 1 (15.4 percent) while lowest rate at province 6 (6.9 percent) (Figure 2.2.1).
Nationally, there was an average of 3 visits per child in FY 2073/74 and it was slightly decreased from
the previous year. As far as provinces are concerned, the provinces 1, 4 and 7 had average visits
more than that of the national average whereas the province 2 had the lowest average visits across
the provinces (Figure 2.2.2).

Figure 2.2.1: Percentage of newborns with low Figure 2.2.2: Average no. of growth monitoring
birth weight (<2.5 kg) visits per child (0–23 months)
4 3.9 3.8
15.4
3.2 3.3
13.3 3 2.9 3
11.8 3
11.3 2.5 2.5
10.5
9.9
9 1.9
8.4
2
6.9
8.9

FY 2071/72 FY 2072/73 FY 2073/74


FY 2071/72 FY 2072/73 FY 2073/74
Source: HMIS/MD/DoHS
Source: HMIS/MD/DoHS

The percentage of children aged 0 to 23 months registered for growth monitoring in 2073/74 (69 per
cents) was sharply increased from the previous fiscal year, however, it was still less than that in FY
2071/72. Across the provinces, the province 7 had the highest percentage while province 3 had the
lowest percentage of children aged 0 to 23 months registered for growth monitoring in 2073/74
(Figure 2.2.3).

In 2072/73, 4.4 percent of 0-23 month olds was reported as underweight at national level among
children at their first growth monitoring while it was tremendously decreased for those at repeated
visits highlighting importance of growth monitoring. The highest proportion of underweight children
were from the provinces 6 and 7 while the least was from provinces 1 and 4 (Figure 2.2.4).

32 DoHS, Annual Report 2073/74 (2016/2017)


Child Health

Figure 2.2.3: Percentage of children aged 0–23 Figure 2.2.4: Percentage of registered children aged 0-23
months registered for growth with underweight (New Vs Repeat Visits)
monitoring

110 10 9.5

100 8 7.3

78.3 79.2 77.1


80 6 4.9
69.1 68.6 4.4 4.4
63.4 63.5 62.9
60
56.4 4 3.3

2 1.5 1.2
40 1.1 0.8
0.5 0.5 0.5 0.6
0.2 0.1
0
20

0
% of children aged 0–23 months registered for growth
monitoring who were underweight (New)
% of children aged 0–23 months registered for growth
FY 2071/72 FY 2072/73 FY 2073/74 monitoring who were underweight (Repeat)

Source HMIS/MD/DoHS Source HMIS/MD/DoHS

2.2.6.2 Infant and young child feeding


Appropriate feeding practices are essential to enhance the nutrition, survival, growth and
development of infants and young children. These infant and young child feeding (IYCF) practices
include exclusive breastfeeding for six months and the providing nutritionally adequate and
complementary feeding starting from six months with continued breastfeeding to two years of age or
beyond. Improving care and practices related to IYCF is a priority strategy of MoH. The IYCF
programme was scaled-up in all 75 districts from FY 2072/73.

IYCF is also linked with the distribution of micro-nutrient powder (Baal Vita) in 15 districts and with
child cash grants (CCG) in the five Karnali Zone districts. However, more effective counselling and
monitoring mechanisms are needed for these programmes.

There is a large provincial difference in the percentage of children aged 0-6 months that registered
for growth monitoring and were exclusively breastfed in their first six months. In FY 2073/74, 40.8
percent of these children were exclusively breastfed in the province 3 compared to only 3.1 percent
of such children in the province 2 (Figure2.2.5). The national average was 25.1 percent, which was
decreased by 7% from the previous year. Moreover, it is much less than the 2016 Nepal Demographic
and Health Survey (NDHS) figure - 66 percent.

The proportion of 6-8 month old children registered for growth monitoring who received
complementary foods varied in FY 2073/74 from about 3 percent of these children in the province 2
to 64.6 percent in the province 3 (Figure 2.2.6). Nationally, only 30.6 percent of these children
received complementary food which is much lower than the NDHS 2016 figure of 84 percent. The
current data suggests reflects the poor timely introduction of complementary feeding and the
consequent need to provide appropriate counselling to mothers and caregivers to improve feeding
practices.

DoHS, Annual Report 2073/74 (2016/2017) 33


Child Health

Figure 2.2.5: Percentage of 0–6


0 6 month olds Figure 2.2.6: Percentage of 6–
6–88 month olds
registered for growth monitoring who registered for growth monitoring who
were exclusively breastfed
breastfed for their had received solid, semi-solid
semi solid or soft
first six months foods

FY 2071/72 FY 2072/73 FY 2073/74 FY 2071/72 FY 2072/73 FY 2073/74

64.6
40.8
40 37.3
35.5
35 31.7
28.5 25.1

39.5
30 26.4

37.2
32.3
30.6
25 20.9

27.5

27.3
23.5
20
14.1

12.3
15
10

2.9
5 3.1

Source HMIS
HMIS/MD/DoHS Source HMIS/MD/DoHS
HMIS/MD/DoHS

2.2.6.3 Integrated management of acute malnutrition


The Integrated Management of Acute Malnutrition (IMAM) Programme (previously the Community
based Management of Acute Malnutrition [CMAM] programme) manages Severe Acute Malnutrition
(SAM) in children aged 0-59 0 59 months through inpatient and outpatient services
services at facility and
community levels. This programme was being implemented in 11 districts (Achham, Kanchanpur,
Bardiya, Jajarkot, Jumla, Mugu, Kapilbastu, Sarlahi, Dhanusha, Saptari and Okhaldhunga) until last FY
2072/073 and was scaled-up
scaled up in 10 MSNP distr
districts
icts in current FY 2073/074. The scaled-up
scaled up districts are
Kalikot, Humla, Dolpa, Dadeldhura, Bajhang, Bajura, Baitadi, Panchthar, Khotang, and Parsa, with
technical and financial support from UNICFE
UNICFE-Nepal.
Nepal. In Chitwan, the program is implemented in only
few VDCs covering the Chepang population. Along with MIYCN promotion and support, IMAM aims
to integrate nutrition support across the health, early childhood development, WASH and social
protection sectors for the continued rehabilitation of cases and to widen malnutrition prevention
programme and services. The programme also acts as a bridge between emergency and
development nutrition interventions.

In 2073/
2073/-74,
74, total 15,633 children with SAM admitted in outpatient’s therapeutic programme 21
districts. Among them, 13,378 were discharged with 10651 with complete recovery. Among all
discharged SAM cases, 80 percent were recovered, less than 1 percent died and 10 percent were
defaulter, which are within the SPHERE standards of effectiveness of IMAM Program: recovery
reco rate
>75 percent, defaulter rate <15 percent and death rate <10 percent. However, few districts, including
Sarlahi, Parsa, Chitwan, and Acham achieved substantially below average results (Table 2.2.2). In
some districts, the number of discharged child
children
ren is higher than that of admitted children, this is due
to reason that some of the children being admitted in previous years and continued treatment in
current fiscal year.

34 DoHS, Annual Report 2073/74


207 (201
(2016/2017)
Child Health
Table 2.2.2: District wise IMAM performance, FY 2073/74
District Total Total # of Total # of Total # Total # IMAM Performance (%)
SN Name Admission Discharge Recovered of of Recovered Death Defaulter
Cases Death Defaulter
1 Okhaldhunga 249 244 193 0 25 79.1 0.0 10.2
2 Khotang 18 196 191 2 0 97.4 1.0 0.0
3 Saptari 2634 1684 1132 4 69 67.2 0.2 4.1
4 Dhanusha 216 116 98 0 4 84.5 0.0 3.4
5 Sarlahi 784 742 466 6 219 62.8 0.8 29.5
6 Parsa 163 244 123 0 96 50.4 0.0 39.3
7 Chitwan 606 463 206 0 223 44.5 0.0 48.2
8 Kapilvastu 1609 1410 1089 0 171 77.2 0.0 12.1
9 Bardiya 670 622 524 1 60 84.2 0.2 9.6
10 Jajakot 169 186 141 1 10 75.8 0.5 5.4
11 Dolpa 168 173 136 9 12 78.6 5.2 6.9
12 Jumla 243 273 190 2 19 69.6 0.7 7.0
13 Kalikot 864 732 590 3 105 80.6 0.4 14.3
14 Mugu 1026 884 792 0 48 89.6 0.0 5.4
15 Humla 893 622 562 1 39 90.4 0.2 6.3
16 Bajura 753 677 640 2 18 94.5 0.3 2.7
17 Bajhang 971 809 704 3 42 87.0 0.4 5.2
18 Achham 421 401 287 1 75 71.6 0.2 18.7
19 Kanchnapur 1215 1035 933 4 53 90.1 0.4 5.1
20 Dadeldhura 629 487 427 0 21 87.7 0.0 4.3
21 Baitadi 1332 1378 1227 0 85 89.0 0.0 6.2
Total 15633 13378 10651 39 1394 79.6 0.3 10.4
Source HMIS/MD/DoHS

2.2.6.4 Nutrition rehabilitation homes


The first Nutrition Rehabilitation Home (NRH) was established in 1998 in Kathmandu aiming to
reduction of child mortality caused by malnutrition through inpatient rehabilitation of acute
malnutrition among the children. Since then, NRH has been scaled-up in 18 districts across Nepal.
The NRH not only treat and manage acute malnutrition with inpatient service, but also provide
nutrition education and counselling to the guardians of admitted children on good nutrition and
health care of their children. In FY 2073/74, total 1261 children were provided with nutritional care
through 16 NRH; and among them 745 were fully recovered. Those not recovered were referred to
the tertiary health facilities for advance treatment. In Kathmandu, around 72 percent of the admitted
cases were found with severe acute malnutrition and almost all of them were managed successfully.
Table 2.2.3: Admission and discharge status of nutrition rehabilitation homes, 2073/74
SN NRH Admitted Discharged
Male Female Male Female
1 Kathmandu 135 (SAM-98) 147 (SAM-105) 130 (SAM-98) 139 (SAM-100)
2 Janakpur 47 34 41 31
3 Rajbiraj 65 79 61 80
4 Bharatpur 79 96 84 83
5 Dailekh 41 22 40 26
6 Baglung 50 50 45 49
7 Dang 55 55 52 50
8 Butwal 42 39 38 35
9 Nepalgunj 73 71 62 65
10 Bhadrapur 72 56 69 59
11 Biratnagar 48 34 51 23
DoHS, Annual Report 2073/74 (2016/2017) 35
Child Health
SN NRH Admitted Discharged
Male Female Male Female
12 Birgunj 110 71 98 72
13 Kanchanpur 71 63 73 64
14 Dhanagadhi 81 50 74 47
15 Pokhara 54 62 52 60
16 Surkhet 69 47 69 47
Total 538 678 171 574
Source: Annual report 2073/074, Nepal Youth Foundation

2.2.6.5 Prevention and control of iron deficiency anaemia


MoH has provided supplementary iron folic acid (IFA) to pregnant and post-partum women since
1998 to reduce maternal anaemia. The protocol is to provide 60 mg elemental ironand400
microgram folic acid to pregnant women for 225 days from their second trimester. To improve
access, in 2003, the Intensification of Maternal and Neonatal Micronutrient Programme (IMNMP)
began IFA supplementation through female community health volunteers (FCHVs). This programme
covered all 75 districts by 2014. The intensification programme improved coverage, although
compliance with taking 180 tablets during pregnancy and 45 tablets post-partum remains an issue.

Figure 2.2.7: IFA distribution by Province, FY 2073/74


120
100
100 93
85 81
74 73
80 66
Percentage

65 60 57 56 52 55
60 44 40 49
41 43 40 40
40 31 32 28
24
20
0
National Province 1 Province 2 Province 3 Province 4 Province 5 Province 6 Province 7
PLW receiving IFA 1st time PLW Receiving 180 IFA PPW receiving 45 IFA

The coverage of first time iron distribution is high at 74 percent nationally with the highest coverage
in province 5,6, and 7 (98 percent, 100 percent, and 81 percent respectively), but the compliance of
taking 180 tablets throughout the pregnancy (44 percent) and 45 days post-partum (40 percent) is
substantially low. Province 3 has the lowest coverage amongst all for all three indicators.

Figure 2.2.8: IFA distribution as percentage of expected live births in Nepal in last three years

Source: HMIS/MD/DoHS. Note: PP = postpartum

36 DoHS, Annual Report 2073/74 (2016/2017)


Child Health
Nationally the trend of first time, 180 days and 45 days post-partum IFA distribution has been
declining slightly over the periods (Figure 2.2.8). Frequent shortage of IFA tablets has further
deteriorated the coverage.
2.2.6.6 Integrated Infant and Young Child Feeding and Micro-Nutrient Powder Community
Promotion Programme
The NDHS 2006 found that 78 percent of 6-23 month old children were anaemic, mostly due to poor
IYCF practices. A Plan of Action subsequently endorsed Sprinkles as the key intervention to address
anaemia in young children. In 2007, the National Nutrition Priority Workshop endorsed the piloting
of sprinkles supplementation as a preventive measure. In June 2009, MoH piloted the home
fortification of complementary food with MNPs for 6-23 months olds in six districts integrated with
the Community IYCF Programme. The successful pilot programme led to MoH expanding it to an
additional nine districts in 2012.

The promotion of MNPs is linked with improving complementary feeding. Mothers and caregivers
are counselled to introduce complementary foods at six months of age, on age-appropriate feeding
frequency, on improving dietary quality of complementary foods by making them nutrient and
calorie dense, as well as on hand washing with soap before feeding. Mothers and caregivers are
trained to prepare ‘poshilo jaulo’ (pulses, rice and green vegetables cooked in oil) and ‘lito’ (mixture
of blended and roasted cereal and legume flours). A feasibility study of the programme in 2008/09
found strong community acceptance with a very high coverage and compliance on the use of MNP.
The linking of IYCF with MNPs has contributed to significant improvement in IYCF practices. The
prevalence of anemia among children age 6-23 months has decreased to 68% (NDHS, 2016) from 78
percent. However, it still calls for continuous effort as the coverage of the program is not very
promising.

In 2073/74 58 percent of children aged 6 to 23 months had taken their first dose of multiple
micronutrient power (MNP-Baal Vita) in the 16 programme districts. Rasuwa and Gorkha has the
highest coverage at 100 percent while Makawanpur has the lowest at 49 percent. Compared to the
1st cycle of MNP intake, the 3rd cycle of intake indicating the compliance is relatively low at 42
percent. Here, it is important to mention that coverage of 1 st cycle intake is calculated based on the
target population of 6-23 months, while that of 3rd cycle is calculated among the children aged 18-23
months, who have ever taken MNP. This was done as the target population for aged 12-18 and 18-23
months is not available in HMIS estimation. Rasuwa and Gorkha seem performing well with the
higher coverage while Rukum west needs to make intensive efforts. Overall, effective nutrition
education, counselling and follow up to the mothers/caretakers is essential to improve coverage as
well as comply with the recommended doses of MNPs.

Table 2.2.4: Micronutrient powder (Baal Vita) distribution status, 2073/74


Children receiving Children receiving
S.N. District Name 1st Cycle of MNP 3rd Cycle of MNP
Target # % Target # %
1 MORANG 34241 20918 61 9889 4104 42
2 SUNSARI 28007 26738 95 14945 4315 29
3 SANKHUWASABHA 5171 2668 52 865 395 46
4 PARSA 21813 16232 74 6603 937 14
5 RASUWA 1459 1526 100 686 317 46
6 MAKWANPUR 14615 7203 49 2426 810 33

DoHS, Annual Report 2073/74 (2016/2017) 37


Child Health
Children receiving Children receiving
S.N. District Name 1st Cycle of MNP 3rd Cycle of MNP
Target # % Target # %
7 GORKHA 8506 9384 100 6431 3290 51
8 PALPA 8417 4562 54 1169 727 62
9 RUPANDEHI 32560 20552 63 9944 4057 41
10 KAPILBASTU 20641 19370 94 11151 4553 41
11 RUKUM 1737 1540 89 807 207 26
12 DANG 20107 10033 50 3739 1009 27
13 BARDIYA 15089 8084 54 5353 4724 88
14 RUKUM WEST 55922 3064 5 1747 444 25
15 ACHHAM 9091 9643 106 5163 3259 63
16 DADELDHURA 5003 3288 66 1866 1310 70
Total 282379 164805 58 82784 34458 42
Source: HMIS/MD/DoHS

2.2.6.7 Prevention and control of iodine deficiency disorder


MoH adopted a policy to fortify all edible salt in 1973 to address iodine
deficiency disorders (IDD) through universal salt iodization. The Salt
Trading Corporation is responsible for the iodine fortification of all
edible salt and its distribution, while MoH is responsible for promoting
iodized salt and its marketing to increase consumption. The
government uses the Two-Child
Two Child-Logo
Logo to certify adequately iodized salt
and DoHS has been implementing a social marketing campaign of this
salt to improve awareness of its use in households. National surveys report an increase in the
number of households using adequately iodized salt from 55 percent in 1998 to 95 percent in 2016
(Figure 2.2.
2.2.9).
). Iodine month was celebrated in February 2017 in all 75 districts to raise awareness on
the use of two
two-child
child-logo
logo salt for optimum iodine intake to combat iodine deficiency disorders.

There are, however, disparities in the use of iodized salt. The NDHS 2016 found the Province 2 to
have the highest coverage (99.3 percent), while the Province 6 had the lowest (85.1 percent) (Figure
2.2.10).
).

Figure 2.2.
2.2.9:: Percentage of households using iodized salt

110
94.9
90 80 81.5

70
55.2 57.5
50.4
50

30

10

-10 1998 NMSS 2005 NIDDS 2010 (FWDR & 2011 NDHS 2014 NMICS 2016 NDHS
MWDR)

38 DoHS, Annual Report 2073/74


207 (201
(2016/2017)
Child Health
Figure 2.2.10: Percentage of households using adequately iodized salt
105
99.3
100 96.7 96.4
95.5
95 91.8 91.8
90
85.1
85
80
75
Provience 1 Provience 2 Provience 3 Provience 4 Provience 5 Provience 6 Provience 7

Source: CHD, Nutrition Section

2.2.6.8 Control of vitamin A deficiency disorders


The government initiated the National Vitamin A Programme in 1993 to improve the vitamin A status
of children aged 6-59 months and reduce child mortality. This programme is recognized as a global
public health success story. It initially covered 8 districts and was scaled up nationwide by 2002.
FCHVs distribute the capsules to the targeted children twice a year through a campaign-style activity.

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


Distribution Round

120
97 100 100
100 93
85 87 88
81 82 84
78 76 80
80 72 75
70
Percentage

60

40

20

0
National Province 1 Province 2 Province 3 Province 4 Province 5 Province 6 Province 7
Kartik 2073 (October 2016) Baisakh 2074 (April 2017)

Source: HMIS/MD/DoHS

From this fiscal year, the progress on biannual Vitamin A supplementation is presented by 1 st Round
(Kartik) and 2nd Round (Baisakh). The overall national achievement is more than 80 percent among
the children aged 6-59 months with 85 percent in Kartik and 81 percent in Baisakh. Nonetheless, the
coverage by provinces varies with province 5 and 6 with higher proportion of children receiving
vitamin A supplementation with the province 4 and 5 with the lover proportions of children receiving
it.

DoHS, Annual Report 2073/74 (2016/2017) 39


Child Health

Figure 2.2.12: Coverage of vitamin A Figure 2.2.13: Coverage of vitamin A


supplementation by age groups for Kartik 2073 supplementation by age groups for Baisakh 2074
(October 2016) (April 2017)

119 118
120 120
97 100 98
96 97 97 97
92 93
100 88 84 90 87 87 100 87 89
84
80 82 80 77 78
74 72 75
80 69 73 80 68 71

Percentage
66
Percentage

60 60

40 40

20 20

0 0

6-11 months 12-59 months 6-11 months 12-59 months


Source: HMIS/MD/DoHS

In both round, except in province 3 and 4, the relatively higher percentage of children aged 6-11
month had received Vitamin A compared to the children aged 12-59 months. The overall national
coverage does not vary much by age-groups in Kartik and Baisakh rounds. Additionally, the provinces
3 and 4 also showed the lowest coverage amongst other provinces. The relatively higher coverage of
the children aged 6-11 months in the Mid-western and Far Western regions could be due to the
introduction of new strategy of vitamin A supplementation to the infants aged 6-11 months in
2014/15. This strategy allowed health facilities and FCHVs to provide vitamin A to children
immediately after they reached six months of age. Under this strategy, children then receive the
second dose at the regular biannual supplementation events. Majority of the districts in provinces 2,
6 and 7 are supplementing Vitamin A with this new service delivery mechanism.

2.2.6.9 Biannual Deworming Tablet Distribution to the Children aged 12-59 months
Child Health Division attempts to include report on biannual deworming tablets distribution to the
children aged 12-59 months. Aiming to reduce childhood anemia with control or parasitic infestation
through public health measures, this activity is integrated with biannual Vitamin A supplementation
to the children aged 6-59 months, which takes place nationally in every ward on first week of Baisakh
and Kartik each year. Deworming to the target children was initiated in few districts during the year
2000 integrating with biannual Vitamin A supplementation and with gradual scaling-up, the program
was successfully implemented nationwide by the year 2010.

The report is presented separately for Baisakh and Kartik round of FY 2073/074. As shown in figure
2.2.13, the national coverage of deworming tablet distribution is 84 percent in Kartik round and 71
percent in Baisakh round. For all the provinces, the coverage shown similar pattern with higher in
Karik and lower in Baisakh with exception in province 3. Province-wise, province 5 and 6 shows
highest coverage with province 2 and 3 with relatively low coverage. In province 1, the coverage for
Baisakh is substantially low (56 percent) than that in Kartik (86 percent).

40 DoHS, Annual Report 2073/74 (2016/2017)


Child Health
Figure 2.2.13: Coverage of Deworming Tablets distribution to the Children aged 12-59 months

120
96 98
100 86 90 87
84 79 84 82
Percentage

80 71 72 73 76 68
56 58
60
40
20
0
National Province 1 Province 2 Province 3 Province 4 Province 5 Province 6 Province 7
Kartik 2073 (October 2016) Baisakh 2074 (April 2017)
Source: HMIS/MD/DoHS

2.2.6.10 School Health and Nutrition Programme


The School Health and Nutrition Strategy (SHNS) was developed jointly in 2006 by Ministry of Health
and Ministry of Education to address the high burden of diseases in school age children. In 2008, a
five-year Joint Action Plan (JAP) was endorsed to implement School Health and Nutrition (SHN)
Program. The improved use of school-based health and nutrition services, improved access to safe
drinking water and sanitation, skill-based health education, community support and an improved
policy environment are the core elements of the School Health and Nutrition Programme.

During 2008-2012, government had implemented a pilot SHN project in primary schools based on the
Joint Action Plan in Sindhupalchowk and Syangja districts. This pilot project has some promising
results recommending to scaling up of the program in other districts. With gradual scaling-up, the
program has covered all 75 districts by FY 2073/074. The current Joint Action Plan (2071/072 to
2075/76) calls for:
 annual health screening
 biannual deworming of Grade 1–10 school children
 a first aid kit box with refilling mechanism in all primary schools
 hand washing facilities with soap in all schools
 toilets in all schools
 the use of the new attendance registers in all schools
 orient school management committees on facilitating health and nutrition activities
 child club mobilization on health and nutrition issues.

One of the major activity under SHN Program is Biannual School Deworming to all the School-aged-
children (SAC) that is conducted in first week of Jestha and Mangsir every year. District (Public)
Health Offices provide deworming tablets to the respective District Education Offices and the school-
focal-teachers distribute the tablets to the SAC in their school. Until the last FY, progress in this
regard has not been reported in the annual report due to the very poor, almost no reporting to the
system. However, though very low, there is some reporting this FY as presented in the figure 2.2.14
below. As reflected, national coverage of school deworming is as low as 29 percent with the highest
in province 6 (81 percent) and with lowest in province 2 (only 5 percent).

DoHS, Annual Report 2073/74 (2016/2017) 41


Child Health
Figure 2.2.14
2.2.14: Coverage of School
School Deworming Tablet Distribution
Distribution,, FY 2073/74

100
81
80
Percentage

60
40
40 29 30 29
26
21
20
5
0
National Province 1 Province 2 Province 3 Province 4 Province 5 Province 6 Province 7
Source: HMIS /MD/DoHS
/DoHS

2.2.6.11
.2.6.11 Adolescent Girls Iron Folic Acid Supplementation

From FY 2072/073, the SHN Program has initiated Weekly Iron Folic Acid (IFA) supplementation to
the adolescent girls aged 10-19
10 19 years aiming to prevent and control the high burden of Iron
Deficiency Anemia among this particular group of population. This ac
activity
tivity was piloted in Kathmandu,
Dolakha, Khotang, Panchthar, Bhojpur, Saptari, Puthan and Kapilvastu in FY 2072/073. In FY
2073/074, scaling up of the program was planned in 17 more districts, namely Humla, Bajura,
Bajhnag, Doti, Bhaktapur, Rupandehi, ManManang,
ang, Surkhet, Parsa, Jumla, Mahottari, Kalikot, Sarlahi,
bara, Mugu, Dolpa, and Udaypur. Child Health Division has completed the Training to the concerned
official from all these districts. However, the program has yet not been implemented in all the
districts
icts due to the various reason.

Under this component, all the adolescent girls aged 10


10--19
19 years are supplemented with weekly Iron
Folic Acid biannually in Shrawan (Shrwan-Asoj)
(Shrwan Asoj) and Magh (Magh
(Magh-Chiatra)
Chiatra) rounds. In each round, they
are provided with one IFA tablet every week for 13 weeks. So, each adolescent girls should get a total
of 26 IFA tablets in a year.

2.2.6.12
.2.6.12 Nutrition in emergencies
In addition to the regular nutrition program intervention, Child Health Division also provide services
of Nutrition in Emergencies. When an emergency caused by any reasons such as natural disasters
(earthquake, flood, drought, etc.), conflicts or any other cause occurs affecting the overall health,
nutrition, and livelihoods of all the population either in any are of the country or nationwide,
Nutrition in Emergencies (NiE) services is provided to the affected areas. NiE interventions focus on
the pregnant and lactating women (PLWs) and children under five years of age as they are
nutritionally most vulnerable during any emergency. Under NiE interventions following Five Building
Blocks of nutrition interventions are implemented in the affected areas of the ccountry.
ountry.
 Promotion, protection and support to breast feeding of infant and young children aged 0-23
0
months.
 Promotion of proper complementary feeding to the infant and young children aged 6-23 6
months.
 Management of moderate acute malnutrition (MAM) among the children aged 6-59
6 59 months and
among PLWs through targeted supplementary feeding program (TSFP).
42 DoHS, Annual Report 2073/74
207 (201
(2016/2017)
Child Health
 Management of severe acute malnutrition among the children aged 6-59 months through
therapeutic feeding.
 Intensification of Micronutrient supplementation for children and women including MNP and
vitamin A for children aged 6-59 months, IFA for pregnant and postnatal women.

During FY 2073/074, NiE interventions were continued in 14 districts (Kathmandu, Lalitpur,


Bhaktapur, Kavrepalanchowk, Dhading, Rasuwa, Nuwakot, Makawanpur, Sinchdupalchowk, Sindhuli,
Dolakha, Ramechhap, Gorkha, and Okhaldhunga), highly affected by the Mega Earthquake in Baisakh
of FY 2071/072 with the recovery phase interventions. The progress in this regard is given below.

Table 2.2.5: Achievement of nutrition in emergency in 14 earthquake affected districts (2015/16)

SN Intervention areas Achievement (%)

Mothers and caretakers of children aged 0-23 months counselled on


1 68
breastfeeding and risks of artificial feeding

Mothers and caretakers of children age 6-23 months counselled on


2 72
complementary feeding

Children aged 6-59 months with moderate acute malnutrition admitted to


3 51
targeted supplementary feeding centres (TSFC)
4 Supplementary feeding of pregnant and lactating women 196

5 Children aged 6-59 months received multiple micronutrient powders (Baal Vita) 85

6 Children aged 6-59 months received vitamin A capsules 79


7 Children aged 12-59 months received deworming tablets 76
8 Pregnant and Lactating Women receiving IFA Supplementation 56
Source: Nutrition Cluster report

Table 2.2.6: IMAM Performance in 14 Highly Earthquake affected Districts.


District Total Total # of Total # of Total # Total # IMAM Performance (%)
SN Name Admission Discharge Recovered of of Recovered Death Defaulter
Cases Death Defaulter
1 Okhaldhunga 249 244 193 0 25 79.1 0 10.2
2 Sindhuli 480 673 611 5 48 90.8 0.7 7.1
3 Ramechhap 244 266 219 10 17 82.3 3.8 6.4
4 Dolakha 219 166 124 1 14 74.7 0.6 8.4
5 Sindhuplachowk 316 502 396 0 72 78.9 0 14.3
6 Kavre 97 157 133 0 8 84.7 0 5.1
7 Lalitpur 555 581 512 0 16 88.1 0 2.8
8 Bhaktapur 297 235 181 0 15 77.0 0 6.4
9 Kathmandu 2591 1705 1076 4 338 63.1 0 19.8
10 Nuwakot 315 356 310 0 20 87.1 0 5.6
11 Rasuwa 74 73 44 0 18 60.3 0 24.7
12 Dhading 381 408 273 1 47 66.9 0 11.5
13 Makawanpur 583 468 375 2 47 80.1 0 10.0
14 Gorkha 91 158 76 1 73 48.1 0.6 46.2
Total 6492 5992 4523 24 758 75.5 0 12.7
Source: Nutrition Cluster report

DoHS, Annual Report 2073/74 (2016/2017) 43


Child Health
% of PSBI cases receiving full dose of Inj.
% of Diarrhoea Cases Treated with ORS and Zinc
Gentamicin
MYAGDI 111.1 JAJARKOT 109.1
SARLAHI 109.1 LALITPUR 108.1
MAHOTTARI 102.5 KATHMANDU 105.5
RAUTAHAT 101.6 PALPA 102.9
KALIKOT 95 RASUWA 100.8
SALYAN 91 DHADING 100.4
BARDIYA 87.8 RAMECHHAP 100.3
DARCHAULA 87.5 PYUTHAN 100
MORANG 85.4 PANCHTHAR 99.9
BAJHANG 82.2 SYANGJA 99.7
DAILEKH 80.4 BHAKTAPUR 99.1
HUMLA 79.5 64 KALIKOT 98.5
JUMLA 78.6 SARLAHI 98.5
ACHHAM 78.2 GORKHA 98.2
DADELDHURA 76.5 SURKHET 98.1
PARSA 73.9 DHANKUTA 98.1
RUKUM WEST 71.4 BARDIYA 97.8
PYUTHAN 70.9 TANAHU 97.8
SURKHET 70.1 DANG 97.7
DOTI 65.8 SANKHUWASABHA 97.6
PANCHTHAR 65.4 63 JUMLA 97.1
BAJURA 65.1 ACHHAM 96.9
MAKWANPUR 63.3 BANKE 96.2
KAPILBASTU 61.1 RUKUM WEST 96.1
SIRAHA 59.3 GULMI 96.1
BARA 59.1 BAJHANG 96
DANG 58.6 LAMJUNG 95.8
SAPTARI 54.5 DARCHAULA 95.3
SANKHUWASABHA 51.3 BAGLUNG 95.2
RUKUM 43.8 ROLPA 95.1
KANCHANPUR 43 RAUTAHAT 95.1
SINDHUPALCHOK 42.9 SAPTARI 95
DOLPA 40.3 RUKUM 94.9
JAJARKOT 37.7 BAITADI 94.8
ROLPA 37 MAKWANPUR 94.7
DHANUSA 35.3 MANANG 94.6
KAILALI 34.9 MAHOTTARI 94.6
MUGU 34.8 65 MUGU 94.4
BANKE 34.7 MYAGDI 94.3
BAITADI 33.3 DADELDHURA 94.1
CHITAWAN 33.3 KAILALI 94
TERHATHUM 33.3 NAWALPARASI 94
ARGHAKHANCHI 28.6 PARSA 93.6
SUNSARI 26.2 BAJURA 93.4
DHANKUTA 25 CHITAWAN 93.2
JHAPA 24.3 PARBAT 93
SINDHULI 22.6 KASKI 92.8
RASUWA 22 DOTI 91.8
KHOTANG 19 DOLAKHA 90.7
TAPLEJUNG 18.2 SINDHULI 90.7
OKHALDHUNGA 17.1 JHAPA 90.7
UDAYAPUR 16.9 KAPILBASTU 90.6
DHADING 16.7 MORANG 90.4
ILAM 16.7 DAILEKH 90.3
DOLAKHA 15.3 TERHATHUM 89.9
BAGLUNG 12.5 KANCHANPUR 89.1
NUWAKOT 12.5 BARA 89
GORKHA 12 SIRAHA 89
SYANGJA 11.1 66 HUMLA 86.6
RUPANDEHI 9.6 BHOJPUR 86.5
NAWALPARASI 7.7 TAPLEJUNG 86.1
TANAHU 6.7 UDAYAPUR 86
RAMECHHAP 6.7 DHANUSA 85.9
KATHMANDU 6.3 ILAM 85.6
SOLUKHUMBU 5.5 NUWAKOT 84.5
GULMI 5.3 SINDHUPALCHOK 83.9
NAWALPUR 5.2 OKHALDHUNGA 83.6
LALITPUR 4.8 KHOTANG 83.4
PALPA 4.3 62 DOLPA 82.8
PARBAT 0 SALYAN 81
MUSTANG 0 RUPANDEHI 80.2
MANANG 0 KAVRE 79.3
KASKI 0 MUSTANG 79.1
LAMJUNG 0 RGHAKHANCHI 78.8
BHAKTAPUR 0 SOLUKHUMBU 78
KAVRE 0 SUNSARI 75
BHOJPUR 0 NAWALPUR 39.1
NATIONAL 59 NATIONAL 92.1

0 50 100 150 0 50 100 150

44 DoHS, Annual Report 2073/74 (2016/17)


Child Health

2.3 INTEGRATED MANAGEMENT OF NEONATAL AND


CHILDHOOD ILLNESS

2.3.1 Introduction

A chronological development: Community Based-Integrated Management of Childhood Illness (CB-


IMCI), Community Based Integrated Management of Newborn Care Program (CB-NCP) and
Community Based-Integrated Management of Neonatal and Childhood Illness (CB-IMNCI)

In Nepal, Child survival intervention began when Control of Diarrhoeal Disease (CDD) Program was
initiated in 1983. Further, Acute Respiratory Infection (ARI) Control Program was initiated in 1987.
To maximize the ARI related services at the household level, referral model and treatment model at
the community level were piloted. An evaluation of this intervention in 1997 revealed that
treatment model was more effective and popular in the community than referral model. In
1997/98, ARI intervention was combined with CDD and named as CB-AC program. One year later
two more components, nutrition and immunization, were also incorporated in the CBAC program.
IMCI program was piloted in Mahottari district and was extended to the community level as well.
Finally, the government decided to merge the CBAC into IMCI in 1999 and named it as Community-
Based Integrated Management of Childhood Illness (CB-IMCI). CB-IMCI included the major
childhood killer diseases like pneumonia, diarrhoea, malaria, measles, and malnutrition. The
strategies adopted in IMCI were improving knowledge and case management skills of health service
providers, overall health systems strengthening and improving community and household level care
practices. After piloting of low osmolar ORS and Zinc supplementation, it was incorporated in CB-
IMCI program in 2005. Nationwide implementation of CB-IMCI was completed in 2009 and revised
in 2012 incorporating important new interventions.

Up to 2005, Nepal had made a huge progress in reduction of under-five and infant mortality,
however, the reduction of neonatal mortality was observed very sluggish because the country had
no targeted interventions for newborns especially at community level. State of world report, WHO
showed that major causes of mortality were infections, asphyxia, low birth weight and
hypothermia. The Government of Nepal formulated the National Neonatal Health Strategy 2004.
Based on this 'Community-Based New Born Care Program (CB-NCP)' was designed in 2007, and
piloted in 2009. CB-NCP incorporated seven strategic interventions: behaviour change
communication, promotion of institutional delivery, postnatal care, management of neonatal
sepsis, care of low birth weight newborns, prevention and management of hypothermia and
recognition and resuscitation of birth asphyxia. Furthermore, in September 2011, Ministry of Health
and Population decided to implement the Chlorhexidine (CHX) Digluconate (7.1% w/v) aiming to
prevent umbilical infection of the newborn. The government decided to scale up CB-NCP and
simultaneously, the program was evaluated in 10 piloted districts. Upto 2014, CB-NCP was
implemented in 41 districts covering 70% population.

DoHS, Annual Report 2073/74 (2016/17) 45


Child Health
As a result of CB-IMCI program strategy, the prevalence of pneumonia and diarrhoea has reduced
significantly over the last decades. The care-seeking practices and household level practices have
been improved. CB-IMCI program has become one of the role models for a community-based
program of Nepal. Other interventions which have a high contribution to the reduction of post-
neonatal child mortality are bi-annual supplementation of Vitamin A program, expanded program
on immunization. On the other hand, essential newborn care practices were improved in CB-NCP
implemented districts.

In both of the programs (CB-IMCI and CB-NCP), FCHVs were considered as frontline health service
providers but quality and coverage of service were very low. CB-NCP and CB-IMCI have similarities
in interventions, program management, service delivery and target beneficiaries. Both programs
have duplicated interventions like management of neonatal sepsis, promotion of essential newborn
care practices, infection prevention, and management of low birth weight. Though FCHVs are doing
very good on the promotion of healthy behaviours, they are found poorly performing in service
delivery. Moreover, they are overburdened with workloads and massive resource was used in a
fragmented manner for the same purpose. Also, inequity in quality service delivery and utilization
are the major challenges in newborn and child health programs. Health governance issue is also
affecting to better functioning of the health system. Considering the management of similar kind of
two different programs, MoH decided to integrate CB-NCP and IMCI into a new package that is
named as CB-IMNCI.

2.3.1.1 Community-Based Integrated Management of Newborn and Childhood Illnesses


(CB‐IMNCI)
CB-IMNCI is an integration of CB-IMCI and CB-NCP Programs as per the decision of MoH on
2071/6/28 (October 14, 2015). This integrated package of child‐survival intervention addresses the
major problems of sick newborn such as birth asphyxia, bacterial infection, jaundice, hypothermia,
low birth-weight, counseling of breastfeeding. It also maintains its aim to address major childhood
illnesses like Pneumonia, Diarrhoea, Malaria, Measles and Malnutrition among under 5 year’s
children in a holistic way.

In CB‐IMNCI program, FCHVs are expected to carry out health promotional activities for maternal,
newborn and child health and dispensing of essential commodities like distribution of iron, zinc,
ORS, chlorhexidine which do not require assessment and diagnostic skills, and immediate referral in
case of any danger signs appeared among sick newborn and children. Health workers will counsel
and provide the health services like management of non‐breathing cases, low birth weight babies,
common childhood illnesses, and management of neonatal sepsis. Also, the program has provisioned
for the post‐natal visits by trained health workers through primary health care outreach clinic.

Development of IMNCI training site has already been started. The program has envisioned that
CHD will act as the quality assurance and monitoring entity for the CB‐IMNCI program. Clinical
training sites and RHTC will be the lead agency for training in near future. IMNCI section has been
focusing on the phase-wise implementation of the program with continuous monitoring and
supportive supervision to strengthen the program and onsite coaching to enhance the clinical skill
among health workers. CB-IMNCI program has been implemented in 75 districts.

2.3.1.2 Facility-Based Integrated Management of Childhood and Neonatal Illnesses

46 DoHS, Annual Report 2073/74 (2016/17)


Child Health
The Facility-Based Integrated Management of Neonatal and Childhood Illnesses (FB-IMNCI) package
has been designed specially to address childhood cases referred from peripheral level health
institutions to higher institutions. The package is linked strongly with the on-going Community
Based Integrated Management of Neonatal and Childhood Illness (CB-IMNCI). The package is
expected to bridge the existing gap in the management of complicated neonatal and childhood
illnesses and conditions. With the gradual implementation of this package, further improvement in
neonatal and child health can be expected. This package addresses the major causes of childhood
illnesses including Emergency Triage And Treatment (ETAT) and thematic approach to common
childhood illnesses towards diagnosis and treatment especially newborn care, cough, diarrhoea,
fever, malnutrition and anemia. It also trains common childhood procedures needed for the
diagnosis and treatment. It aims to capacitate team of health workers at district hospital with
required knowledge and skills to manage complicated under-five and neonatal cases and to ensure
timely and effective management of referral cases. This training package will be delivered to
paramedics and nursing staffs (3 days) and doctors (6 days) district, zonal, sub-regional and regional
hospitals.

2.3.1.3 Comprehensive Newborn Care Training package


As indicated by various evidences, extra efforts are necessary for overcoming barriers to accelerate
the reduction in neonatal mortality. As a result of the step towards reducing these newborn deaths,
"Comprehensive Newborn Care Training Package (For Level II Hospital Care)" was developed in
order to provide training to paediatricians, senior medical officers and medical officers working in
the hospitals providing level II care services. This will help on building a strengthened health system
supported by fully trained and skilled health workers in all tiers of health facilities. This is a 6 days
training package focused to help the health workers to develop basic skills and knowledge
necessary for management of normal as well as sick newborn. This package covers counselling,
infection prevention, care of normal newborn, feeding, neonatal resuscitation, thermal protection,
fluid management, identification and management of sick neonates, disorder of weight and
gestation, neonatal sepsis and common neonatal procedures. The training was started from 19th
December, 2016 and has covered all development regions.
In this fiscal year, National Health Training Centre has developed Comprehensive Newborn Care
Training (Level II) package and conducted three batches training for Nurses in coordination with
Child Health Division.

2.3.1.4 Free Newborn Care Services


The Government of Nepal (GoN) has made provisions on treating sick newborn free of cost through
all tiers of its health care delivery outlets. The aim of this program is to prevent any sorts of
deprivation to health care services of the newborn due to poverty. Based on the treatment services
offered to the sick-newborn, the services are classified into 3 packages: A, B and C. The new born
corners in health posts and PHCs offer Package ‘A’, district hospitals with Special Newborn Care Unit
(SNCU) offer Package ‘B’ and zonal hospitals and other tertiary hospitals offering Neonatal Intensive
Care Unit (NICU) provide services for Package ‘C’. The government has made provisions of required
budget and issued directives to implement the free newborn care packages in Nepal. The goal of
the Free Newborn Care Service Package is to achieve the sustainable development goal through
increasing access of the newborn care services to reduce newborn mortality. The program makes
the provision of disbursing Cost of Care to respective health institutions required for providing free
care to inpatient sick newborns.
DoHS, Annual Report 2073/74 (2016/17) 47
Child Health
2.3.2 Goals, targets, objectives, strategies, interventions and activities of IMNCI program
Goal
 Improve newborn and child survival and healthy growth and development.
Targets of Nepal Health Sector Strategy (2015-2020)
 Reduction of Under-five mortality rate (per 1,000 live births) to 28 by 2020
 Reduction of Neonatal mortality rate (per 1,000 live births) to 17.5 by 2020
Objectives:
 To reduce neonatal morbidity and mortality by promoting essential newborn care services
 To reduce neonatal morbidity and mortality by managing major causes of illness
 To reduce morbidity and mortality by managing major causes of illness among under 5 years
children
Strategies
1. Quality of care through system strengthening and referral services for specialized care
2. Ensure universal access to health care services for new born and young infant
3. Capacity building of frontline health workers and volunteers
4. Increase service utilization through demand generation activities
5. Promote decentralized and evidence-based planning and programming

Major interventions

Newborn Specific Interventions


 Promotion of birth preparedness plan
 Promotion of essential newborn care practice sand postnatal care to mothers and newborns
 Identification and management of non‐breathing babies at birth
 Identification and management of preterm and low birth weight babies
 Management of sepsis among young infants (0‐59days) including diarrhoea

Child Specific Interventions


 Case management of children aged between 2‐59 months for 5 major childhood killer diseases
(Pneumonia, Diarrhoea, Malnutrition, Measles and Malaria)

Cross -Cutting Interventions


 Behaviour change communications for healthy pregnancy, safe delivery and promote personal
hygiene and sanitation
 Improved knowledge related to Immunization and Nutrition and care of sick children
 Improved interpersonal communication skills of HWs and FCHVs

48 DoHS, Annual Report 2073/74 (2016/17)


Child Health
Vision 90 by 20
Institutional
CB-IMNCI program has a Delivery

vision to provide targeted


services to 90% of the
estimated population by
2020 as shown in the Under 5
children with
To provide Newborn
service to 90% of who had
diagram below. Pneumonia
treated with targeted group by CHX gel
applied
Antibiotics 2020

Under five
children with
Diarrhoea
treated with
ORS and Zinc

Major activities

Major activities carried out under the IMNCI programme in FY 2073/74 were as follows:
- Development and certification of Mid-western Regional Hospital as an IMNCI Clinical
Training Site as Nepal’s first IMNCI Clinical Training Site
- Expansion of IMNCI Training Site at Pokhara (Pokhara Academy of Health Science) and
Dang (Rapti Sub-regional Hospital): On-going
- Development of National Medical Standard for Care of Newborns and Children has been
started: On-going
- Development of FB-IMNCI package: On-going
- Implementation of Remote Area Guideline for CB-IMNCI program (on-going)
- Development a pool of IMNCI trainers for CB-IMNCI and Comprehensive Newborn Scale up
of Navi care Program in public as well as private sector
- Procurement of commodities and equipment related to IMNCI
- Establishment/Strengthening of SNCU
- Printing of CB-IMNCI, Comprehensive New born Care (Level II) Training Materials
(Guidelines, Handbook, Chart, Flex, etc.)
- Training of Trainers (TOT) for CBIMNCI and Comprehensive Newborn Care Training (Level II)
- Implementation of free sick newborn care program through five hospitals (Kanti Children
Hospital, Koshi Zonal Hospital, Western Regional Hospital, Lumbini Zonal Hospital and Seti
Zonal Hospital)
- Initiation of Perinatal Quality Improvement Initiative in 12 hospitals

CB-IMNCI Program Monitoring Key Indicators

Regular monitoring is important for better management of program. Therefore, CB-IMNCI program
has identified 6 major indicators to monitor the programs that are listed below:
1. % of Institutional delivery
2. % of newborn who had applied Chlorhexidine gel immediately after birth (within one hour)
3. % of infants (0-2 months) with PSBI receiving complete dose of Injection Gentamicin
4. % of under 5 children with pneumonia treated with antibiotics

DoHS, Annual Report 2073/74 (2016/17) 49


Child Health
5. % of under 5 children with diarrhoea treated with ORS and Zinc
6. Stock out of the 5 key CB-IMNCI commodities at health facility (ORS, Zinc, Gentamicin,
Amoxicillin/Cotrim, CHX)

All indicators except number six are related to HMIS. It is expected that if there is high institutional
delivery, there would be good essential newborn care and immediate management of
complications like birth asphyxia that will ultimately contribute to reduce the neonatal mortality.
The 2073/74 monitoring results of the CB-IMNCI programme were as follows (Table 2.3.1).

Table 2.3.1: CB-IMNCI programme monitoring indicators by province (FY 2073/74)


% of % of newborns % of PSBI cases % of % diarrhoeal
institutional applied received pneumonia cases treated
deliveries chlorhexidine complete dose of cases treated with ORS and
(CHX) gel inj. Gentamicin with antibiotics zinc
Province 1 49.1 42.7 46.3 179.7 86.4
Province 2 43.9 77.1 78.5 264.4 94.8
Province 3 52.8 48.1 24.2 162.6 92.2
Province 4 46.0 50.7 16.4 270.7 96.6
Province 5 69.3 80.1 64.2 244.2 88.8
Province 6 60.2 81.5 71.4 167.3 96.2
Province 7 67.8 78.0 60.4 210.3 93.9
National 54.6 63.7 58.4 208.9 92.1
Source: HMIS/MD/DoHS
National average for Institutional deliveries in 2073/74 was 54.6 percent. By province the lowest
was observed in Province 2 (43.9%) and highest (67.8%) in Province 7. Chlorhexidine was applied in
63.7 percent new-born’s umbilicus (HF+FCHV) among total expected live births. The average use of
CHX was highest (81.5%) in province 6 and lowest (42.7) in province 1.

Compliance of injection Gentamicin at national level for PSBI cases among under two months child
was 58.35 percent, which was highest in province 2 (78.5%) and lowest in province 4 (16.4%).
Percentage of Under 5 years children with pneumonia treated with antibiotics (excluding FCHV) was
208.9 percent at national level. In the previous years, the pneumonia cases reported by FCHV were
used to be included. But, from this fiscal year the indicator is in the process of revision and the
cases of pneumonia reported by FCHVs are excluded. The figure exceeded 100 percent in all
provinces because the treatment of cases by antibiotics other than pneumonia was also added like
skin infection, ear infection etc. which is actually the reporting error. As per CB-IMNCI treatment
protocol, all diarrhoeal cases should be treated with ORS and Zinc. Based on HMIS data, U5 children
suffering from diarrhoea treated with ORS and Zinc at National level was 92.1 percent, which was
highest in province 4 (96.6%) and lowest in province 1 (86.4 %).

2.3.3 Achievements

Since FY 2064/65, CB‐IMCI services data (as received from Health Facilities, VHWs/MCHWs and
FCHVs) has been incorporated into HMIS. Therefore, from FY 2064/65 onwards, service provided at

50 DoHS, Annual Report 2073/74 (2016/17)


Child Health
community level (PHC/ORCs and FCHVs) is considered as community level data whereas total
service provided from Health Facility level in addition with community level constitutes the national
aggregated data for this program. CB-IMNCI program has been initiated from FY 2071/72 and from
FY 2071/72 Health Facility Level and Primary Health Care/Out Reach Clinics (PHC/ORC) data has
been incorporated into HMIS. Consequently, the role of FCHV at community level has been
redefined and limited to counselling service for newborn care. Obviously, the treatment protocol
has also been changed and role of FCHVs at the community level has been assigned as health
promoters/counsellors rather than health service providers. As per the new reporting and recording
system, the achievements of management of under 5 children are given in the table below.

2.3.3.1 Management of newborns (0-28 days)

Table 2.3.2: Classification and treatment of 0-28 day newborn cases by province (FY 2073/74)
National
Province 1

Province 2

Province 3

Province 4

Province 5

Province 6

Province 7
%
Indicators among
No.
total
cases

Total cases (HF+ORC) 4,573 2,370 2,989 1,888 5,694 3,967 4,261 25,742 NA
Possible severe bacterial
578 217 246 124 1035 752 761 3,713 14.4
infections (PSBI) (HF+ORC)
Local bacterial infections
2,549 1,660 1,296 904 1,887 1,745 2,255 12,296 47.8
(HF+ORC)
Jaundice (HF+ORC) 298 122 320 296 339 181 184 1,740 6.8
% of Low weight or feeding
3.98 5.23 5.16 7.40 6.06 8.55 10.55 1,605 6.8
problem (HF only)
Referred 357 183 214 88 252 131 185 1,410 5.5
Deaths 7 2 13 2 45 12 23 104 0.4
FCHVs
Sick baby 2,607 2,105 1,794 783 1,982 1,391 2,357 13,019 NA
Treated with antibiotic and
1,656 1,121 534 193 1,118 865 855 6,342 48.7
referred to a health facility
Deaths 168 70 155 52 204 145 249 1,043 8.01
Source: HMIS/MD/DoHS

In FY 2073/74, a total of 25,742 newborns cases were registered and treated at health facilities and
PHC/ORC level (HF-23,650 and PHC/ORC-2,092). Province 5 had highest number of registered cases
followed by province 1 and least case load was in Province 1. Out of total registered cases in FY
2073/74, 3,713 cases were classified as Possible Severe Bacterial Infection (PSBI) which accounts for
14.4 percent at national level and among the total registered cases the proportion of PSBI was
highest in province 6 (19%) followed by Province 5 (18%). Among the total registered cases at the
national level ( Health facilities and PHC-ORC level), 47.8 percent cases were classified as LBI, 6.8
percent as Jaundice, and 6.2 percent as Low Birth weight or Breast Feeding Problem. Among the
total registered cases the proportion of LBI was highest in province 2 (70%) followed by Province 1
DoHS, Annual Report 2073/74 (2016/17) 51
Child Health
(56%). All classified cases were treated accordingly following the national protocol and out of the
total recorded cases (25,742) in FY 2073/74, i.e. 27.5 percent were treated by Cotrim paediatric
tablet, 5.5 percent cases were referred and 0.4 percent was reported dead from health facilities and
PHC-ORC level.

Total 13,019 cases were identified by FCHVs as sick children out of which 48.7 percent were treated
with antibiotic and referred to health facilities and 8.01 percent were reported as death (as shown
in table 2.3.2) in FY 2073/74.
2..3.3.2 Management of 2-59 months children

Diarrhoea

Classification of diarrhoeal cases by province 2073/74

CB-IMNCI program has created enabling environment to health workers for better identification,
classification and treatment of diarrhoeal diseases. As per CB-IMNCI national protocol, diarrhoea
has been classified into three categories: 'No Dehydration', 'Some Dehydration', and ‘Severe
Dehydration'. The reported number and classification of total new diarrhoeal cases has been
presented in table 2.3.3 below.

Table 2.3.3: Classification of diarrhoeal cases by province (FY 2073/74)


Indicators
Province 1

Province 2

Province 3

Province 4

Province 5

Province 6

Province 7

National
Total 55,474 88,821 47,379 22,220 65,641 45,216 58,433 383,184
HF + ORC diarrhoeal cases

No 42,643 69,566 40,920 19,288 56,679 35,058 49,793 313,947


dehydration 11.13% 18.15% 10.68% 5.03% 14.79% 9.15% 12.99% 81.93%

Some 12,589 18,937 6,285 2,909 8,585 9,796 8,449 67,550


dehydration 3.29% 4.94% 1.64% 0.76% 2.24% 2.56% 2.20% 17.63%

Severe 242 318 174 23 377 362 191 1687


dehydration 0.06% 0.08% 0.05% 0.01% 0.10% 0.09% 0.05% 0.44%

FCHV 130,616 116,656 133,692 54,669 140,718 82,848 141,737 800,936


(diarrhoeal cases) 11.03% 9.85% 11.29% 4.62% 11.88% 7.00% 11.97% 67.64%
Total diarrhoeal 186,090 205,477 181,071 76,889 206,359 128,064 200,170 1,184,120
cases (HF &
Communities) 15.72% 17.35% 15.29% 6.49% 17.43% 10.82% 16.90% 100.0%
Source: HMIS/MD/DoHS

In FY 2073/74, a total of 1,184,012 diarrhoeal cases were reported out of which about one third
(32%) were reported from health facilities and ORC and rest two third (68%) by FCHVs. Among
registered cases in Health Facilities and PHC/ORC more than three fourth (82%) were classified as
having no dehydration. Severe dehydration among registered diarrhoeal cases remained below 1%
across all provinces.

52 DoHS, Annual Report 2073/74 (2016/17)


Child Health
Table 2.3. 4: Incidence and case fatality of diarrhoea among children under 5 years of age by
province (FY 2073/74)

Province 1

Province 2

Province 3

Province 4

Province 5

Province 6

Province 7
Indicators National

Estimated <5 year


population that are 494,301 613,361 629,577 254,998 502,216 177,389 287,244 2,959,086
prone to diarrhoea

Incidence of
diarrhoea/1,000 <5 376 335 288 302 411 722 697 400
years population
Diarrhoeal deaths
7 16 4 1 1 2 2 33
(HF+ORC)
Case fatality rate
0.13 0.18 0.08 0.05 0.02 0.04 0.03 0.09
per 1000 (HF+ORC)
Source: HMIS/MD/DoHS

Incidence of diarrhoea per thousand under age 5 children was highest in province 6 (722) followed
by province 7 (697) where incidence was 1.5 times higher than the national average. Further, the
lowest incidence was in province 3 (288).Case fatality rate across all the provinces was below 1 per
thousand.

Treatment of diarrhoea

Table 2.3.5: Treatment of diarrhoea cases by province (FY 2073/74)


Province 1

Province 2

Province 3

Province 4

Province 5

Province 6

Province 7

Indicators National

Total cases
186,090 205,477 181,071 76,889 206,359 128,064 200,170 1,184,120
(HF+ORC+FCHV)
Diarrhoeal cases 160,798 194,706 166,946 74,298 183,273 123,139 187,923 1,091,083
treated with ORS
and zinc 86.41% 94.76% 92.20% 96.63% 88.81% 96.15% 93.88% 92.14%

Intravenous (IV) 1,113 2,282 1,026 285 937 975 1,117 7,735
fluid (HF) 0.09% 0.19% 0.09% 0.02% 0.08% 0.08% 0.09% 0.65%
Source: HMIS/MD/DoHs
In FY 2073/74, the proportion of diarrhoeal cases treated with ORS and Zinc as per IMNCI national
protocol at national level was 92% and was highest in Province 4 (97%) and lowest in province 5
(88%).

DoHS, Annual Report 2073/74 (2016/17) 53


Child Health
Acute Respiratory Infections

ARI management is one of the components of CB-IMNCI program. As per CB-IMNCI protocol, every
ARI cases should be correctly assessed and classified as no pneumonia, pneumonia or severe
pneumonia; and given home therapy, treated with appropriate antibiotics or referred to higher
centre as per the indications.

Table 2.3.6: Acute respiratory infection (ARI) and pneumonia cases by provinces (2073/74)

Province 1

Province 2

Province 3

Province 4

Province 5

Province 6

Province 7
Indicators National

Target pop. (<5 years that


494,301 613,361 629,577 254,998 502,216 177,389 287,244 2,959,086
are prone to ARI)

Total ARI cases 354,323 289,278 276,317 152,164 289,294 164,473 284,873 1,810,722

ARI incidence per 1,000<5


717 472 439 597 576 927 992 612
year population
Total Pneumonia cases
43913 32333 32032 13247 27707 20811 24619 194662
(HF+ORC)
Incidence of pneumonia
89 53 51 52 55 117 86 66
per 1,000 <5 children
% of pneumonia among
12.15% 10.88% 11.29% 8.59% 9.36% 12.14% 8.31% 10.47%
ARI cases
% of severe pneumonia
0.25% 0.30% 0.30% 0.11% 0.22% 0.51% 0.33% 0.29%
among ARI cases
Deaths due to ARI at HF 11 58 7 62 13 5 20 176
ARI Case fatality rate per
0.086 0.629 0.073 1.155 0.126 0.083 0.224 0.283
1000 at HF
Source: HMIS/MD/DoHS

In FY 2073/74, a total of 1,810,722 ARI cases were registered, out of which 10.5% were categorized
as pneumonia cases and 0.29% were severe pneumonia cases. The incidence of pneumonia (both
pneumonia and severe pneumonia at HF and PHC/ORC) at national level was 66 per 1000 under five
children. The incidence of pneumonia among under five children has decreased sharply because in
the past years, the reported cases of pneumonia by FCHV were included in the numerator, but from
this fiscal year the indicator is in the process of revision and the cases of pneumonia reported by
FCHV is excluded from the numerator. Likewise, highest ARI incidence was seen at Province 7
(992/1000 U5 children) followed by Province 6 (927/1000 U5 children) and least at Province 3
(439/1000 U5 children). Similarly, Provinces 1 and 6 had the highest percentage of pneumonia
cases among ARI cases (12.15% and 12.14%) and Province 7 has the lowest (8.31%).
The total ARI-related deaths at health facilities were reported to be 176 which is more compared to
previous FY 2072/73 which was 155. The ARI case fatality rate per thousand at health facility also
increased to 0.28 per 1000 in FY 2073/74 compared to last fiscal year (0.08). ARI case fatality rate
shows a wide variation in between the provinces ranging from the lowest 0.073 per 1000 in
province 3 to the highest 1.16 per 1000 in province 4.
54 DoHS, Annual Report 2073/74 (2016/17)
Child Health
Other common childhood illnesses
CB-IMNCI Program also focuses on identifying and treating Malaria, Malnutrition, Measles, and
other common illnesses among children under five. The interventions to address malnutrition
among children are being led by Nutrition Section and interventions to address measles and other
vaccine preventable diseases are being led by EPI Section, Child Health Division and Malaria is led by
EDCD. IMNCI Section would actively collaborate with EPI, Nutrition Sections and with EDCD for the
reduction of Malnutrition and Measles and other common childhood diseases in an integrated
approach to childhood diseases.

Table 2.3.7: Classification of cases as per CB-IMNCI protocol by province (FY 2073/74)
Malaria Very severe
Severe mal-
Non- febrile Measles Ear infection Anaemia
Falciparum nutrition
falciparum disease

Province 1 13 24 0 164 14,443 324 595


Province 2 0 2 0 555 22,017 903 938
Province 3 42 27 0 632 9,497 1287 569
Province 4 24 28 0 51 5,393 109 369
Province 5 56 66 0 104 15,351 2035 762
Province 6 51 20 0 90 8,187 2190 359
Province 7 30 51 0 41 9,920 3155 770
National 216 218 0 1,637 84,808 10,692 4,965
Source: HMIS/MD/DoHS
Under the CB-IMNCI programme, health workers identified 216 falciparum malaria cases, 218 non-
falciparum malaria cases, 1,736 measles cases, 89,489 ear infection cases, 10,692 severe
malnutrition cases and 4,965 anaemia cases in children under five years of age in 2073/74. There
were no reported cases of very severe febrile disease in this fiscal year.

2.3.4 Problem, constraints and actions

Table 2.3.8: Problem, constraints and actions to be taken


Problem/Constrains Action to be taken Responsibility
No sanctioned position for CB-IMNCI focal  Policy level decision needed to MoH, DoHS,
persons at district and regional levels allocate sanctioned position, and CHD
make necessary arrangements so that
Unclarity in roles of staffs (including CB- there is no void in implementation of
IMNCI focal person) in the new federal the program and in service delivery
context during the transition period

Unable to implement free newborn care  Better coordination and collaboration Hospitals,
guideline since last FY as expected. between related hospitals, Palikas, Palikas,
D/PHOs and CHD. Better orientation D/PHOs and
about the program and clsrity in its
CHD
implementation modality

DoHS, Annual Report 2073/74 (2016/17) 55


Child Health
Problem/Constrains Action to be taken Responsibility
Limited IEC/BCC interventions as compared  More priority be given to the IEC/BCC NHEICC, CHD,
to the approved program implementation interventions so as to improve the D/PHO,
guideline, so as to improve the demand of demand for CH services by all Palikas, HFs
concerned stakeholders
CH services
Frequent stock outs of essential  The timely supply of commodities LMD, CHD
commodities in districts and communities
Lack of equipment to deliver newborn and  The timely procurement and supply of LMD, CHD
child health services at service delivery equipment
points
Poor service data quality  Carry out routine data quality MD, CHD
assessments
 Strengthen regular feedback
mechanisms
Poor quality of care  Strengthen quality improvement MD, CHD,
system RHDs, DHOs,
 Enhance the use of health facility DPHOs
quality improvement tools
 Onsite coaching
 Supportive supervision

Increase in percentage of severe pneumonia  Targeted interventions (BCC activities, RHDs, DHOs,
cases and for early detection, treatment DPHOs
and referral) needs to be focused

Though recent research findings have shown  Ensure better involvement of private DoHS, CHD
more care seeking practice towards private sector to ensure quality services are
sectors, there has been limited engagement provided with proper follow up of
childhood treatment protocols.
of private sectors to ensure their better
involvement
Poor referral mechanism  Strengthen the referral mechanism FHD, CHD,
DHOs, DPHOs

56 DoHS, Annual Report 2073/74 (2016/17)


Chapter 3
Family Health

FAMILY HEALTH

3.1 Family Planning


3.1.1 Background
Family planning (FP) refers to a conscious effort by a couple to limit or space the number of children
through the use of contraceptive methods. Classically, contraceptive methods are classified as
modern or traditional. Modern methods include female sterilization (e.g. minilap), male sterilization
(e.g. no-scalpel vasectomy), intrauterine contraceptive device (IUCD), implants (e.g. Jadelle),
injectables (e.g. Depo Provera), the pill (combined oral pills), condoms (male condom), lactational
amenorrhea method (LAM) and standard days method (SDM). Methods such as rhythm including
abstinence, withdrawal, and folk methods are grouped as traditional.
The FP program of Nepal has contributed significantly in reducing total fertility, unintended
pregnancies, unsafe abortions, high-risk births, maternal and neonatal deaths and has played crucial
role in protecting the health of women and children.
The main aim of the National Family Planning Programme is to ensure that individuals and couples
can fulfil their reproductive needs by using appropriate FP methods voluntarily based on informed
choices. To achieve this, the Government of Nepal (GoN) is committed to equitable and right based
access to voluntary, quality FP services based on informed choice for all individuals and couples,
including adolescents and youth, those living in rural areas, migrants and other vulnerable or
marginalized groups ensuring no one is left behind.

GoN also commits to strengthen policies and strategies related FP within the new federal context,
mobilize resources, improve enabling environment to engage effectively with external development
partners and supporting partners, promote public-private partnerships, and involve non-health
sectors. National and international commitments will be respected and implemented (such as
NHSSIP 2015-2020, Costed Implementation Plan 2015-2020 and FP2020 etc.).

From program perspective, GoN through its subsidiary (FHD/DoHS/MoH and the new structures
under federal system) will ensure access to and utilization of quality FP services through improved
contraceptive use especially among hard to reach, marginalised, disadvantaged and vulnerable
groups and areas, broaden the access to range of modern contraceptives method mix including long
acting reversible contraceptives such as IUCD and implant from service delivery points, reduce
contraceptive discontinuation, scale up successful innovative evidence informed FP service delivery
and demand generation interventions.

In Nepal, FP information, education and services are provided through the government, social
marketing, NGOs and the private sector (including commercial sectors). In the government health
system, short acting reversible contraceptive methods (SARCs: male condoms, oral pills and
injectables) are provided through PHCCs, health posts and PHC-ORCs. FCHVs provide information
and education to community people, and distribute male condoms and resupply oral contraceptive
pills. Long acting reversible contraceptive (LARC) services such as intrauterine contraceptive devices
(IUCDs) and implants are only available in hospitals, PHCCs and health posts that have trained and
skilled providers. Access to LARC services is provided in remote areas through satellite clinics,

DoHS, Annual Report 2073/74 (2016/2017) 57


Family Health
extended visiting providers and mobile camps. Male and female sterilization services (e.g. voluntary
surgical contraception [VSC]) are provided at static sites or through scheduled seasonal and mobile
outreach services. Increasingly for the past couple of years, the delivery of comprehensive FP (e.g.
VSC plus) have been initiated in most districts through modified mobile camps. Unlike the previous
‘seasonal’ one-time approach modified comprehensive family planning mobile camps are now
providing LARCs services simultaneously at VSC camps. Most district’s FP maternal and child health
clinics provide all types of temporary FP methods while integrated family planning service centres
provide VSC services in selected districts.

Quality FP services are also provided through private and commercial outlets such as NGO run
clinic/centre, private clinics, pharmacies, drug stores, hospitals including academic hospitals. FP
services and commodities are made available by some social marketing (and limited social
franchising) agencies.
FP services are part of essential health care services and are provided free in all public sector outlets.

3.1.2 Objectives, policies and strategies


The overall objective of Nepal’s FP programme is to improve the health status of all people through
informed choice on accessing and using voluntary FP. The specific objectives are as follows:
 To increase access to and the use of quality FP services that is safe, effective and acceptable
to individuals and couples. A special focus is on increasing access in rural and remote places
and to poor, Dalit and other marginalized people with high unmet needs and to postpartum
and post-abortion women, the wives of labour migrants and adolescents.
 To increase and sustain contraceptive use, and reduce unmet need for FP, unintended
pregnancies and contraception discontinuation.
 To create an enabling environment for increasing access to quality FP services to men and
women including adolescents.
 To increase the demand for FP services by implementing strategic behaviour change
communication activities.

The five policies and strategic areas to achieve the above objectives are presented in Box 3.1.1.
Box 3.1.1: Policies and strategic areas for FP
1. Enabling environment: Strengthen the enabling environment for FP by:
 advocacy for FP;
 legal and socio-cultural barriers to access to FP services for young people and other
groups;
 integration of FP services;
 task shifting and sharing; and
 FP as the reproductive right of females and males.
2. Demand generation: Increase health care seeking behaviour among populations with high unmet
need for modern contraception by:
 integration and implementation of comprehensive sexuality education in secondary
schools and higher education;
 innovative approaches to reach adolescents with FP messages;
 designing, implementing and evaluating programmes to increase access to and the use of
FP among adolescents and young people;
 increasing knowledge about FP among individuals and couples to facilitate decision-
making on contraceptive use;

58 DoHS, Annual Report 2073/74 (2016/2017)


Family Health
 socio-cultural barriers to accessing FP services;
 reducing the fear of side-effects and dispelling myths and misconceptions about FP;
 developing and implementing FP micro-plans for specific groups;
 developing and implementing a programme focused on the FP needs of migrants and their
spouses;
 targeting hard-to-reach people;
 information on FP to postpartum and post-abortion women; and
 male involvement in FP including by conducting male-friendly reproductive health
programmes.
3. Service delivery: Enhance FP service delivery including commodities to respond to the needs of
marginalized people, rural people, migrants, adolescents and other special groups by:
 integrated FP services provided by FCHVs in communities;
 improving services at PHC-ORC clinics, health posts and PHCCs, including birthing centres;
 improving services in district, zonal and regional hospitals;
 availability of a broad range of modern contraceptives and an improved method mix;
 delivery of FP services through government, private, NGO and social marketing;
 supporting medical college teaching hospitals to deliver FP services;
 integration of FP services with other non-health and health services like immunization,
HIV, postpartum, post-abortion and urban health;
 improving facility recording and reporting;
 quality of FP care including contraceptives;
 contraceptive security and procurement and logistics management to ensure the
availability of FP commodities.
4. Capacity building: Strengthen the capacity of service providers to expand FP service delivery by:
 training of service providers on contraceptive technology;
 task-shifting and sharing non-scalpel vasectomy (NSV) training;
 strengthening FP training capacity, preparing a pool of clinical mentors and expanding
recanalization training and post-training follow-up.
5. Research and innovation: Strengthen the evidence base for programme implementation through
research and innovation:
 Generate evidence through operational research to promote FP innovations.

3.1.3 Major activities in 2073/74


Key FP activities carried out in 2073/74 as follows:

1. Condom Box Distribution


Correct and consistent use of condom reduces the risk of unintended pregnancy and risk of acquiring
STI and HIV. Condom is the only contraceptive method that has this dual protection characteristic.
To make condoms easily accessible condom boxes were installed in strategic locations such as health
facilities, public places (bus park, petrol pump, and toilets etc.) of nine districts namely Jhapa,
Sunsari, Kathmandu, Makwanpur, Palpa, Kaski, Surkhet, Kailali and Achham districts.
2. Provision of regular comprehensive FP service
With the aim of making year round availability of FP services including voluntary surgical
contraception (e.g. minilap and no scalpel vasectomy) and LARCs, regular comprehensive FP services
initiative was conducted in district hospitals and PHCCs of five districts namely Sunsari, Bardia,
Surkhet, Lalitpur, and Kavrepalanchok.
DoHS, Annual Report 2073/74 (2016/2017) 59
Family Health
3. Provision of long acting reversible services (LARCs)
To make LARCs easily available at local level, IUCD and implant insertion/removal sets, medicines
and supplies were procured by district health offices and more than 30 public sector hospitals.
Support cost for IUCD and implant service providers were continued as in the previous years.
4. FP strengthening program through the use of DMT and MEC wheel
Shared decision making between FP counsellors/service providers and potential FP clients is
important for initiating contraceptives and maintaining their use effectively to achieve the
reproductive and FP goals. To help this endeavour FP service providers use WHO adapted decision
making tool (DMT), a flipchart, and medical eligibility criteria for contraceptive (MEC wheel) wheel, a
job aid during client-provider interaction. The quality of FP counselling and service provision is
expected to be improved through this activity. The DMT and MEC wheel also helps update
contraceptive knowledge of FP counsellors and service providers. A three day training of trainer
(TOT) orientation/training program was conducted on DMT and WHO MEC wheel to service
providers of hospitals, DHOs, PHCCs, and HPs. The TOT orientation/training at central/regional level
was followed by district level orientations at 16 new districts and a follow up orientations at 10
districts in 2073/74.
5. Expansion of family planning service at urban health clinic
Rapid urbanization, increasing rural to urban migration and population growth at urban areas has
significantly challenged the FP service delivery especially to women, men and adolescents in slums,
industries/industrial areas, and other hard to reach pockets of the city. With the aim of increasing
awareness, access to and utilization of FP information, education and services through strengthening
of urban health clinics/centres services were ensured through availability of condom boxes, FP
counselling kits, and IEC/BCC materials.
6. Micro planning for addressing unmet need of FP in low modern CPR district
Micro-planning for FP is a situation analysis that helps to identify challenges, gaps, weakness and
strengths in FP program and make context specific action and response plans. Adapted from
successful approach of microplanning for child immunization, microplanning for FP initiative aims to
improve FP service delivery by hard to reach groups leaving no one behind. This is in line with right
based FP service where FP rights of woman, man and adolescent are respected, fulfilled and
protected.
For the last couple of years FHD/DoHS/MoH is steadily expanding the implementation of this
approach in districts with low contraceptive use. Thirty two districts implemented this activity in
2073/74. Anecdotal reports from districts who have implemented micro-planning for FP reported
increased access, method choice and utilization of contraceptives by hard to reach groups or remote
areas of wards.
7. Permanent FP Methods or Voluntary Surgical Contraception (VSC)
VSC services include no scalpel vasectomy for male and minilaparotomy including postpartum tubal
ligation for female. VSC mobile outreach programmes were conducted in multiple sites of about 65
districts in 2073/74. VSC camps (VSC and comprehensive FP service camps) were preceded by
meetings with FCHVs in 57 districts to map potential VSC clients and to disseminate timing of VSC
mobile outreach services.
8. Implementation of PPP program at high population district
FP services are also provided by INGOs, private sectors and academic hospitals. To expand and
strengthen delivery of quality FP services from private and academic hospitals FHD/DoHS started
public private partnership initiatives through 5 regional health directorates.
9. Family planning onsite coaching program
60 DoHS, Annual Report 2073/74 (2016/2017)
Family Health
Clinical onsite coaching is one of the effective approaches that enhance capacity of service
providers. This reduces service providers’ absenteeism from services delivery site as seen with most
group based training. Skilled birth attendants (SBAs) in birthing centres and other IUCD trained
service providers who are not confident to provide IUCD services were coached onsite by another
experienced IUCD provider/coach in 10 districts.
10. FP Satisfied Client Interaction Program
Customer satisfaction is of great importance, because a satisfied customer is the best multiplier for
any product or service. Satisfied clients are also the best sources of referrals and patronage.
Interaction program using clients who are satisfied with their use of FP methods to influence
positively other potential FP acceptors were conducted in 15 districts in 2073/074.
11. Development of institutionalized family planning service center as a training center
There are 24 institutionalized FP service centres (IFPSCs) in 21 districts providing FP and MCH
services. FHD/DoHS envisioned developing, in a phased manner, these sites to FP/MCH training
centres. IFPSC of Lalitpur district public health office (DPHO) was identified for this purpose. IFPSC of
Lalitpur has been successfully converted as a training centre in this fiscal year.
12. Provision of VP service to increase FP service user
The visiting provider (VP) intervention was incorporated to FHD/DoHS work plan since 2072/73
following the successful piloting in Ramechhap district in 2014/2015. VPs are motivated, competent,
female nursing (ANM or staff nurse) service providers on IUCD and implant services. The key
purpose of VP program is to expand contraceptive choice and improve IUCD and implant uptake by
women in rural areas by providing IUCD and implant services in rural health facilities where implant
and IUCD service providers are not available and enhancing the IUCD and implant skills of SBAs and
paramedics in rural health facilities through mentoring/coaching. VP program was implemented by
most of the planned 18 districts in this fiscal year.
13. Integration of FP and immunization service
By combining EPI and FP services, women in remote rural settings could be spared the
inconvenience of travelling long distances over difficult terrains on multiple occasions to access
separate services such as FP and routine child immunization. The FP/EPI program was incorporated
to FHD/DoHS work plan since 2015/2016 following the successful piloting in Kalikot district in 2012.
UNFPA also supported FP/EPI program implementation in 4 additional districts. Five districts (Parbat,
Doti, Rukum, Sindhuli and Salyan) through FHD AWPB implemented FP/EPI program in 2073/74.
14. Satellite clinic services for long acting reversible contraceptives
FP satellite clinic focuses on providing LARCs (IUCD, implant) services from health facilities that lacks
availability of these services in regular basis targeting to reach the poor and unreached groups. FP
satellite camp was conducted in 57 districts in this fiscal year.
15. FP updates orientation for Obs/Gyne doctors and other key players
The aim of FP update orientation is to inform FP key providers on the latest evidence based
information and practices so that quality FP services are ensured while unnecessary medical barriers
are minimized during contraceptive service initiation, repeat and referrals. One of the 2 districts
conducted this program this fiscal year.
16. Roving ANM (RANM) for FP in Disadvantaged Community (Mushar, Dom, Chamar, etc.)
RANM program was planned to address some of the perennial public health challenges such as high
unmet need for contraceptives, low uptake of FP method, low ANC/PNC care, high prevalence of
malnutrition among women and children, and short pregnancy intervals among hard to reach groups
(e.g. Mushar, Dom, Chamar etc.). RANMs through community and house to house visit (where

DoHS, Annual Report 2073/74 (2016/2017) 61


Family Health
possible) provides short acting reversible contraceptives (condom, oral pills, and Depo) and basic
first aid treatments. RANM promotes ANC/delivery/PNC visits from health institutions, encourages
breast feeding/nutrition/growth monitoring practices including healthy spacing messages, and
provides FP/RH related information to adolescents.
Based on the promising results from an ongoing pilot of RANM by Save the Children, FHD has
incorporated RANM program in its AWPB since 2016/2017. Five districts (Siraha, Rautahat,
Kapilvastu, Banke and Darchula) implemented RANM initiative in 2073/74.

3.1.4 Achievements
Current users
As with the previous years, female sterilization (38%) occupies the greatest part of the contraceptive
method mix for all current user, followed by Depo (17%), male sterilization (13%), implant (11%) and
lastly IUCD (6%) in 2073/74 (Figure 3.1.1).
The number of FP users at the national level was 93 percent of projected users in FY 2073/74
(2,707,553 against 2,900,000 projected).
Figure 3.1.1: Proportion of FP current user— Figure 3.1.2: Share of FP current users (%), all
method mix, 2073/74 methods, by Province, 2073/74
Male Condom 25% 23%
sterilizatio 221,311 Pills 19%
19% 17%
n 345,634 (8%) 185,545 20%
(13%) (7%)
15%
9%
Depo 10% 7%
5%
451,790 5%
(17%)
Female 0%
IUCD
Province 1

Province 2

Province 3

Province 4

Province 5

Province 6

Province 7
sterilizatio
n 175,593
1,040,078 Implant (6%)
(38%) 287,602
(11%)

Province 2 has the highest proportion (22.6%) of current users while Province 6 (5.1%) the lowest
(Table3.1.1) in 2073/74. Total number of permanent current users exceeds that of spacing method
at national level and in Province 2 and 4.

Table 3.1.1: FP current users (modern methods) by Province, 2073/74


Method Province National
Prov 1 Prov 2 Prov 3 Prov 4 Prov 5 Prov 6 total Prov 7
users
Spacing 266,042 126,579 304,099 99,497 295,681 80,613 149,331 1,321,841
methods
Permanent 239,889 486,213 223,315 103,016 176,140 57,057 100,082 1,385,712
methods
Total 505,931 612,792 527,414 202,513 471,821 137,670 249,413 2,707,553
Share of 18.7% 22.6% 19.5% 7.5% 17.4% 5.1% 9.2%
total
methods
as % of
total users

62 DoHS, Annual Report 2073/74 (2016/2017)


Family Health
The modern contraceptive prevalence rate (mCPR) for modern FP methods is computed based on
service data reported to HMIS, although HMIS does not capture all private sector service data. The
mCPR, at national level, is 44 in 2073/74 (Figure 3.1.3). mCPR of Terai (50%) is higher than national
average (44%) while that of Mountain and Hill ecological region below the national average (figure
3.1.4).
Province 2 has the highest mCPR of 49 percent while Province 4 the lowest (35 percent). Four
Provinces (3, 4, 6 and 7) have mCPR less than national average (Figure 3.1.3).

Figure 3.1.3: mCPR by Province, 2073/74 Figure 3.1.4: mCPR by ecological zones,
60% 2073/74
48% 49%
50% 44% 41% 44% 60%
35% 37% 40% 50%
40% 50% 44%
30% 40% 36% 36%
20% 30%
10% 20%
0% 10%
0%
Nation Mountain Hill Terai

District-wise HMIS data indicates that in 2073/74 fifteen districts had mCPR greater than or equal to
50 percent, 52 districts had mCPR between 30-50 percent and 10 districts had mCPR less than 30
percent (Figure 3.1.5). Parsa had the highest mCPR (70.7 percent) while Humla had the lowest (23.4
percent).

Figure 3.1.5: Modern contraceptive prevalence rate (mCPR) by districts, 2073/74

The average mCPR is 59.6 percent for the top 10 districts and 26.1 percent for the bottom 10
districts — a difference of 33.5 percent. The number of districts with mCPR below 30 percent

DoHS, Annual Report 2073/74 (2016/2017) 63


Family Health
decreased from 17 in 2071/72 to 10 in 2073/74, indicating improved performance among the low
mCPR districts (Figure 3.1.6 and 3.1.7).

Figure 3.1.
3.1.6: S-Curve
Curve pattern of CPR growth, 2073/74 Figure 3.1.7:
3.1. : Trends in mCPR by districts,
FY 2071/72-2073/74
2071/72

100
80
16 15 15
60
40 42 47 52
20
17 13 10
0
2071/72 2072/73 2073/74

CPR <30 CPR 30-50 CPR >50

It is evident that female sterilization (minilap under local anaesthesia


anaesthesia--ML/LA)
ML/LA) is popular in
Terai which have contributed also in national average (Figure 3.1.8). Male sterilization (NSV)
on the other hand is more popular
popular in Mountain and Hiil than Terai. Contraceptive implant
compared to IUCD seems to be more popular among women of reproductive age in all
ecological region of Nepal. Depo followed by Pills and implant has the highest share among
temporary methods in all ecological
ological regions (Figure 3.1.8 and 3.1.9).
3.1.

Figure 3.1.
3.1.8: Share of long acting and permanent Figure 3.1.9:
3.1. Share of temporary methods as % of
method (LAPM) as % of total current users by total current users by ecological region 2073/74
ecological region, 2073/74
30% 28%
25%
20% 17%
15% 11%
10%
8%
6% 5% 6% 6%
5% 1% 2% 3% 3%4%3% 3%5%
0%
Mountain Hill Terai Nation

IUCD Implant NSV ML/LA

Except Province 2 all Provinces


Province have higher proportion of share of temporary method (Figure
3.1.10). Contraceptive implant is more accepted compared to IUCD in all Provinces (data not shown).
As mentioned earlier, female sterilization (ML/LA) con
contributes
tributes about 79% in contraceptive method
mix in Province 2 and 35% in total national VSC. It is also evident that female sterilization (minilap

64 DoHS, Annual Report 2073/74


207 (201
(2016/2017)
Family Health
under local anaesthesia--ML/LA) is popular in Terai which have contributed also in national average
(Figure 3.1.8).
Figure 3.1.10: Share of spacing and permanent methods among total current users by province
2073/74
60%
49%51%
50%
40%
30%
18%
20%
10% 9% 11% 11%
8% 7%
10% 5% 4% 4% 3% 2% 6% 4%

0%
Province 1 Province 2 Province 3 Province 4 Province 5 Province 6 Province 7 Nation
Spacing methods Permanent methods

Contraceptive defaulters (for all temporary methods excluding condom), a proxy indicator for
contraceptive discontinuation, is high. In Nepal about 46% of contraceptive users have discontinued
using the method or switched to another contraceptive method (Figure 3.1.13). These women may
choose (switch to) less effective methods or remain method unused (discontinued while still in need)
leading to risk of unintended pregnancy and its consequences. Province 5 (36%) has the lowest
defaulter rate while Province 6 has the highest (73%). Compared to SARCs (short acting reversible
contraceptives—pills and Depo), LARCs has low defaulter rate (Figure 3.1.14) in all Provinces. LARCs
are the most effective as well as cost-effective contraceptives, can be used for longer period of time,
have very low discontinuation rates, and also has higher client satisfaction. Globally, SARCs are
promoted as first line contraceptives for all prospective clients. The high discontinuation of SARCs
and low uptake of LARCs in Nepal indicates concerns over and the need of programmatic focus on
both supply and demand aspect sustaining the past achievements and focusing more on LARCs.
Figure 3.1.11: Percentage of contraceptive Figure 3.1.12: Percentage of contraceptive method
method defaulters by Province 2073/74 defaulters by methods, 2073/74

80% 73% 150% 122%


62% 62% 98%
60% 48% 100% 82% 79% 82% 73%
41% 46%
40% 36% 55% 56%
40% 50%
9% 10% 10% 7% 8% 12% 11% 9%
20%
0%
0%

SARCs % defaulter LARCs % defaulter

New acceptors
Depo (36%) occupies the greatest part of the contraceptive method mix for temporary method new
acceptors, followed by condom (29%), male sterilization (19%), implant (12%) and lastly IUCD (4%) in
2073/74 (Figure 3.1.13).

DoHS, Annual Report 2073/74 (2016/2017) 65


Family Health
Figure 3.1.14: Share of FP new acceptors (%), all
Figure 3.1.13: FP spacing method mix among new
methods, by Province, 2073/74
acceptor, 2073/74
25% 21%
20%
20% 17%
14%
Condom, 15%
Pill, 142,7 11%
221,311
26 (19%) 10% 8% 8%
(29%)
5%
0%

Implant,
95,605 Depo, 27
(12%) 9,209
(36%)
IUCD, 34,
028 (4%)

New acceptors of voluntary surgical contraception


As in the past, Province 2 recorded the highest number of VSCs (9,988) while Province 4 the lowest
(1,749) (Table 3.1.2 and Figure 3.1.15 and 3.1.16). Note that the projected numbers of new VSC
acceptors was reduced from 50,000 in 2071/72 to 40,000 in 2073/74.

Table 3.1.2: New acceptors (modern methods) by Province, 2073/74


Method Province National total
Prov 1 Prov 2 Prov 3 Prov 4 Prov 5 Prov 6 Prov 7 users
Permanent 5,989 9,988 3,955 1,749 3,617 1,880 3,055 30,233
methods
LARCs 21,744 12,945 35,812 10,838 25,595 7,386 15,313 129,633
SARCs 68,846 60,252 78,332 33,965 95,830 37,100 47,250 421,575
Condom 26,799 25373 30,200 20,820 61,662 18,088 38,370 221,312
Total new
123,378 108,558 148,299 67,372 186,704 64,454 103,988 802,753
acceptors
Share of total 15% 14% 18% 8% 23% 8% 13%
new acceptors
as % total
users

Percentage of share of VSC among total new acceptors is highest (33%) in Province 2 and female VSC
contributed 88% of VSC (Figure 3.1.15 and 3.1.16). Women and men in Province 4 and 6 accepted
least number of VSCs. Male acceptors dominated in Province 3,4 and 6 (Figure 3.1.16).

66 DoHS, Annual Report 2073/74 (2016/2017)


Family Health

Figure 3.1.15: Share of VSC as of total new Figure 3.1.16: Share of male and female VSC as of
accepto
acceptors
rs by Province, 2073/74 total new acceptors by Province, 2073/74

35% 33%
30%
25% 20%
20% 13%
15% 12% 10%
10% 6% 6%
5%
0%

Female VSC acceptors were highest in Terai ecological region followed by Hill (Figure 3.1.17).
3.1. As
mentioned earlier female acceptors significantly
significantly dominates the total VSC in Terai (Figure 3.1.18).
3.1.18)

Figure 3.1.1
3.1.17:: Share of VSC procedure as % of Figure 3.1.18:
3.1.1 Share of male and female VSC as of total new
total VSCs by ecological zones, 2073/74 acceptors by Ecological Regions,2073/74
Regions,2073/74

80.0% 70.6% 80% 71%


61%
60%
60.0%
40% 29%
40.0% 15%
22.9% 20% 8% 10%
2% 5%
20.0% 6.5% 0%
0.0% Nation Mountain Hill Terai
Mountain Hill Terai
Female Male

Achievement,
ievement, minilap and Vasectomy new acceptors
acceptors, against the projection for 2073/74 is 75.6%.
Province 5 achieving the lowest (64.8%) (Table 3.1.3). However, in absolute numbers (9,988), as
expected, Province 2 outperformed others.

3.1.3: VSC new acceptors


acceptors against projection by region, 2073/74

Method Province National total


Prov 1 Prov 2 Prov 3 Prov 4 Prov 5 Prov 6 Prov 7 users
Projected 6,875 11,600 6,100 2,400 6,600 2,150 4,275 40,000
Achievement 5,989 9,988 3,955 1,749 3,617 1,880 3,055 30,233
% achievement 87.1% 86.1% 64.8% 72.9% 54.8% 87.4% 71.5% 75.6%

New acceptors of spacing methods


Highest numbers of new
new acceptors for spacing (temporary) methods in 2073/74 are reported in
Province 5 (183,087) and the lowest numbers in Province 6 (62,574) (Table 3.1.4).

DoHS, Annual Re
Report
port 2073/74
207 (201
(2016/2017) 67
Family Health
Table 3.1.4: New acceptors (temporary modern methods) by Province, 2073/74
Method Province National
Prov 1 Prov 2 Prov 3 Prov 4 Prov 5 Prov 6 Prov 7 total
users
IUCD 3,998 5113 10
10,758 3,599
599 6,388
388 828 3,217 33,901
Implant 17,746 7,705 25
25,054 7,239
239 19,207
207 6,558 12,096 95,605
Depo 45,752 38,379 55
55,247 20,698 61,948
948 26,005 31,180 279,209
Pills 23,094 21,873 23
23,085 13,627 33,882
882 11,095 16,070 142,726
Condom 26,799 25,373 30
30,200 20,820 61,662
662 18,088 38,370 221,312
Total new 117,389 98,443 144,344 65,983 183,087 62,574 100,933 772,753
temporary
methods
thods acceptors
Share of total new 15.2% 12.7% 18.7% 8.5% 23.7% 8.1% 13.1%
acceptors as %
total users

Method wise Depo followed by pills topped in all Provinces. Among LARCs LARCs, implant significantly
dominated over IUCD in all provinces (Table
(Table 3.1.4 and Figure 3.1.19). Likewise, implant acceptors
are higher than IUCD in all ecological regions (Figure 3.1.20). Women in mountain accepted lower
number of contraceptive methods than other ecological regions.

There has been nominal post-partum


post partum uptake of FP method (Figure 3.1.
3.1.22).. Implant uptake within 48
hours of delivery as reported in HMIS reports needs to be verified as the National Family Planning
Protocol (NMS Vol 1, 2010) has yet to promote this practice in Nepal. This could be reporting error
or providers are already inserting implants
implants to post
post-partum
partum women before discharge from hospitals
or birthing centres.

Figure 3.1.19: Share (%) of temporary


temporary methods of new acceptors Figure 3.1.21: Share (%) of temporary methods of
by Province, 2073/74 new acceptors as of total new acceptors by
Ecological Regions, 2073/74

FP use aafter
fter abortion is encouraging.
encouraging. Contraceptive uptake among total reported abortion services is
70.7% (Figure 3.1.24)
3.1.2 ) and with the lowest uptakes in Province 2 and 6 (Figure(Figu 3.1.23).). But the
contribution of LARCs is only 16% (Figure 3.1.2
3.1.24)) indicating women after abortion are relying on less
effective methods. This trend was evident also in all ecological regions (Figure 3.1.25)
3.1.2

68 DoHS, Annual Report 2073/74


207 (201
(2016/2017)
Family Health
Figure 3.1.22: Post-partum FP method Figure 3.1.23: Post abortion FP uptake by Province
acceptance as proportion against expected live among total new acceptors of post abortion FP, 2073/74
births, 2073/74
0.8% 0.7% 20% 19%
0.7% 18% 16% 15%
16%
0.6% 14%
0.5% 12% 9% 10%
10%
0.4% 0.3% 0.3% 8% 6%
4% 5% 5%
0.3% 6% 3% 3% 3%
4% 2% 1%
0.2% 0.1% 2%
0.1% 0%
0.0%

Province 1

Province 2

Province 3

Province 4

Province 5

Province 6

Province 7
SARCS LARCS
3.1.24 ; Proportion of post abortion FP method 3.1.25 ; Proportion of post abortion FP method uptake
uptake by method type, 2073/74 by Province, 2073/74
50% 39%
LARCS, 1 36%
40%
5.8% 30%
20% 11% 10%
10% 3%1%
0%
SARCS, 5 3% 48% 49%
4.9%
Mountain Hill Terai
SARCs LARCs

Only about 8 to 9 percent of under 20 years of age population (a proxy for adolescent population)
accepted modern contraceptive methods (Figure 3.1.28). More than half of the method mix is
contributed by Depo (Figure 3.1.26). Adolescents in Province 2 reported to accept lower proportion
of contraceptives compared to other Provinces (Figure 3.2.28). Condom and LARCs use is lower than
SARCs in all Provinces (Figure 3.2.27). Contraceptive use was lowest in mountain ecological region
(Figure 3.2.29). Adolescents have high unmet need while contraceptive use is low, this is indicative
of implementation challenges of comprehensive sexual and reproductive health programmatic in
general and adolescent’s family planning program in particular in Nepal.

3.1.26: Temporary method mix among under 3.1.27: Under 20 years temporary method new acceptors
20 total new acceptors, 2073/74 among adolescent target population by method, 2073/74
Implant
10%

12%
9%

9%
8%

Pills 10%
7%
6%

6%

IUCD
6%

6%

(4,060)
6%

34% 8%
5%
5%

5%
4%

4%

(14,892) 6%
3%
3%

2%
2%
2%

2%
2%
2%

2%
2%

(2,146) 4%
1%

2%
0%

Depo
52%
(22,960)
Condom SARCs LARCs

DoHS, Annual Report 2073/74 (2016/2017) 69


Family Health
3.1.28: Under 20 years temporary method new 3.1.29: Share of under 20 years temporary method new
acceptors among adolescent target population acceptors among total <20 years temporary method users,
by Province, 2073/74 2073/74
100%
14% 11% 12% 86%
12% 10%
10% 9% 9% 8% 9% 80%
8% 6%
6% 60%
43%
4% 34%
2% 40%
0% 14%
20% 9% 7%
1% 5%
0%
Mountain Hill Terai Nation
SARCs LARCs

3.1.5 Issues, constraints and recommendations

Table 3.1.5: Issues and constraints — family planning


Issues and Recommendations Responsibility
constraints
 Disparity of  Implementation of FP micro-planning in low mCPR FHD, DHOs,
access and use wards/councils councils
of FP services  Conduct targeted mobile outreach and satellite clinics
 Limited health focusing on LARCs
facilities  Mobilize VPs for LARC services
providing five  Expand comprehensive VSC service delivery (VSC+)
contraceptive  Ensure availability of LARCs commodities LMD, FHD, DHOs,
methods councils
 High unmet  Improve FP education, information and services for FHD, CHD,
need and adolescents councils
unintended  Scale up integrated FP/EPI clinics and postpartum and
pregnancies post-abortion services
 High  Strengthen FP services in urban health clinics FHD, PHCRHD,
discontinuatio councils
n  Ensure timely procurement of FP commodities FHD, LMD
 Underutilized  Preposition contraceptives and other supplies at FHD, LMD, DHOs,
LARCs strategic sites for emergency use PHCRD
 Frequent  Ensure training programmes are based on local needs FHD, NHTC,
commodity
 Strengthen and expand the capacity of FP training sites RHTC, DHOs
stock outs
 Inadequate  Strengthen FP services in private hospital FHD, MD, RHDs
trained human  Update the knowledge of FCHVs on LARC FHD, DPHOs,
resources on councils
LAPM  Run awareness raising campaign and activities to FHD, DPHOs
 Misuse of promote the rational use of abortion services
abortion  Update service providers on the use of emergency FHD, DHOs
services contraception

70 DoHS, Annual Report 2073/74 (2016/2017)


Family Health

3.2 Safe Motherhood and Newborn Health

3.2.1 Background
The goal of the National Safe Motherhood Programme is to reduce maternal and neonatal morbidity
and mortality and improve maternal and neonatal health through preventive and promotive activities
and by addressing avoidable factors that cause death during pregnancy, childbirth and the postpartum
period. Evidence suggests that three delays are important factors for maternal and newborn morbidity
and mortality in Nepal (delays in seeking care, reaching care and receiving care).

The following major strategies have been adopted to reduce risks during pregnancy and childbirth and
address factors associated with mortality and morbidity:
 Promoting birth preparedness and complication readiness including awareness raising and
improving preparedness for funds, transport and blood supplies.
 Expansion of 24 hours birthing facilities alongside Aama Suraksha Programme promotes antenatal
check-ups and institutional delivery.
 The expansion of 24-hour emergency obstetric care services (basic and comprehensive) at selected
public health facilities in all districts.

The Safe Motherhood Programme has made significant progress since it began in 1997 and with
formulation of safe motherhood policy in 1998. Service coverage has grown along with the development
of policies, programmes and protocols. The policy on skilled birth attendants (2006) highlights the
importance of skilled birth attendance (SBA) at all births and embodies the government’s commitment
to train and deploy doctors, nurses and ANMs with the required skills across the country. Introduction of
Aama programme to ensure free service and encourage women for institutional delivery has improved
access to institutional deliveries and emergency obstetric care services. The endorsement of the revised
National Blood Transfusion Policy (2006) was another significant step for ensuring the availability of safe
blood supplies for emergency cases. The main programme strategies are listed in Box 3.2.1.

The Nepal Health Sector Strategy (NHSS) identifies equity and quality of care gaps as areas of concern
for achieving the maternal health sustainable development goal (SDG) target, and gives guidance for
improving quality of care, equitable distribution of health services and utilisation and universal health
coverage with better financing mechanism to reduce financial hardship and out of pocket expenditure
for ill health.

Box 3.2.1: Main strategies of the Safe Motherhood Programme


1. Promoting inter-sectoral coordination and collaboration at central, regional, districts and community levels
to ensure commitment and action for promoting safe motherhood with a focus on poor and excluded
groups.

DoHS, Annual Report 2073/74 (2016/2017) 71


Family Health
2. Strengthening and expanding delivery by skilled birth attendants and providing basic and comprehensive
obstetric care services at all levels. Interventions include:
o developing the infrastructure for delivery and emergency obstetric care;
o standardizing basic maternity care and emergency obstetric care at appropriate levels of the
health care system;
o strengthening human resource management —training and deployment of advanced skilled birth
attendant (ASBA), SBA, anaesthesia assistant and contracting short-term human resources for
expansion of services sites;
o establishing a functional referral system with airlifting for emergency referrals from remote areas,
the provision of stretchers in VDC wards and emergency referral funds in remote districts; and
3. Strengthening community-based awareness on birth preparedness and complication readiness through
FCHVs and increasing access to maternal health information and services.
4. Supporting activities that raise the status of women in society.
5. Promoting research on safe motherhood to contribute to improved planning, higher quality services and
more cost-effective interventions.

3.2.2 Major activities in 2073/74


Birth Preparedness Package and community level maternal and newborn health
FHD continued to expand and maintain MNH activities at community level including the Birth
Preparedness Package (jeevansuraksha flipchart and card) and distributed the matrisurakshachakki
(misoprostol) to prevent postpartum haemorrhage (PPH) in home deliveries.

Through FCHV, public health system promotes:


 birth preparedness and complication readiness (preparedness of money, health facilities for the
delivery, transport and blood donors);
 self-care (food, rest, no smoking and alcohol) in pregnancy and postpartum periods;
 antenatal care (ANC), institutional delivery and postnatal care (PNC) (iron, tetanus toxoid,
albendazole);
 essential newborn care; and
 identification of and timely care seeking for danger signs in the pregnancy, delivery, postpartum
and newborn periods.

In 2066/67, the government approved PPH education and the distribution of the matrisurakshachakki
(MSC) tablets through FCHVs to prevent PPH in home deliveries. For home deliveries, three misoprostol
tablets (600 mcg) are handed over to pregnant women during ANC or by FCHV to take immediately after
delivery and before the placenta is expelled. Forty-five districts were implementing the programme in
2072/73 and FHD implemented three new districts in 2073/74 (Kaski, Parbat and Syangja districts). Two
batches of TOT were conducted with 30 trainers from these three districts. These trainers in turn
conducted training of all health workers from all three districts and all FCHV in Kaski districts, FCHVs
from 23 VDCs in Parbat district and FCHVs from two VDCs in Syangja district. Recent NDHS (2016) shows
that only 13 percent of women who gave childbirth without skilled assistance took MSC tablets, this call
for the importance of strengthening this programme as women who delivered at home are likely to be
higher risk.

72 DoHS, Annual Report 2073/74 (2016/2017)


Family Health
Rural Ultrasound Programme
The Rural Ultrasound Programme aims for the timely identification of pregnant women with risks of
obstetric complication to refer to comprehensive emergency obstetric and neonatal care (CEONC)
centres. Trained nurses (SBA) scan clients at rural PHCCs and health posts using portable ultrasound.
Women with detected abnormalities such as abnormal lies and presentation of the foetus and placenta
previaare referred to a CEONC site for the needed services. This programme is being implemented in the
12 remote districts of Dhading, Darchula, Sindhupalchowk, Solukhumbu, BajuraBajhang, Achham,
Dhankuta, Dolpa, Humla, Baitadi, and Sindhuli. Eight SBAs from Sindhuli district received three weeks
training on antenatal ultrasonography in 2073/74 with the support of partner organisation.

Reproductive health morbidity prevention and management programme


a. Management of pelvic organ prolapse: Pelvic organ prolapse (POP) is common reproductive health
morbidity in Nepal and contributes to disability adjusted life years (DALYs) and social consequences.
Multiparity, maternal malnutrition, too frequent pregnancies and heavy work after delivery are the main
risk factors. Each year the government allocates funds to manage POP including free screening,
providing silicon ring pessaries, Kegel’s exercise training and free surgical services at designated
hospitals. In 2073/74 more than 14,600 women were screened for the reproductive morbidity, 23
percent of women (3374 women) were diagnosed of having POP. Among women who were screened
8.9 percent had first degree POP, 6.6 percent second degree POP and 7.5 percent third degree POP. 52
percent of these women with POP received ring pessary treatment. More than 2,000 women received
surgical treatment.

b. Cervical cancer screening and prevention training: Cervical cancer is the most common cancer of
women in Nepal, accounting for 21.4 percent of all cancer among 34–64 year old women. The national
guidelines on cervical cancer screening and prevention (2010) call for screening at least 50 percent of
women aged 30–60 years and for reducing the mortality due to cervical cancer by 10 percent with
recommended screening among this group every five years. Cervical cancer screening is done by visual
inspection of the cervix by trained nurses or doctors using acetic acid. If any signs of a pre-cancerous
lesion are seen, women are referred for cryotherapy to cure the lesion. This approach is cost-effective as
the early detection of lesions and early management by cryotherapy will usually prevent progression to
cervical cancer, and the cost of scaling up this activity is relatively low. As of 2073/74, cervical cancer
screening has been expanded to 64 districts. In the reporting year 98 nurses and doctors were trained
on visual inspection with acetic acid and cryotherapy. Vaccination to adolescent under the human
papilloma virus (HPV) demonstration project in coordination with CHD with support from WHO.

c. Obstetric fistula management: Obstetric fistula affects many women from poorer communities and
significantly impairs their quality of life due to the social stigma attached to this condition and their
physical suffering. The government has allocated funds for the free screening of obstetric fistula
integrated with pelvic organ prolapsed screening and free surgical services at the BP Koirala Institute of
Health Sciences (BPKIHS, Dharan) and Model hospital, Kathmandu. In 2073/74, 120 women received
free surgical treatment for obstetric fistula.

DoHS, Annual Report 2073/74 (2016/2017) 73


Family Health
Human resources
A significant share of FHD’s budget goes for recruiting ANMs on short term contracts to ensure 24 hour
birthing services at PHCCs and health posts. FHD also provides funds to DHOs and DPHOs to recruit the
human resource mix needed to provide surgical management for obstetric complications at district
hospitals.

FHD has been coordinating with the National Health Training Centre (NHTC) and the National Academy
for Medical Sciences (NAMS) for the pre-service and in-service training of health workers. NHTC
provides training on SBA, ASBA, operating theatre management, family planning (including implants and
IUCD), and antenatal ultrasonography. In 2073/74, 582 SBA, 28 ASBA and 20 AA were trained by NHTC
and NAMS. By the end of 2073/74 a total of 9,000 SBAs and 168 ASBAs have been trained.The proper
placement of trained staff such as ASBAs and anaesthesiologist assistants (AAs) has been a continuous
challenge. FHD continued to monitor the deployment of doctors (MDGP, OBGYN, ASBA) and AAs,and
inform DOHS and MOH as necessary for appropriate transfer. This has resulted in improved functionality
of CEONC services.
Expansion and quality improvement of service delivery sites
FHD continued to expand 24/7 service delivery sites like birthing centres, BEONC and CEONC sites at
PHCCs, health posts and hospitals. The expansion of service sites is possible mostly due to the provision
of funds to contract short-term staff locally. By the end of 2073/74 CEONC services were established in
72 districts, only 60 districts were functional throughout the year. During the fiscal year 8-12 districts
provided interrupted C-section services.

A total of 1,811 birthing centres and 158 BEONC sites were functioning by the end of 2073/74. In line
with strategies of the Nepal Health Sector Strategy (2015–2020), in 2072/73 FHD began strengthening
strategically located birthing centres towards upgrading them to comprehensive centres of excellence
(CCEs) and in 2073/74in 98 strategically located birthing centresin 17 districts with support from UNICEF
and NHSSP.

Study in 2013 (FHD 2013) shows that the overcrowding of normal delivery services at referral hospitals
has contributed to poor quality of care. To expand and improve the quality of maternity services, FHD
has been allocating budget to overcrowded hospitals since 2069/70. IN 2073/74,five overcrowded zonal
and regional hospitals are receiving funds for recruiting staff and for quality improvement. FHD has also
allocated budgets for recruiting staff nurses and ANMs in these hospitals to cope with the overcrowding
of maternity wards and MOH is developing master plan for these hospitals to overcome this problem.
Emergency referral funds
It is estimated that 15 percent of pregnant women will develop serious complications during their
pregnancies and deliveries, and 5 to 10 percent of them will need caesarean section deliveries (WHO,
2015) to avoid deaths or long-term morbidity. In cases of difficult geographical terrain and unavailable
CEONC services, it is crucial that these women are referred to appropriate centres. To address this issue
FHD allocated emergency referral funds to Regional Directorate for air lifting of women in need of
immediate transfer to higher centres. A total of 4,000,000 Rupees was allocated to five regions and

74 DoHS, Annual Report 2073/74 (2016/2017)


Family Health
fourteen women from nine districts received support from this fund in 2073/74. Additional 4,400,000
Rupees was allocated to 46 districts to support transport fares women who could not afford referral to
high facility. The main objective of this programme is to support emergency referral transport to women
from poor, Dalit, Janajati, geographically disadvantaged, and socially and economically disadvantaged
communities who need emergency caesarean sections or complication management during pregnancy
or child birth. In addition, the regional health directorates also have funds to airlift to women from areas
where motorised transport is not available or when immediate transfers are needed. Based on national
MNH referral guidelines, free referrals for obstetric complications from birthing centres to CEONC
centres are being implemented in Ramechhap and Dolakha districts in 2072/73 and 2073/74.Almost 300
women with obstetric complications received transport subsidy to three CEONC sites from 60 BCs in
these two districts.
Safe abortion services
Global and national evidence shows that many women face unwanted pregnancy including due to
limited access to family planning information and services. Such women who cannot access safe
abortion services in a timely way are at a high risk of developing complications due to unsafe abortions,
or in the worst case, suicide due to social pressure. In Nepal abortion rate among WRA is 42 per 1000
women of reproductive age women (15-49), highest in central region (59) and lowest in Far Western
region (21). Out of all these abortions, only 42 percent were provided legally at government approved
service sites, (CHREPA 2016). Thus, there is a need to make safe abortion services available, accessible
and affordable to all women with unwanted pregnancies. FHD has defined the four key components of
comprehensive abortion care as:
 pre and post counselling on safe abortion methods and post-abortion contraceptive methods;
 termination of pregnancies as per the national protocol;
 diagnosis and treatment of existing reproductive tract infections; and
 provide contraceptive methods as per informed choice and follow-up for post-abortion
complication management.

Comprehensive abortion care (manual vacuum aspiration [MVA]) services are available in all 75 district
hospitals and majority of PHCCs. Additionally, second trimester abortion services are available in 30
hospitals where CEONC services are also available. Medical abortion (MA) services are being expanded
in health posts through the additional training of SBAs. Medical abortion services have been expanded
to 60 districts with the support of various partners.At the end of 2073/74, total 1,020 ANMs and 466
health facilities were listed for providing MA services and 1,414 doctors and 526 nurses as MVA service
providers and 538 health facilities were listed as MVA service sites. During reporting year 182 ANMs and
132 health facilities were listed for providing MA services and 93 doctors and 64 nurses were trained as
MVA service providers and 15 health facilities were listed as MVA service sites.

Obstetric first aid orientations

In 2070/71, FHD started orienting paramedics on first aid to manage obstetric complications at health
facilities without birthing centres and to enable paramedics to support SBAs and ANMs at times of
emergency. In 2073/74, 51 trainers were trained on this subject in 17 districts.
DoHS, Annual Report 2073/74 (2016/2017) 75
Family Health
Nyano Jhola Programme
The Nyano Jhola Programme was launched in 2069/70 to protect newborns from hypothermia and
infections and to increase the use of peripheral health facilities (birthing centres). Two sets of clothes
(bhoto,daura, napkin and cap) for newborns and mothers, and one set of wrapper, mat for baby and
gown for mother are provided for women who give birth at birthing centres and district hospitals. The
programme was interrupted due to financial constraints, however MOH allocated extra budget for
2073/74 due to popular demand.

Aama and Newborn Programme

The government has introduced demand-side interventions to encourage women for institutional
delivery. The Maternity Incentive Scheme, 2005 provided transport incentives to women to deliver in
health facilities. In 2006, user fees were removed from all types of delivery care in 25 low HDI districts
and expanded to nationwide under the Aama Programme in 2009. In 2012, the separate 4ANC
incentives programme was merged with the Aama Programme. In 2073/74, the Free Newborn Care
Programme (introduced in FY 2072/73) was merged with the Aama Programme with the provisions
listed in Box 3.2.2.
Box 3.2.2: Provisions of the Aama and Newborn Programme
a. For women delivering their babies in health institutions:
 Transport incentive for institutional delivery: Cash payment to women immediately after institutional
delivery (NPR 1,500 in mountains, NPR 1,000 in hills and NPR 500 in Tarai districts).
 Incentive for 4 ANC visits: A cash payment of NPR 400 to women on completion of four ANC visits at 4, 6, 8
and 9 months of pregnancy, institutional delivery and postnatal care.
 Free institutional delivery services: A payment to health facilities for providing free delivery care. For a
normal delivery health facilities with less than 25 beds receive NPR 1,000 and health facilities with 25 or
more beds receive NPR 1,500. For complicated deliveries health facilities receive NPR 3,000 and for C-
sections (surgery) NPR 7,000. Ten types of complications (antepartum haemorrhage (APH) requiring blood
transfusion, postpartum haemorrhage (PPH) requiring blood transfusion or manual removal of placenta
(MRP) or exploration, severe pre-eclampsia, eclampsia, MRP for retained placenta, puerperal sepsis,
instrumental delivery, and management of abortion complications requiring blood transfusion) and
admission longer than 24 hours with IV antibiotics for sepsis are included as complicated deliveries. Anti-D
administration for RH negative is reimbursed NPR 5,000. Laparotomies for perforation due to abortion,
indicated or emergency C-sections, laparotomy for ectopic pregnancies and ruptured uteruses are
reimbursed NPR 7,000.
b. For newborns: A payment to health facilities for providing free sick newborn care. Facilities are reimbursed
for set packages of care: Packages 0, A, B and C costing nothing, NPR 1,000, NPR 2,000 and NPR 5,000
respectively. Health facilities can claim a maximum of NPR 8,000 (packages A+B+C), depending on medicines
and diagnostic and treatment services provided.
c. Incentives to health workers (to be arranged from health facility reimbursement amounts):
 For deliveries: A payment of NPR 300 to health workers for attending all types of deliveries.
 For sick newborn care: A payment of NPR 300 to health workers for providing all forms of packaged
services.

76 DoHS, Annual Report 2073/74 (2016/2017)


Family Health
There has been a large increase in the number of facilities providing delivery services and of institutional
deliveries since the launch of the Aama Programme. All government health facilities/hospitals and 61
non-state health facilities are currently implementing the Aama Programme.

Figure 3.2.1: Women receiving free delivery care and transport incentive as percentage of expected
live births
49

48 48 48

47 47

FY 2071/72 FY 2072/73 FY 2073/74

Free Delivery Transport incentive

Aama Programme data shows that only 48 percent of expected deliveries received free care and 47
percent received transport incentives, one percent point decline from 2072/73. (Figure 3.2.1).

Table: Aama Programme Budget Authorized and Expenditure over years


FY 2071/72 FY 2072/73 FY 2073/74
Budget Expenditure Budget (NPR) Expenditure Budget (NPR) Expenditure
(NPR) (NPR) (NPR) (NPR)

Transport and 1,136,250,000 612,294,184 1,101,251,000 798,226,573 1,157,329,000 987,643,563


reimbursement
incentives
4ANC 90,000,000 22,502,186 44,800,000 34,158,871 82,380,400 42,266,701

Free newborn - - 48,000,000 7,045,670 48,000,000 12,149,524


care
Source: TABUCS

In 2071/72, 54 percent of Aama Programme related expenditure (transport and health facility
reimbursement) and 25 percent of 4ANC related expenditure was captured in MoH’s Transaction
Accounting and Budget Control System (TABUCS). This increased to 73 percent for Aama Programme-
related expenditure and 76 percent for 4ANC expenditure in 2072/73 (note that the increase in
expenditure for 4ANC is due to reduced budget allocation). Almost 86 percent Aama programme budget
and 51 percent 4 ANC budget has been absorbed in FY2073/74. The data indicates that there is an
increasing trend in absorption of Aama programme budget, which is mainly due to improvement in
TABUCS entry by cost centres. The free newborn care programme expenditure has improved from 15
percent in FY2072/73 to 25 percent in FY 2073/74.

DoHS, Annual Report 2073/74 (2016/2017) 77


Family Health
3.2.3 Achievements
Antenatal care
WHO recommends a minimum of four antenatal check-ups at regular intervals to all pregnant women
(at the fourth, sixth, eighth and ninth months of pregnancy). During these visits women should receive
the following services and general health check-ups:
 Blood pressure, weight and foetal heart rate monitoring.
 IEC and BCC on pregnancy, childbirth and early newborn care and family planning.
 Information on danger signs during pregnancy, childbirth and in the postpartum period, and timely
referral to appropriate health facilities.
 Early detection and management of complications during pregnancy.
 Provision of tetanus toxoid and diphtheria (Td) immunization, iron folic acid tablets and deworming
tablets to all pregnant women, and malaria prophylaxis where necessary.

Pregnant women are encouraged to receive at least four antenatal check-ups, give birth at a health
institution and receive three post natal check-ups, according to the national protocols. HMIS reported
since 2066/67 to track the timing of ANC visits as per the protocol. All antenatal indicators
perfoamncedropped in 2073/74. The national average of first ANC visits as a percentage of expected
pregnancies increased from 96 percent in 2071/72 and 97 percent in 2072/73 which has declined to
87percent in 2073/74.The proportion of pregnant women who visit antenatal first visit on-time also
declined from 76 percent 2072/73 to 59 percent in 2073/74. The proportion of pregnant women attending
at least 4 ANC visits among expected pregnancies as per the protocol has declined from 51 percent in
2072/73 to 45 percent in 2073/74 at the national level (Figure 3.2.2). As the trend of all these indicators
were increasing for the last three year, the reasons for declined in all indicators could not be identified,
except poor reporting from referral hospitals. FHD is able to get information on institutional deliveries
from these referral hospitals; however data on antenatal and post-natal care is not possible to get from
these hospitals.

Figure 3.2.2: Regional and national trends of percentage pregnant women with four ANC visits(as per protocol)
among expected pregnancies

100
90
80 68
70 58 60
60 51 55 55 52 51
50 49 49 47
50 45 43 45 44 45
39
40
30
20
10
0
EDR CDR WDR MWDR FWDR Nepal
2071/72 2072/73 2073/74

78 DoHS, Annual Report 2073/74 (2016/2017)


Family Health

Figure 3.2.3: Fourth ANC visit (as per protocol) as a percentage of first ANC visits (as per protocol)

100 88
83 80
79 78 78 78 76 76 76
80 71 70 70 69 73 72
64 67
60

40

20

0
EDR CDR WDR MWDR FWDR Nepal
2071/72 2072/73 2073/74

While the percentage of pregnant women who received antenatal care (at any time, first visit by 4 th
month, and 4 ANC according to protocol) declined the proportion of women who came for four visits (as
per protocol) among w
who
ho did their first visit per protocol is constant over the last two years (figure
3.2.3).

In 2073/74seventeen
2073/74seventeen districts had 4 ANC coverage per national protocol of above 70 70 percent (Figure
3.2.4) an increase from eight districts in 2072/73
2072/73.However
However,, districts with 4 ANCcoverage less than 30
percentincreased
increased from 10 districts in 2072/73 to 18 districts in 2073/74. Percentage of pregnant women
who visit ANC at least one time is more than 7700 percent in 66 districts. These results show the need to
focus on the quality of the ANC consultation process as it is expected that satisfied and well informed
pregnant women will be more likely to complete the recommended four visits.
Figure 3.2.4: ANC 4 visits by expected number of pregnant women as pe
per the protocol by district,
2073/74

DoHS, Annual Report 207


2073/74 (2016/2017)
(201 79
Family Health
Delivery care
Delivery care services include:
 skilled birth attendance at home and facility-based deliveries;
 early detection of complicated cases and management or referral (after providing obstetric first aid)
to an appropriate health facility where 24 hours emergency obstetric services are available; and
 the registration of births and maternal and neonatal deaths.

Although women are encouraged to deliver at a facility, home deliveries using emergency obstetric care
kits, and obstetric first aid at home if complications occur, are important components of delivery care in
settings where institutional delivery services are not available.

Nepal is committed to achieving 70 percent of all deliveries by SBAs and at institutions by 2020
(2076/77) to achieve the SDG target in 2030. In 2073/74, nationally and in CDR and WDR, the proportion
of deliveries attended by SBAs increased (Figure 3.2.5).

Figure 3.2.5: Trend of deliveries attended by SBAs as percentage expected live births (2071/72–2073/74)

100 2071/72 2072/73 2073/74


80
57 56 54 60 60 62 59 59 59 59
60 53 57 54 56 57 54 56
47
40
20
0
0
EDR CDR WDR MWDR FWDR Nepal

Institutional deliveries as a percentage of expected live births increased from 55 to 59 percent over
the last year, compensating the lost due to the effects of the 2015 earth quake and fuel crisis
(Figure 3.2.6). Institutional deliveries increased in all regions in 2073/74 from the previous year
except for EDR.

Figure 3.2.6: Trend of institutional deliveries as percentage of expected live births (2071/72 – 2073/74)

100 2071/72 2072/73 2073/74

80 68 68
68
57
66 66 67 57 59
56 56 58 54 56 55
60 55 51 47

40

20

0
EDR CDR WDR MWDR FWDR Nepal

80 DoHS, Annual Report 2073/74 (2016/2017)


Family Health
The 18 districts shaded in light green in Figure 3.2.7 achieved the 2020 20 NHSS target o off 70
70 percent
institutional delivery, eight districts achieved more than 60 percent (in 2072/73, 21 districts achieved 60
percent MDG target), while 18 districts achieved less than 30 percent institutional deliveries
(improvement from 30 districts in 2072/73)) (Fig 3.2.7).. The proportion of institutional deliveries taking
place at birthing centres (i (in
n health posts) declined from 27 percent of all instituti
institutional
onal deliveries in
2072/73 to 26 percent in 2073/74
2073/74.. This is a concern considering the increasing number of birthing
centres (BCs) at health posts — from 1,755 in the previous year to 1,881 in the current ye year
ar (Table 3.2.3
and 3.2.4
3.2.4). Deliveries at higher level hospitals increased from 36% in 2071/72 to 39
39% % in 2073/74
2073/74,, calling
to strengthen these hospitals as overcrowding of maternity wards results in poor quality of care
care.

Table 3.2.2:
3.2.2: Proportions of Institutional Deliveries at Different types of Health Institutions
HP PHCC District and Referral or Private and Others2
General Specialised NGO
Hospitals Hospitals1
2072/73 27.4 8.0 25.9 35.9 1.4 1.5
2073/74 27.4 7.8 23.9 38.5 1.7 0.8

Figure: 3.2.7: Institutional delivery rate by district, 2073/74

Source: HMIS

1
Zonal, Sub-regional,
Sub regional, regional, central, specialized and teaching hospitals. Janakpur Zonal hospital did not report in 2071/72.
BPKIHS and Bharatpur data were not captured in 2073/74 HMIS report.
2
Institutional clinics, health centres, urban health clinics, CHU, aand
nd other health facility
DoHS, Annual Report 207
2073/74 (2016/2017)
(201 81
Family Health
Table 3.2.3: Status of birthing centre, BEONC and CEONC expansion
2071/72 2072/73
Region Districts
BCs BEONC CEONC* Total BCs BEONC CEONC* Total
Eastern 16 281 31 16 332 301 26 26 353
Central 19 366 41 17 431 394 40 27 461
Western 16 278 40 13 334 340 44 22 406
Mid-western 15 399 28 13 444 399 28 17 444
Far Western 9 297 26 9 334 321 21 12 354
Total 75 1,621 166 67 1,875 1,755 159 104 2,018
*Number of districts with CEONC services established in the district

Table 3.2.4: Status of birthing centre, BEONC and CEONC services in Provinces
2073/74
Province Districts Total
BCs BEONC CEONC*
(BC and BEONC)
Province 1 14 291 24 14 315
Province 2 8 129 13 8 142
Province 3 13 309 30 12 339
Province 4 11 253 26 9 279
Province 5 12 307 30 10 337
Province 6 10 248 16 10 264
Province 7 9 344 19 9 363
Total 77 1881 158 72 2039
*Number of districts with CEONC services established in the district

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

82 DoHS, Annual Report 2073/74 (2016/2017)


Family Health
The number of mothers who received their first postnatal care at a health facility within 24 hours of
delivery is similar to the number of institutional deliveries in almost all health facilities as most health
workers reported to have provided post-natal care to both mothers and babies on discharge. The
revised HMIS introduced the monitoring of three PNC visits according to a protocol since 2071/72. The
proportion of mothers attending three PNC visits as per the protocol is slightly declined in
2073/74(Figure 3.2.8). Cultural and geographical factors affecting the movement of postnatal mothers
could be reasons for the low coverage while the perceived low importance of care in the postpartum
period could also be significant. There is a need for culturally sensitive interventions to promote access
to and the use of postnatal services, especially in geographically challenging areas.

Figure 3.2.8: Trend of three PNC as per protocolas percentage of live births
60
2071/72 2072/73 2073/74
50
40 35 35
30 24 24 26
23
18 18 17 19 19 17 18 20 19
20 15
11 11
10
0
EDR CDR WDR MWDR FWDR Nepal

Source: HMIS

Newborn care
Newborn care includes:
 delivery by a skilled birth attendant at home and facility births with immediate newborn care
(warmth, cleanliness, immediate breast feeding, cord care, eye care and immunization) for all
newborns and the resuscitation of newborns with asphyxia;
 health education and behaviour change communication for mothers on early newborn care at
home;
 the identification of neonatal danger signs and timely referral to an appropriate health facility; and
 community based newborn care (see Section 2.3 above).

A separate report on post-natal care to new born is not reported in HMIS and it can be assumed that the
percentage of new born who received PNC as per protocol is similar to as of mothers. Among 343,577
live births reported 91 percent received application of Chlorhexidine (Nabi care) at umbilical cord at
delivery. Total low birth weight (LBW) was 11.5 percent among institutional deliveries -2.5 percent were
very low birth weight (less than 2000 gm) and another 9 percent were LBW (2000-2499 gm). Reported
still birth rate among deliveries at health institutions increased from 14 in 2072/73 to 17 per 1000 total
births in 2073/74.

DoHS, Annual Report 2073/74 (2016/2017) 83


Family Health
Emergency obstetric care
Basic emergency obstetric and newborn care (BEONC) covers the management of pregnancy
complications by assisted vaginal delivery (vacuum or forceps), the manual removal of placentas, the
removal of retained products of abortion (manual vacuum aspiration), and the administration of
parental drugs (for postpartum haemorrhage, infection and pre-eclampsia and eclampsia) and the
resuscitation of newborns and referrals. Comprehensive emergency obstetric care (CEONC) includes
surgery (caesarean section), anaesthesia and blood transfusions along with BEONC functions.

The proportion of caesarean sections among expected live births slightly increased in 2073/74 to 10.1
percent of expected live births with increases in all regions. WHO (2015) puts the acceptable C-section
rate at 5–10 percent of all live births. While the C-Section rate in EDR, CDR and WDR are higher than
10percent the rate in FWDR is 3.9 percent, below the minimum accepted level of 5 percent. The
proportion of C-sections among total expected births in mountain districts does not increase from
2072/73 at 1.7 percent (Table 3.2.3), although 2016 NDHS data show higher percentage of C-Section
rate at 2.6 percent in mountain areas.This indicates limited availability of C-Section services in mountain
areas with almost one percent of pregnant women (of expected livebirths) from these areas getting
service out of their districts.

Table 3.2.5: Trends of proportion of caesarean sections among total expected live births
2070/71 2071/72 2072/73 2073/74
Mountain districts 0.7 1.0 1.7 1.7

Hill districts 8.3 9.3 8.9 9.9

Teri districts 8.0 9.8 9.7 11.4

Nepal 7.6 8.7 8.8 10.1

The met need for emergency obstetric care (EOC) increased to 29 percent of estimated complications in
2073/74 from 23.6 percent the previous year based on Aama reporting (Table 3.2.4). The WHO standard
is that 15 percent of expected birth cases suffer major direct obstetric complications throughout
pregnancy, childbirth or the immediate postpartum period. The data indicates that less than a third are
reported to have received emergency obstetric care services from Aama programme implementing
sites.

Table 3.2.6: Met need for EOC based on Aama Programme reporting*
Total expected live 15% of expected live Number of obstetric Met need for EOC
births births (estimated complications managed services
Fiscal year
proportion needing (%)
EmOC)
*2071/72 614,666 92,200 23,611 25.6
2072/73 637,263 95,590 22,563 23.6
2073/74 641,899 96,285 28,011 29.1
*2071/72 data is based on HMIS data
84 DoHS, Annual Report 2073/74 (2016/2017)
Family Health
Provincial level Performance

The performance of provinces of Nepal varies in maternal and newborn health care utilisation. (figure
3.2.9). The continuum of care in maternal and newborn health care services shows that there needs to
be more awareness and encouragement of pregnant women to seek timely first antenatal care, improve
quality of counselling during antenatal care, improved access to delivery care services and post-natal
care services. C-Section rate in province number 1 and 3 is higher than maximum desirable rate
10percent while that of province 2, 6 and 7 is lower than minimum acceptable rate of 5percent.

Figure 3.2.9: Maternal health care indicators in seven Provinces of Nepal

% of pregnant women who had first ANC visits as per protocol


% of pregnant women who had four ANC checkups as per protocol
Institutional deliveries
100 Deliveries attended by SBA
C-Section rate
90 % of women who had three postnatal check-ups as per protocol
78

77

75
80

72
70
69
68

68
65
70
64
63
63

60
60

60
59

59
59
58

57
57

56
55
60
51
49
46
46
45

50

45
44

44
35

40

30
30
21
17.2
16.6

19

19
17

20

10.1
11

11

9.8
9.0
8

3.9
3.5

10
2.4

0
Province 1 Province 2 Province 3 Province 4 Province 5 Province 6 Province 7 Nepal

Source: HMIS

Safe abortions
More than1,005,000 women have received safe abortion services from certified service sites since the
service began in Nepal in 2060/61. The use of safe abortions services increased from 89,214 in 2072/73
to 96,417 women in 2073/74, of which 56 percent received medical abortions. Fourteen percent of safe
abortion service users were adolescents (<20 years) slight decline from 16 percent in 2072/73. Thought
the number of women who received safe abortion services increased in 2073/74 from previous year, it is
still less than one third of the total estimated abortion occurred in Nepal in 2014 (CREHPA 2016).
Compared to fiscal year 2072/73, the proportion of women who had a safe abortion and then used
contraceptives increased from 69 percent in 2072/73 to 71 percent in 2072/73 (Figure 3.2.10). The
acceptance of post abortion contraception among medical abortion service users was high compared to
DoHS, Annual Report 2073/74 (2016/2017) 85
Family Health
among surgical abortion users (medical abortion 77% versus surgical abortion 63%). Overall, post-
abortion LARC use is higher among women who had surgical abortion (18 percent) than among medical
abortion (14 percent).

Figure 3.2.10: Trend of post abortion contraceptive use (%)


120

100
40.3 31.3 29.3
80

60 14.3 15.8
11.4
54.4 54.9
40 48.1

20

0
2071/72 2072/73 2073/74
Source: HMIS Short Term Methods Long Term Methods No Method

3.2.4 Issues, constraints and recommendations


Table 3.2.7: Issues, constraints and recommendations— safe motherhood and newborn health
Issues and constraints Recommendations Responsibilities
 Review of programme implementation and effectiveness
FHD, DoHS,
High maternal mortality rate  Plan for road map to reduce MMR based on global and
MoH
Nepal evidences
 Review/assessment of referral strengthening at district
level
Referral mechanism needs
 Revise the Aama Programme to facilitate an appropriate FHD
to be established
referral mechanism and improve access to life-saving
services
 Monitoring service provision status and availability of
human resource
 Promote the production of skilled service providers (AAs,
MDGPs, MD obgyn) and ensure appropriate skill mix at
CEONC sites by deployment and appropriate transfer of
skilled human resources
Fluctuating functionality of
 Continue allocation of fund for contracting out short – MoH , DoHS,
CEONC and birthing centre
term service providers FHD, NHTC
services
 Provide locum doctors and anaesthesia assistants in
strategically located referral hospitals for each province
 Introduce a special package to provide CEONC services in
mountain districts
 Support local government for training of human
resources in necessary skills
Availability of quality  Introduce quality improvement process for all maternity MoH, DoHS
maternity care services at care services including process and on-site coaching
hospitals and birthing  Adequate budgets allocated for equipment in birthing
86 DoHS, Annual Report 2073/74 (2016/2017)
Family Health
Issues and constraints Recommendations Responsibilities
centres: centres and CEONC sites FHD (quality of
 24/7 availability of  Regular MNH skills update programmes for nurses care)
services  Introduce monitoring process indicator for quality
 skills and knowledge of maternity care in health facilities
staff  Introduce construction standards for birthing centres FHD
 enabling environment  Support birthing centres at strategic locations
and motivation  Provide additional budgetary support for overcrowded FHD, DHOs,
 overcrowding at hospitals DPHOs
referral hospitals.  Develop quality improvement tools and minimum service FHD, DoHS
standards
 Provide on-site coaching and mentoring for MNH health
workers
 Raise the quality of ANC counselling services.
Plateauing of 4ANC use and
 Develop a special package to encourage timely first ANC DHOs, DPHOs,
timely first ANC visits, and
visits. FHD
very low PNC coverage
 Initiate PNC home visit in selected councils
Low use of institutional  Produce a strategy to reach unreached sub-populations
delivery and C-section  Rapidly assess and expand rural ultrasonography (USG)
FHD, DHOs,
services in mountain  Expand services in remote and difficult locations and
DPHOs
districts, and province ensure continuous availability of services (birthing
number 2 and 6 centres and CEONC services)
No CEONC services in some  Discussion with local government on the advantages of
remote districts: Rasuwa, have CEONC, and challenges in maintaining CEONC FHD
Manang and Mustang functionality in low population areas
The high public demand for
MoH, BPKIHS,
free delivery services at  Implement the Aama Programme at BPKIHS
FHD, RHDs
BPKIHS
 The strategic upgrading of health facilities into birthing
The inadequate use of some
centres
birthing centres and
 Upgrade strategically located birthing centres to provide
increasing the number of FHD, DHOs
comprehensive quality primary health care services and
birthing centres, and DPHOs
aim for ‘home delivery free’ VDCs
increasing use of referral
 Run innovative programmes to encourage delivery at
hospitals
birthing centres
High demand for free  Increase the budget and target for regional health
surgery for uterine prolapse directorates and hospitals in uterine prolapse (UP) FHD
cases surgery
Federal structure and
governance of health
 Orientation of local and provincial level government on
institutions; limited FHD/MOH
their roles in health services delivery and governance
understanding of health
service delivery

DoHS, Annual Report 2073/74 (2016/2017) 87


Family Health

3.3 FCHV Programme

3.3.1 Background
The government initiated the Female Community Health Volunteer (FCHV) Programme in 2045/46
(1988/1989) in 27 districts and expanded it to all 75 districts thereafter. Initially one FCHV was
appointed per ward following which in 2050 (1993/94) a population-based approach was introduced
in 28 districts. There are 51,420 FCHVs working in Nepal. The goal and objectives of the programme
are listed in Box 3.3.1.

FCHVs are selected by health mothers' groups. FCHVs are provided with 18 days basic training
following which they receive medicine kit boxes, manuals, flipcharts, ward registers, IEC materials,
and an FCHV bag, signboard and identity card. Family planning devices (pills and condoms only), iron
tablets, vitamin A capsules, and ORS are supplied to them through health facilities.

The major role of FCHVs is to advocate healthy behaviour by mothers and community people to
promote safe motherhood, child health, and family planning and other community based health
issues and service delivery. FCHVs distribute condoms and pills, ORS packets and vitamin A capsules,
treat pneumonia cases, refer serious cases to health institution and motivate and educate local
people on healthy behaviour. They also distribute iron tablets to pregnant women.

The government is committed to increase the morale and participation of FCHVs for community
health. Policies, strategies and guidelines have been developed to strengthen the programme. The
FCHV programme strategy was revised in 2067 (2010) to promote a strengthened national
programme. In fiscal year 2064/65 MoH established FCHV funds of NPR 50,000 in each VDC mainly
to promote income generation activities. FCHVs are recognised for having played a major role in
reducing maternal and child mortality and general fertility through community-based health
programmes.

Box 3.3.1: Goal and objectives of the FCHV Programme

Goal — Improve the health of local communities by promoting public health. This includes imparting
knowledge and skills for empowering women, increasing awareness on health related issues and involving
local institutions in promoting health care.

Objectives — i) Mobilise a pool of motivated volunteers to connect health programmes with communities and
to provide community-based health services, ii) activate women to tackle common health problems by
imparting relevant knowledge and skills; iii) increase community participation in improving health, iv) develop
FCHVs as health motivators and v) increase the use of health care services.

3.3.2 Major activities in 2073/74


 Dress allowance for FCHVs increased from NPR 6,000 to NPR7,500.
 Since 2071/72 the government has allocated budget for farewells to FCHVs over 60 years of age
as recommended by health mothers’ groups.
 The training, orientation and mobilization of FCHVs for national health programmes.
 Biannual FCHV review meeting held, FCHV Day celebrated on 5th December.

88 DoHS, Annual Report 2073/74 (2016/2017)


Family Health
3.3.3 Major achievements in 2073/74
Progress reports, which provide the basis for the following analysis, were only received from
534,626 FCHVs for 2073/74. In 2073/74 Nepal’s FCHVs distributed fewer pills, condoms. (Table 3.3.1
and Figure 3.3.1). The number of mothers participating in health mother's group meetings also
decreased.

Table 3.3.1: Trend of services provided by FCHVs


Services 2071/72 2072/73 2073/74
Pills distribution (no. cycles) 866,881 840,762 808,138

Condom distribution (pieces) 10,512,449 10,068,095 9,983,379

Iron tablet distribution 932,945 743,297 717,267

Health mother’s group meetings 702,823 488,377 506,909


Source: HMIS

Figure 3.3.1: FCHV contribution on selected health services in FY 2071/72–2073/74 (,000)

25000 933

2071/72 2072/73 2073/74


20000

10512
15000
10068
9983
10000

5000
840 488
867 808 743 717 703 507
0
pills distribution cycle condom distribution iron tab distribution health mother's group
cycle meeting

Source: HMIS

Support for home deliveries


FCHVs support home deliveries. In 2073/74 they initiated baby to mother skin-to-skin contact after
delivery in 101,997 cases, applied chlorhexidine to the umbilicus after delivery for 95,283 cases and
ensured the taking of misoprostol for preventing PPH in 38,462 cases (Table 3.3.2).

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Table 3.3.2: Support provided by FCHVs for home deliveries, 2073/74
Initiating skin-to-skin Chlorhexidine applied on Ensured misoprostol
Region
contact after birth umbilicus tablets taken
Province 1 16,790 15,223 3,824
Province 2 40,674 38,664 17,474
Province 3 10,301 7,565 3,524
Province 4 4,731 4,458 1,590
Province 5 14,170 13,619 5,703
Province 6 8,564 8,644 3,995
Province 7 6,767 7,110 2,352
National 101,997 95,283 38,462
Source: HMIS

Fewer CB-IMCI services were provided by FCHVs in communities in 2073/74 (Table 3.3.3). FCHVs
treated 166,202 no. of children with infections treated with cotrim. Also, FCHVs assisted the
immunization against polio of children below 5 years on National Immunisation Day, the community-
based management and treatment of acute respiratory infections and control of diarrheal diseases,
community nutrition programmes and other public health activities.

Table 3.3.3: CB-IMCI service provided by FCHVs at the community level


Services 2071/72 2072/73 2073/74
Cotrim treatment (cases) 277,095 221,716 166,202

Total diarrhoea cases reported by FCHVs 1,136,165 931,376 800,936

Treated with ORS and zinc 1,088,979 853,924 713,728

Source: HMIS

3.3.4 Issues and constraints


Table 3.3.4: Issues and constraints — FCHVs

Issues and constraints Recommendations Responsibility


Low utilization of FCHV Fund Strictly implementguidelines and audit FHD, DHOs, HFs
FCHV fund every year
FCHV are not interested in farewell Rethink the farewell package FHD, DHOs
programmes
Decreasing work performance of Motivate FCHV through FCHV Review FHD, DPHOs, HFs
FCHV meeting and program related orientation

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3.4 Primary Health Care Outreach
3.4.1 Background
Health facilities were extended to the village level under the National Health Policy (1991). However,
the use of services provided by these facilities, especially preventive and promotive services, was
limited due to accessibility factors. Primary health care outreach clinics (PHC-ORC) were therefore
initiated in 1994 (2051 BS) to bring health services closer to communities.

The aim of these clinics is to improve access to basic health services including family planning, child
health and safe motherhood. These clinics are service extension sites of PHCCs and health posts. The
primary responsibility for conducting them lies with maternal and child health workers (MCHWs) and
village health workers (VHWs) at sub-health posts and ANMs, AHWs and VHWs at PHCCs and health
posts. With the upgrading of MCHWs and VHWs and the upgrading of all sub-health posts the
responsibility is being shared with all ANMs and AHWs. FCHVs and local NGOs and community based
organisations (CBOs) support health workers to conduct clinics including recording and reporting.

Based on local needs, these clinics are conducted every month at fixed locations on specific dates
and times. They are conducted within half an hour's walking distance for their catchment
populations. VHWs and MCHWs or ANMs/AHWs provide the basic primary health care services listed
in Box 3.4.1.

Box 3.4.1: Services to be provided by PHC-ORCs according to PHC-ORC strategy

Safe motherhood and newborn care: Child health:


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

3.4.2 Service coverage


In 2073/74, 2.5 million people were served at 133,147 outreach clinics (Table 3.4.1). A total of
133,147 clinic events (days) were run which represents 91 percent of the targeted number (133,147
clinics x 12 = 1,597,764 in a year). An average of 19 clients were served per day per outreach clinic, a
increase from 18 the previous year with the highest average number being in province 2. The
average number of daily clients served by PHC-ORC is higher than the number of served in Health
posts (Table 3.4.2).

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Table 3.4.1: PHC-ORCs conducted and people served in 2073/74 by Province
Province Total no. clinics Services provided to clients (new+old)
Province 1 24,792 451,341
Province 2 23,984 483,682
Province 3 20,542 340,889
Province 4 15,464 257,018
Province 5 21,264 463,944
Province 6 11,024 212,788
Province 7 16,077 372,779
National 133,147 2,582,441
Source: HMIS

Table 3.4.2: Average number of people served per clinic per day by province in FY 2073/74
Province PHCC/day Health post/day PHC-ORC/clinic
Province 1 33 13 18
Province 2 32 12 20
Province 3 37 13 17
Province 4 33 10 17
Province 5 38 19 22
Province 6 27 13 19
Province 7 42 15 23
National 35 13 19

3.4.3 Services provision


The number of people served by PHC-ORCs increased in the past two years (Table 3.4.3). In FY
2073/74 primary treatment has been increased in comparison to last FY (Table 3.4.3).

Table 3.4.3: Trend of services provided by PHC-ORCs


Service Types 2071/72 2072/73 2073/74
Primary treatment 754,413 736,538 817,748

Depo (times) 214,370 193,030 189,686

ANC (times) 258,979 227,230 249,525

PNC (times) 56,917 45,968 43,752

Growth monitoring 931,097 852,701 385,076


Source: HMIS

3.4.4 Issues, constraints and recommendations


Table 3.4.4: Issues, constraints and recommendations— primary health care outreach
Issues / constraints Recommendation Responsibility
All the PHC-ORCs are not functional Functionalize all PHC-ORCs by resolving all FHD, DPHOs
issues at every levels

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3.5 Demography and Reproductive Health Research


3.5.1 Background
The planning, monitoring and evaluation of reproductive health activities are key functions of the
Programme, Budget and Demography Section. This section conducts studies and coordinates
reproductive health related research and studies carried out by other organisations in Nepal.

The major responsibilities of this section are as follows:


 Estimate annual national targets for family planning, safe motherhood and adolescent
reproductive health services including family planning acceptors and reproductive health
commodities.
 Regularly monitor reproductive health and essential obstetric care (EOC) activities.
 Provide supportive supervision to DHOs, DPHOs and all levels of health facilities on reproductive
health services.
 Conduct periodic and ad-hoc research and studies on family planning, maternal and neonatal
health, safe abortion services, adolescent sexual and reproductive health and FCHV services.
 Conduct and support the piloting of maternal and newborn health initiatives.

3.5.2 Major activities in 2073/74


Annual programme and budget
 The annual programme and budget was prepared based on programme continuation, district,
regional and national reproductive health review recommendations, sub-committee
recommendations, district and regional office demands, research and study findings and HMIS
information.
Target population setting, monitoring and research
 The target populations wererevised for reproductive health programmes led by HMIS and
supported by FHD and sent to the districts.
 Forecasting for contraception and other reproductive health commodities was done in
coordination with LMD and the HMIS Section.
 The DoHS regional and national reviews were supported by the documentation and
presentation of reproductive health programmes. A national reproductive health review
meeting was conducted. The NHSS Result Framework development process was supported by
developing Reproductive Health Program-related indicators and activities.
 The internal monitoring was carried out of various district offices and hospitals focusing on the
finance flow of the Aama Programme, uterine prolapse management, family planning services
and maternal and perinatal death surveillance responses (MPDSR). CEONC strengthening was
done through mentoring and FHD officials.
 Community-based maternal and perinatal death surveillance and response was scaled up in
Baitadi in addition to five districts (Solukhumbu, Dhading, Kaski, Banke and Kailali) where it was
started in 2072/73. Hospital-level MPDSR was strengthened in 65 hospitals with reorientation at
the hospitals on revised formats and guidelines.

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 The Rapid Assessment of Demand Side Financing (Aama and 4ANC) round 10 was conducted in
11 districts.
 Assessment of the Integration of Family Planning and Expanded Program of Immunization (EPI)
was conducted in 4 districts
Guidelines and document development
 An MPDSR training package was developed for hospitals and communities and has been
instrumental to expand the carrying out of MPDSRs.
 A revised draft of the Safe Motherhood Policy was prepared to incorporate maternal death
notification, newborn health and contemporary safe motherhood issues.
Implementation of Maternal and Perinatal Death Surveillance and Response (MPDSR)
GoN prioritized and implemented MPDSR in FY 2073/74 MPDSR with further strengthening and
expansion. The program envisions eliminating preventable maternal and perinatal mortality by
obtaining and using information to guide public health actions and monitor their impact. This is a
continuous identification, notification, quantification and determination of causes and avoidability of
all maternal and perinatal deaths, as well as the use of this information to respond with actions that
will prevent future deaths.

MPDSR was scaled up in Baitadi in FY2073/74. As in previous 5 MPDSR implementing districts,


District level government and NGO stakeholders were orientated on their role in implementing
MPDSRs. Hospital health workers were orientated on the objectives and processes of MPDSRs, the
tools, the causes of maternal and perinatal deaths and mechanisms to improve quality of care.
Community health workers were orientated on the objectives and processes, shown how to use the
verbal autopsy tool at health posts and planned for orienting FCHVs on the identification and
notification of deaths.

Table 3.5.1: Participants in MPDSR trainings, 2072/73& FY 2073/74


District Number of participant
Stakeholder orientations Hospital health workers Community health
workers
FY2072/73
Dhading 44 46 116

Kaski 42 55 124

Kailali 39 47 93

Banke 40 54 198

Solukhumbu 41 36 101
FY2073/74
Baitadi
Totals 206 238 632
Source: MPDSR training report

Following the trainings, DHO and DPHO personnel oriented FCHVs on carrying out MPDSRs and the
notification of the deaths of local women. MPDSR committees were formed at district, hospital and
health facility levels in the five districts.
94 DoHS, Annual Report 2073/74 (2016/2017)
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Community-based MPDSR:

The community-based MPDSR process was started in Solukhumbu, Dhading, Kaski, Banke and Kailali
districts in FY 2072/73. During this FY 2073/74 it was further expanded to Baitadi with orientations
and trainings. Forty District Stakeholders, 22 hospital staff, 183 Community Health Service Providers
and 1063 FCHVs and HFOMC were oriented and trained at Baitadi during roll out.
An international trainer was mobilized for trainers’ training on maternal death cause assignment
from verbal autopsy with 26 participants from GoN, Nepal Society of Obstetrician/Gynaecologists
(NESOG), Perinatal Society of Nepal (PESON), Nepal Medical Association (NMA), tertiary hospitals
and external development partners. This was followed by training for the 12 medical doctors at the
districts implementing Community-based MPDSR.

Figure 3.5.1 Coverage of MPDSR Program


Hospital-based MPDSR:

By the end of In this FY 2073/74, hospital-based MPDSR was expanded into 65 hospitals. Training of
trainers was conducted at Kathmandu with participants from referral hospitals of all regions. This
was followed by seven batches of trainings for staff at65 hospitals. There were 29 participants in the
trainers training including Obstetrician/Gynecologists, Pediatricians, Medical Officers, Nursing Staff
and Medical Recorders. The roll out training was conducted for at regional level with 175
participants from RHDs, PHCs, DHOs, RHDs and 65 hospitals.

Following the community and hospital trainings, six districts and 65 hospitals in 38 districts are now
implementing the program.

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Formation of MPDSR Committees at different levels
Following the guidelines, there were formation of National MPDSR Committee chaired by the
Director General, Directorate of Health Services and MPDSR Technical Working Group (TWG) chaired
by Director, Family Health Division in 2015. At the local levels, districts implementing MPDSR have
committees at district, hospital and health facility levels with separate VA and cause of death
assignment teams.For each hospital implementing MPDSR, there is MPDSR committee formed as per
the level of the hospital.
Web-based reporting system

A web-based reporting system is developed by the Family Health Division for enhancing functional
recording and reporting of the data related to the community- and hospital-based mortality.
On-site coaching and supportive supervision

Family Health Division conducted on-site coaching for supporting the districts and hospitals for
implementing MPDSR. Standard checklists were used during the process of monitoring and on-site
coaching was provided at individual sites.The on-site coaching covered Solukhumbu, Dhading, Kaski,
Kailali and Baitadi for community based MPDSR and 40 hospitals.

The visiting team met with the MPDSR committee, reviewed available data, forms and documents to
discuss on issues. Discussions were mainly prioritized to orient the MPDSR committee on process of
MPDSR focusing on identifying avoidable factors contributing to the maternal and perinatal deaths
and developing action plans to prevent such avoidable factors which improved quality of services
and ultimately contributed in reducing maternal and perinatal mortalities.

Findings from implementation of MPDSR

With the MPDSR process initiated in the community and strengthened in the hospitals, FHD is
receiving the tools with information on the maternal and perinatal deaths from many sites. There
are still gaps in regular implementation and reporting of the information and reporting. The
information received the web-based system till FY 2073/74 has been presented below.

Community-based MPDSR:

During the period, death of 192 women of age 12-55 years have been notified by the FCHVs which
have been screened by the staff from respective health posts. Among the 192 deaths, 48 (25%) were
pregnancy-related deaths. Verbal autopsy was conducted by the respective District (Public) Health
Offices (D(P)HOs for almost all (47) pregnancy-related deaths except one. One verbal autopsy could
not be conducted as the woman, who had committed suicide, used to live with her husband in
Pokhara who was untracable after the event

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Figure 3.5.2 Death identified in MPDSR

Figure 3.5.4Cause of Direct Maternal Deaths


Figure 3.5.3 Types of deaths (N=47) (N=31)

Once the verbal autopsy was completed, doctors in the district reviewed the verbal autopsy forms
and identified delays and cause of deaths. Based on the cause of deaths assigned by the doctors,
among all pregnancy-related deaths, 66% were direct maternal deaths, 26% were indirect maternal
deaths and 8% were accidental/incidental deaths (accident and suicide). Among the direct maternal
deaths, 42% were due to obstetric hemorrhage, 22% were due to eclampsia, 13% were due to
abortion related complications, 13% due to obstetric embolism and 10% due to pregnancy-related
sepsis.

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Delays identified from Community-based MPDSR:

First Delay:
• Sought care from traditional healer, home delivery, lack of knowledge of danger signs, did
not share problem with family, took medicine from local medical shop, did not take proper
nutrition during pregnancy, unwanted pregnancy, did not take misoprostol at home to
manage hemorrhage, no antenatal care, did not take medical advice

Second Delay:
• Delay in arranging money, delay in reaching facility due to public transport, delay in getting
referred from medical shop

Third Delay:
• No proper primary management at HP, delay in receiving care in hospital, delay in admitting
the patient at hospital, long time waiting at hospital before taking care, substandard care
received at hospital, no proper communication between facilities during referral

Action plans developed by District MPDSR Committees:


 Awareness raising:
• Mobilize local leaders to ensure institutional delivery, disseminate information on danger
signs during pregnancy among mother’s group and pregnant women through FCHVs,
community drama for awareness regarding institutional delivery, focus on Family Planning
during ANC and PNC, awareness program on unsafe abortion in VDC level, awareness on
birth preparedness packages and waiting homes, awareness program for adolescent on
harmful effects of early marriage and pregnancy

 Coordination:
• Advocate on need of road construction with local development offices for raising
accessibility to health services, advocate for Calcium tablets distribution to pregnant women,
advocate for safe roads and bridges specially during rainy season, arrangement of stretchers
for local transportation

 Quality of service:
• Referral system strengthening by co-
ordination with hospital and
Ambulance service providers,
provision of hotline number to
facilitate referral, provision of
ambulance driver's number of all
available ambulances at all health
facilities, ensure antenatal services in
all primary health care outreach
clinics, monitoring for proper
counseling as per protocol to mothers
attending ANC clinic, proper recording
of all cases in health facilities, ensure Figure 3.5.5 Cause of death

98 DoHS, Annual Report 2073/74 (2016/2017)


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presence of health workers during service hours at health facilities for antenatal check-up,
orient health workers and FCHVs on referral mechanism with communication between
health facilities.

Hospital-based MPDSR:

The hospitals implementing MPDSR started entering the maternal death review form and perinatal
death review forms in the web-based system. The received data related to the maternal deaths
received so far was analysed and presented below. However, there are gaps in reporting from the
hospitals.

Action plans developed at hospitals:


 Revision of history taking forms, revision of ANC cards to include information on danger
signs during antenatal and postnatal period, ensure continuous availability of emergency
equipment at the ER, ensure availability of Hepatitis E test kit, functional ABG machine,
establish blood cross matching facility, change in protocols for high risk pregnancy
preparation for LSCS

Lessons learned from MPDSR:


 Increase in case notification with
identification of hidden cases
 Increased responsibility and
accountability on maternal death at
community level
 Need of multi-sectoral approach
required to implement actions

Figure 3.5.6Cause of direct maternal deaths

Challenges to MPDSR Implementation:


 Under reporting of suspected maternal deaths
 Blame culture at some places that inhibits health professionals and others from participating
fully in the MPDSR process
 Incomplete or inadequate legal frameworks
 Inadequate staff numbers, resources and budget
 Cultural norms and practices that inhibit the operation of MDSR
 Problems of geography and infrastructure that inhibit the timely operation of MDSR.
 Review and reporting of perinatal deaths in hospitals
 Implementation of action plans developed by the MPDSR committees
 Cause of death assignment process
 Delay/Incomplete notification, screening, VA, review, response &reporting in web-based
MPDSR system

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Figure 3.5.2: Hospital and community-level MPDSR processes

Maternal Death Surveillance and Response [MDSR]

Communities Health Facilities

1. FCHVs identify and notify deaths of WRA


(12-55yrs) to health facility 1. Identification and notification of suspected
[Notification Form within 24 hours] maternal death to MDR Committee

2. Health facility screens pregnancy related deaths


[Screening Form]
2. Attending team screens the death

3. Health facility notifies pregnancy related death 3. Attending team completes MDR Form and
to DHO/DPHO notifies FHD and DPHO
[Phone call/Form] [MDR Form within 24 hours]

4. District verbal autopsy (VA) team completes 4. Medical team reviews MDR form and assigns
verbal autopsy with health facility cause of death
[Verbal autopsy form] [Cause assignment]

5. Medical team within district MPDSR committee 5. Medical team within MPDR committee prepares
reviews VA and assigns cause of death summary report for hospital MPDR committee
[Cause assignment] [SummaryReport]

6. District VA team prepares summary report for 6. Hospital MPDR committee reviews the death and
district MPDSR committee uploads the data
[Summary report] [Hospital MPDR Committee Review within 72 hours]

7. District MPDSR committee reviews death 7. Hospital MPDR committee identifies and
[District MPDSRctte review] prioritizes the response activities
[MDR Form]

8. District MPDSR committee identifies and 8. Hospital MPDR committee prepares action plan
prioritizes response activities and acts
[Prioritization Form] [Hospital: Action plan]

9. District MPDSR committee prepares action plan


and acts Note: [Examples of possibilities]:
[District: Action plan - Action] Both VA and MDR: If a woman of Dhading district dies in
a hospital in Dhading district.
VA only: If a woman of Lamjung district dies in a
10. Health Facility MPDSR committee prepares community in Dhading district.
action plan and acts If a maternal death occurs at a PHCC or health post the
[HF: Action plan - Action] Hospital MPDR team does the review.

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Figure 3.5.3: Hospital MPDSR Process

Perinatal death surveillance and response [PDSR]

Hospitals

1. Identification and notification of perinatal death to


MDR committee
[Perinatal death notification]

2. Perinatal death review committee screens death


[Perinatal death screening]

3. Attending team completes PDR Form


[PDR Form within 72 hours]

4. Doctors review PDR form and assign cause of death


[Cause assignment]

5. PDR team prepares summary report for hospital


MPDR committee
[Summary report]

Hospital MPDR Committee reviews the death District MPDSR Committee reviews the death
[Hospital MPDRctte meeting, once a month] [District MPDSR committee meeting]

Hospital MPDR Committee identifies and prioritizes District MPDSR committee identifies and prioritizes
response activities response activities
[Prioritization of response activities] [Prioritization of response activities]

Hospital MPDR committee prepares action plan and District MPDSR committee prepares action plan and
acts acts
[Hospital: Action plan and actions] [District: Action plan and actions]

3.5.1 Major reproductive health studies carried out in FY2073/74


3.5.1.1 The Rapid Assessment of Aama and 4ANC Program round 10
AamaSurakshyaProgrammeme is a national priority one programmeme implemented by the
Department of Health Services, Family Health Division. AamaProgrammeme aims to reduce financial
barriers that prevent women from accessing quality delivery care services. The primary objective of
this X round rapid assessment is to assess compliance of Aamaprogrammeme according to
programmeme implementation guideline 2065 third edition 2073.

A cross-sectional descriptive study design using both quantitative and qualitative approaches was
applied to get valid and reliable information from both the services providers and service users.
Eleven districts were purposively selected for this RA based on the guidance provided by FHD. A total
of 69 health facilities (12 government hospitals, 15 PHCCs and 42 HPs) were sampled for this RA
from the list of all public and private facilitiesimplementing AamaProgrammeme. In-depth interviews
were carried out among 1561 recently delivered women. In addition, 72 exit client interviews were
carried out to understand women’s perception on the receipt of delivery service received.
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Qualitative information was obtained from in-depth interviews conducted with 219 key informant
interviews which included AamaSurakshya Programme focal person, service provider, account
officer, and health facility management committee members. The key findings of this RA are:
Use of delivery care
At the national level institutional delivery has increased from 14% in 2005/06 to 55% in 2015/16 and
during the same period, the home delivery has been declined from 20% to 4%.

Management of Aama Programme


Budget for AamaSurakshya programme was adequate in the sampled districts, however issues of
delay in receiving budget was reported by PHCC and HP level mainly due to delay in receiving
authorization from center. Women were still provided with transport incentive using health facility
reimbursement made under Aamaprogrammeme deposited in the health facility management
committee account. Almost one-third of the health facilities did not send the AamaSurakshya
Programme financial report to D(P)HO on time as a result some delay in disbursement of
programme budget was reported and a few clients had to come to facility again to collect the
incentive and some did not get the incentive. The use of Aama unit cost is not different to the
conditions stipulated in the guideline.

Receipt of transportation incentive


Women giving birth in hospital (45%) were less likely to receive 4ANC incentive than women giving
birth in PHCC (57%) or HP (58%). But women giving birth in hospital (89%) were more likely to get
transportation incentive on the day of discharge than those who give birth in PHCC (65%) and HP
(64%). About 87% women giving birth at selected health facilities received deliveryservice free of
cost. This percentage was highest in Jajarkot (100%) and lowest in Pyuthan (41%). Women giving
birth in HP were most likely to receive the delivery care free of cost (95%) and women giving birth in
PHCC were least likely to receive free delivery care (75%).
Cross-verification
Overall, in an average less than 0.5% mismatch was observed between facility record and women
interview for normal delivery, 6% for complicated delivery and 4% for CSdelivery, however the
mismatch varies across districts.

Major Recommendations
DoHS/FHD to ensure availability of Aama guideline in implementing facility, timely flow of
funds to all spending units, and send letter to D(P)HO and health facilities requesting them
to use the facility management committees fund in case of delay in receiving budget. Clear
instruction on timely reporting of financial progress should be made from FHD to D(P)HO
and D(P)HO to the health facilities. All health facilities should send the Aamaprogrammeme
progress every month and also update the progress in Transaction Accounting and Budget
Control System (TABUCS). Ensure the compliance ofAama guideline in terms of providing
incentive in day of discharge, provided to women, displaying the name of Aama
beneficiaries and use of unit cost in improving the overall quality of the services.
3.5.1.2 Assessment of the Integration of Family Planning and Expanded Program of Immunization
(EPI)

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Reproductive Health guideline suggests to keep at least two-year interval between births as a means
to reduce the risk of adverse maternal and child health outcomes. In order for mothers to space
births at least two-year apart, they need to practice some form of birth control measure. The Family
Health Division, Ministry of Health (MoH), Government of Nepalrecommendations underscores the
importance of strengthening the provision of family planning and counselling for healthy timing and
spacing of births, particularly for mothers in the first year after child birth. The available evidence in
Nepal, however, indicates that 21% of births occur within the two-year period and 50% within less
than 36 months (NDHS, 2011)). Only 8.5% of women who had a live birth in the past 5 years were
found being counselled on family planning during postpartum check-up. Therefore, postpartum
family planning may be the biggest missed opportunity in Nepal.

As Immunization programme has the highest coverage rate in Nepal, the GoN/FHD initiated a pilot
to integrate FP into routine EPI in Kalikot in 2070/71. Because of the positive result of the FP/EPI
integration pilot, FHD expanded the programme to Bajhang in FY 2071/72 and further to Doti,
Parbat, Bajhang and Rukum in FY 2072/73.

This quick assessment of the integrated model selected one PHCC and one HP from Doti, Parbat,
Bajhang and Rukum districts. The rapid evaluation used a mix of quantitative and qualitative
methods including semi-structured questionnaires and discussion guidelines.

Findings

1. In the four districts studied the integrated model successfully increased access to family
planning.

 In the 8 health facilities of the four districts studied the number of FP clients has increased
after the intervention compared to the period before intervention.

 With the introduction of FP/EPI programme, increasing number of women is utilizing FP


services from EPI outreach and EPI static clinics than static regular clinics. The share of FP
clients of regular Health Facility static clinics is increasingly declining since the FP/EPI
intervention.

2. Method mix is more balanced after the introduction of integrated model.

 The uptake of pills, implant and IUD has also improved and thus method mix has balanced
after the integration.

3. The integrated model has allowed an opportunity for marginalized population group to
benefit from FP.

 Of the total clients who received family planning methods, a little over a quarter (27%) are
Dalits and this proportion of Dalit FP users is more than the actual proportion of Dalits
population of 22% in four districts combined.

 The total number of EPI users increased in 2073 during programme intervention period (six
months data) compared to the six months before the intervention with some fluctuations of
service in the last two months of comparison.

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4. All study sites were found adhering to the FP & EPI integration intervention activities.

 They had initial training, FP registers updated at least partially, and FP/EPI clinics
implemented the model as per MOH, FHD guidelines

5. Clients’ perspectives

 Mothers who attended FP/EPI integrated clinics were overall happy with the model.
 They see a lot of benefits in it as they say they can get two services from one place.
 Women who did not go for FP service to FP/MCH static clinic now are easily accessing FP
services because of close vicinity of the service delivery point (referring to EPI ORCs or EPI
static clinics)
 Most mothers accept FP service during their 2nd visit to the EPI/ORC
 Those who do not accept FP at first visit is mainly because of no resumption of
menstruation.
 Mothers who do not accept FP at 2nd visit mainly do so because of absentee husbands.
 A fair number of mothers cannot accept FP at second visit because they cannot decide on
their own after getting FP counselling; they need to ask their husbands.

3.5.3 Major issues


Research in reproductive health is crucial for the design, planning, monitoring and evaluation of
interventions. However, there is often inadequate coordination by non-government partners during
different stages of their studies (design, implementation, analysis and dissemination) against the
stipulations of the Reproductive Health Research Strategy (2000), which leads to gaps and
redundancy. Even though several reproductive health-related studies were approved by NHRC every
year, only few of them were shared with the Family Health Division. As a result, findings and
recommendations are not being incorporated in reproductive health programme planning and
implementation. DoHS should plan to enhance the monitoring and research capacity of FHD
personnel to enable it to monitor and appraise reproductive health research and studies conducted
in Nepal.

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3.6 Adolescent Sexual and Reproductive Health


1. Background
National Adolescent Sexual and Reproductive Health is one of the priority program of Family Health
Division (FHD), Department of Health Services. Nepal is one of the country in South Asia developed
and endorsed the first National Adolescent Health and Development (NAHD) Strategy in 2000. To
address the needs of emerging issues of adolescents in the changing context, the NAHD strategy is
revised in 2017 and is under process of endorsement.

The goal of National ASRH programme


Goal: To promote the sexual and reproductive health of adolescents.

Objectives:
 To increase the availability of and access to quality information on adolescent health and
development, and provide opportunities to build the knowledge and skills of adolescents,
service providers and educators.
 To increase the accessibility and use of adolescent health and counselling services.
 To create safe and supportive environments for adolescents to improve their legal, social
and economic status.
 To create awareness on adolescence issues through BCC campaigns and at national,
provincial and community levels through FCHVs and mother groups

Targets:
To make all health facilities as adolescent friendly as per the envision of National Health policy
(2014) and NHSS (2016-2021)
To ensure universal access to ASRH services, the Nepal Health Sector Strategy Implementation Plan
(2016-2021) aims to:
 scale up Adolescent Friendly Service (AFS) to all health facilities;
 behavioral skill focused ASRH training to 5,000 Health Service Providers and
 more than 100 health facilities to be certified with quality AFS by 2021
The programme aims to reduce the adolescent fertility rate (AFR) by improving access to family
planning services and information.

Prioritizing the integration and effective program management, FHD established Family Welfare
Section in four thematic areas: Adolescent Sexual and Reproductive Health (ASRH); Family Planning
(FP); Female Community Health Volunteers (FCHVs); and PHC-Out reach Clinic since BS FY 2073/74
(FY 2016/17).

To support district health managers to operationalize the strategy, an implementation guideline on


Adolescent Sexual and Reproductive Health (ASRH) was developed in 2007 and piloted in 26 public
health facilities of 5 districts (Bardiya, Surkhet, Dailekh, Jumla, Baitadi) with the support from GIZ.

DoHS, Annual Report 2073/74 (2016/2017) 105


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National Health Sector Program (NHSP)-IP-II (2010 to 2015) set a target of expanding 1000 public
health facilities for provision of Adolescent Friendly Service (AFS) and revised the National ASRH
Programme Implementation Guideline accordingly and is implementing from 2011.

As per recommendations of the ASRH barrier study entitled “Assessing supply side constraints
affecting the quality of adolescent friendly services (AFS) and the barriers for service utilization”
carried out in 2014 under leadership of FHD technically and financially supported by UNFPA and
UNICEF, two major interventions were implemented in BS.2072 (2015) as part of system
strengthening (capacity building, certification for quality delivery of AFS in friendly manner) and
awareness raising interventions among adolescents and key stakeholders. Over the period of time
ASRH training package was revised as per national standards; establish and strengthen ASRH clinical
training sites within RH comprehensive training sites and additional 2 training sites in Bharatpur
Hospital and Koshi Zonal Hospital were established. Different training materials, quality
improvement tools were developed and printed which were subsequently distributed in different
districts (UNFPA supported to print 3000 ASRH training manuals, 3000 Adolescent Job aids; 1000 QI
and Certification tool, 3000 Flip Charts and 20,000 eight sets of ASRH booklets) for strengthening
health system.

2. Achievements in FY 2073-74 (FY 2016-17):


Result # 1. Scale-up of Adolescent Friendly Service:

The National ASRH program has been gradually scaled up to 70 of the 75 districts covering 1134
health facilities till the end of current fiscal year 2073/74. Different development partners such as
UNFPA, UNICEF, WHO, Save the Children, Ipas, ADRA Nepal and MSI Nepal at national and
subnational level supported to Family Health Division (FHD) for scaling up and strengthening ASRH
services in the health facilities in order to make those health facilities as adolescent friendly service
sites. The remaining five districts (Manang, Mustang, Dolpa, Rasuwa and Sindhupalchowk) will be
covered in the running FY 2074/75.

Result # 2. Strengthening Health facilities for AFS:

2.1 ASRH Clinical Training site development: ASRH clinical training sites were established at Seti
Zonal Hospital, Bheri Zonal Hospital, Western Regional Hospital, Paropakar Maternity Hospital within
RH Comprehensive Training sites, and Bharatpur Hospital in FY 2072/73 (FY 2015-16) and Koshi Zonal
Hospital in FY 2073/74 (FY 2016-17).

2.2 Competency based ASRH training to the Health service providers: Total 1415 health service
providers trained on behavioural and skill focused competency based 5 days ASRH training from
2015 to Dec 2017 (BS. FY 2071/72 to 2073/74) from AFS sites to be implemented for making
Adolescent Friendly Services under leadership of National Health Training centre. Among 1415
trained HSPs, 74 trainers received Training of Trainers (TOT) and developed pool of trainers on ASRH
first time in Nepal at national and regional level. Out of total trained on ASRH, 1073 (76%) HSPs were
trained with the support of UNFPA through Redbook (NHTC) and ADRA Nepal and rest of them
trained from NHTC (Red book- UNICEF), Save the Children, and MSI.

106 DoHS, Annual Report 2073/74 (2016/2017)


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Figure 1

One of the participants of the ASRH training reflected his opinion that "I will make a separate
room for Adolescent in my hospital. I am also planning to attend school health programs to tell
adolescents that this facility is adolescent friendly. Lastly, I will make sure that confidentiality
and privacy guaranteed and secured for whatever problems they consult with"

2.3 AFS sites certification through joint monitoring: Upon request of DHO with pre-certification
pre certification of
minimum 80% of the overall WHOs WHO 9 standards’ score, a joint monitoring team, comprises of
FHD/UNFPA/DHO/ADRA/SAVE/MSI, has visited health facilities for certification of AFS using “QI and
Certification Tool for AFS 2015”. Joint monitoring team followed 4
4-step
steps processes of certification of
AFS as follows:
1. Facility Observation
2. Interview with health workers (at least 2)
3. Interview with HFOMC members (at least 2)
4. Client Exit interview with Adolescent Girls and Boys (at least 2)
The main objective of Certification is to: Certify with assurance of availability of "Quality and
Friendly" ASRH services in health facility as per WHOs 9 standards with minimum overall 80% score.

The monitoring process of HF takes about 4 to 5 hours in the HF to accomplish above mentioned 4
steps with debriefing to the same team announcing the result of certification if HF is being able to
achieve minimum 80% overall score. The criteria set for being adolescent
adolescent-friendly
friendly services (AFS)
include the availab
availability
ility of trained staff, proper information delivered to adolescent on sexual and
reproductive health, delivery of ASRH services in a confidential way, display of the AFS logo in the
health facilities and including two adolescents as an invitee in the Healt
Health
h Facility Operation and
Management Committees (HFOMC) meetings.

The summary table of the AFS certified sites shows two times increase in FY 2073/74 (FY 2016-17)
2016
(total 28 HFs in 13 districts) compared to total 14 HFs in 6 districts in FY 2072/73 (FY 2015-16).
2015 16). Total
DoHS, Annual Report 2073/74
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6/2017) 107
Family Health
51 HFs certified in between Dec 2015 to Dec 2017 in 20 districts (45 supported by UNFPA; 1 by
Government; 2 by MSI and 3 by SAVE the Children). The certified sites received “appreciation letter
of certification” for 5 years of period effective from August 2017 with signature of FHD Director and
Family Welfare Section Chief, FHD.

Table 1: Summary of certified Health facilities from Dec 2015 to Dec 2017 (BS. FY 2072/73 to FY
2073/74)
In December 2015 9 HFs- certified in 4 districts
(9 UNFPA supported sites)
January to July 2016 5 HFs- certified in 2 districts
(4 UNFPA supported sites including 1 HF by SCI)
Total in FY 2015-16 (BS FY 2072/73) 14
16 July to Dec 2016 15 HFs- certified in 6 districts
(15 UNFPA supported sites)
Jan to July 2017 13 HFs- certified in 7 districts
(9 UNFPA supported sites including 2 HF by MSI & 2
HF by SCI)
Total in FY 2016-17 (BS. FY 2073/74) 28
16 July to Dec 2017 9 HFs- certified in 4 districts
(8 UNFPA supported sites including 1 HF by GON)
Total in FY 2017-18 (BS. FY 2074/75) 9
Grand total from Dec 2015- Dec 2017 51 HFs- certified in 20 districts

The detail list of certified health facilities is in Annexe I table 1 and average score obtained in each 9
sections by 51 HF is in Figure 1 of Annexe I.

Result # 3: Demand generation interventions on ASRH Program:

Different awareness raising activities on ASRH was carried out in this FY in support of different
partners (UNFPA, UNICEF, GIZ, and USAID-Health for Life, Save the Children, UMN, ADRA Nepal,
FPAN Nepal and MSI Nepal) under leadership of National Health Education Information and
Communication Center (NHEICC) and FHD among the adolescents at community level. Different
approaches like My First Baby (MFB), Partner Defined Quality for Youth (PDQY), school health
program etc were applied to raise the awareness among adolescents and other communities. These
very many activities helped adolescents to understand the problems during adolescents, their
mitigation approach and services available at HF addressing their needs.

3.1 Establishment of AFICs in schools: A total of 212 AFICs established in UNFPA supported districts
in order to link between AFS in health facilities and AFICs in schools. Similarly, Save the Children
supported to establish 85 AFICs in its working districts. The AFICs is equipped with ASRH related
IEC/BCC materials such as 8 sets of ASRH booklet, Adolescent health and development flip chart;
comic book on ASRH, poster on finger pointing to AFS, brochure on delay marriage, danger signs
during pregnancy with orientation to the teachers, parents, school health management, and health
service providers from AFS to utilize the IEC materials by both teachers and adolescents girls and
boys as well as access to AFS services by adolescents when and as needed. A total of 2,822 teachers,
parents, students and Health Service Providers were sensitized on ASRH, AFIC, and CSE, contributing
to an open and enabling environment in the community and promote the utilization of AFS during
this fiscal year.
108 DoHS, Annual Report 2073/74 (2016/2017)
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3.2 Menstrual Hygiene Management (MHM): Menstrual Hygiene management is implemented in 14


earthquake affected districts and 3 other districts by different partners. The training package was
developed jojointly
intly by Ministry of Health and Ministry of Education and designed to build capacity of
teachers of the AFIC in schools and health workers of the Adolescent Friendly service sites. During
this reporting year total 73 participants (8 participants from DEO, 6 from DHO, 29 nurses from HF
and 30 school teachers) of schools and health facilities trained on MHM in Sindhuli district and 42
participants from Kapilbastu, Pyuthan and Saptari trained on MHM through SC SC. The school teachers
who are trained on MHM are regularly
regularly conducting menstrual management session in schools. The
schools with AFIC are also coordinating with the trained health service providers to conduct session
on MHM for students.

3.3 Comprehensive Sexuality education (CSE) in schools


schools: Total 87 trainers of 29 Educational Training
Centres trained on CSE, who will be a trainer for teachers training at the district level. Advocated
with and support the MOE in integrating CSE in the education curricula; reviewing the curriculum
and national policies to assess the inclusion of CSE and supporting to fill the gaps in collaboration
with NCED, CDC and the Ministry of Education are ongoing interventions. As a result of our
recommendations, the School Sector Development Plan 2017 2017-2022
2022 has included the importance
import of
CSE in their strategy, where they have included the provision of teachers’ training and curriculum
revision. Moreover, UNFPA has been providing technical support to the governmental entities in
integrating CSE components into the curriculum. Furthe
Furthermore,
rmore, a high-level
high level technical working group
has been created, with the presence of national health and education partners including FHD/MOH,
to discuss the inclusion of CSE in the national strategies and plans at all levels.

3.4 Rupantaran for out of schools


schools and in school’s girls
girls:: Total 5612 out of school girls enrolled and
trained on “Rupantaran from 2016-2017
2016 2017 to empower adolescent girls and capacitate them to be
Change Agent in their communities. Total 49 Community Learning centers’ facilitators under Non- Non
Formal Education Center (NFEC), Department of Education have been trained on CSE/Social and
Financial Skill Package (SFSP or Rupantaran) to deliver CSE components to out of school
children/adolescents.

3.5 Advocacy workshops at national with parliamentari


parliamentarians
ans and journalists:
journalists: More than 200
parliamentarian members, policy level key stakeholders and Journalists sensitized on importance of

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CSE in schools, AFS in the health facilities with ASRH issues including harmful practices through
national and regional level
level advocacy workshop from 2016 to 2017.

At the regional level, advocacy workshops conducted for Journalists from 10 UNFPA supported
districts and sensitized total 39 journalists on ASRH, AFS and CSE issues. As a result; Journalists are
conducting various media related interventions focusing on ASRH and CSE.

More than 200 Community key stakeholders; religious leaders; parents and teachers sensitized on
ASRH/FP issues as well as social norms through Intergenerational dialogue in FY 2073-74
2073 74 (2016-
(2016
2017).

Result
lt # 4 ASRH Service Utilization:
4.1 Proportion of adolescent new acceptors among total new acceptors of spacing modern
contraceptives by provinces (2073/74)

The proportion of pills users is observed highest in Province # 2 followed by province number 6,
whereas Depo users was highest in Province # 6 followed by province 1 and 3. Overall users for all
temporary commodities observed low in Province number 7 (Figure 2).
Figure 2
2:

Source: HMIS raw data

4.2 Proportion of adolescent Antenatal Check


Check-ups
ups (ANC) among total antenatal check-up
check up visits by
provinces (2073/74):

In 2073/74, the proportion of adolescents getting antenatal check check-ups


ups among total ANC check-up
check
visits, both at any time and as per the protocol, is highest in province number 6 and lowest observed
in province number 3.

110 DoHS, Annual Report 2073/74


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Table 4:: Proportion of adolescent ANC among total ANC visits by provinces (2073/74)
National and First ANC Visit
First ANC as per protocol Four ANC as per protocol
Province (any time)
National 19.2 18.9 15.4
Province 1 21.1 21.0 18.9
Province 2 22.1 20.2 16.3
Province 3 13.8 15.2 10.2
Province 4 19.3 19.6 17.7
Province 5 16.6 16.7 14.9
Province 6 32.8 32.8 27.9
Province 7 17.7 17.4 15.0
Source: HMIS

4.3 Safe abortions:: The proportion having medical abortions was highest in the province number 3
and lowest in province number 7 whereas the proportion of surgical abortion was highest in
province number 5 and lowest in province number 4. The proportion of adolescent abortion at
National level by both medical and surgical procedure w
was
as 13.8% of the total abortion done in this
reporting Fiscal Year.

Table 5:: Proportion of adolescent safe abortion service users among total safe abortion service
users by provinces (2073/74)
(
National and Provincial total abortion among
Medical abortion Surgical abortion
level adolescent
National 11.6%( 6196) 16.7% (7138) 13.8% (13334)
Province 1 9.6% (1037
1037) 10.3% (703) 9.9% (1740)
Province 2 12.4% (547
547 ) 20.8% (570) 15.6% (117)
Province 3 18.5% (2486)
2486) 16.9% (2025) 17.7% (4511)
Province 4 8.0% (643)
643) 8.5% (431) 8.2% (1074)
Province 5 10.1% (841) 29.7% (2751) 20.4% (3592)
Province 6 13.3% (279) 11.3% (163) 12.5% (442)
Province 7 5.5% (279) 9.1% (495) 7.2% (858)
Source: HMIS
Number of Abortion cases (medical and surgical among Adolescents) at province level.

Source: HMIS 2073


2073-74
74 SM raw data
DoHS, Annual Report 2073/74
207 (2016
6/2017) 111
Family Health
The figure above showed that the number of cases of abortion by both Medical and surgical
procedure is highest in Province Number 3 followed by Province Number 5 which is lowest in
province
ce Number 6. There might be different reasons behind this.

4.. Lessons learnt and way forward:

5.. Issues and recommendations — Adolescent Sexual and Reproductive Health


Issues and problems raised at recent regional and national review meetings and during joint
monitoring of the certification process are summarized in Table 3.6.6.
Issues Recommendations Responsibility
High prevalence of early Intensify community awareness activities and NHEICC, FHD, MoH,
marriage and teenage effectively implement the law line ministries and
pregnancy partners
Low CPR and high unmet Run innovative activities to increase access to FHD, DoHS, MoH
need for contraception family planning services and information in hard
among vulnerable to reach areas and among vulnerable
populations including populations including adolescents
adolescents
Quality assurance of ASRH Certify health facilities using “the quality FHD and ASRH
Programme improvement and certification tool for AFS partners
2015” to promote the delivery of adolescent
friendly quality services. Total 51 certified
health facilities/ AFS sites in 20 districts from
Dec 2015-
2015 Dec 2017.
Inadequate trained human Strengthen ASRH clinical training sites and NHTC and ASRH
resources on ASRH in health develop the capacity of service providers with Partners
facilities “behavioural and skill focused competency

112 DoHS, Annual Report 2073/74


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Issues Recommendations Responsibility
based 5 days ASRH training” at all health
facilities and specially AFS sites
Inadequate monitoring Increase the number of joint monitoring visits FHD, MD, DHOs and
to AFS sites at different levels ASRH partners
Inadequate resources Allocate sufficient resources at central, district FHD, DHOs
allocated to the programme and local levels
Inadequate links with other Advocate for the functional integration of ASRH FHD and ASRH
programmes (family issues and services in other thematic partners
planning, safe motherhood, areas/programmes
HIV)
Inadequate IEC/BCC Ensure the supply of ASRH related IEC/BCC FHD, NHEICC, DHOs
materials materials to health facilities and ASRH partners
Lack of disaggregated ASRH Revise the monthly/annual reporting format FHD, NHTC, and
data (by age/sex) and (Annex 5: ASRH Programme Implementation ASRH partners
integration in HMIS Guidelines, 2011) and advocate to incorporate
in HMIS

6. ASRH Programme: proposed plan for FY 2074/75 (2017-18)

Proposed Programmes Agency


1 Continue supporting health facilities for strengthening AFS sites GoN, FHD
2 ASRH review
3 Health facilities certification using the QI and certification tool for AFS through
Joint monitoring
4 Print and distribute the ASRH guidelines and tools
5 Continue supporting health facilities for strengthening AFS sites UNFPA,
DFID, ADRA
6 Behavioural and skill focused competency based 5 days ASRH training to the
and Health service providers working at AFS sites/health facilities
7 Health facilities certification using the QI and certification tool for AFS through
Joint monitoring
8 Strengthen ASRH clinical training sites with provision of necessary support
(ASRH training package plus ASRH related IEC/BCC materials and training of
trainers on 5 days ASRH training for medical officers)
9 Joint monitoring and follow up of trained health service providers and trainers
10 ASRH review meeting at province level
11 Continue support to establish Adolescent friendly information corners in
schools nearby AFS sites with ensuring ASRH related IEC and BCC materials

DoHS, Annual Report 2073/74 (2016/2017) 113


Family Health

Proposed Programmes Agency


12 Support for school health programme including comprehensive sexuality
education
13 Continue support for menstrual hygiene management
14 Continue support social and financial skill package (SFSP- Rupantaran), to reach
out of school adolescents through kishwori circles under leadership of Ministry
of Women and Children
15 Support for ASRH mobile app jointly by UNFPA, GIZ and USAID-Health for Life
under leadership of NHEICC
16 Continue supporting health facilities for strengthening AFS sites UNICEF
17 Behavioural and skill focused competency based 5 days ASRH training to the
and Health service providers working at AFS sites/health facilities
18 Continue support Roll out social and financial skill package (SFSP-Rupantaran)
to reach out-of-school adolescents through kishwori circles under leaderships
of Ministry of Women, Children and Social Welfare
19 Continue supporting health facilities to strengthen adolescent friendly service Save The
centres in the Save the Children Initiative supported districts Children
20 Behavioural and skill focused competency based 5 days ASRH training to the
and Health service providers working at AFS sites/health facilities
21 Health facilities certification using the QI and certification tool for AFS through
Joint monitoring in Saptari, Kapilvastu and Pyuthan

Table 1: List of Certified AFS sites with pre- certification and certification score obtained
disaggregated by Provincial level (From Dec 2015 to Dec 2017)
Certificati Date of
S. N. District AFS sites Pre-score
on Score Certification
Province 1
1 Sunsari Sitapur HP 92.00% 91.00% 16-Apr
2 Sunsari Ithari PHCC 91.30% 93.00% 16-Apr
3 Udaypur Jogidah HP 98.70% 98.80% 17-Nov
4 Udaypur Sundurpur HP 94.70% 94.70% 17-Nov
5 Udaypur Hardeni HP 94.70% 94.70% 17-Nov
Province 2
6 Mahottari Bardibas Hospital 90.70% 93.30% 16-Nov
7 Mahottari Gaushala PHCC 89.40% 94.00% 16-Nov
8 Mahottari Bharatpur HP 93.60% 81.00% 17-Nov
9 Rautahat Kanakpur HP 93.00% 93.00% 16-Nov
10 Rautahat Patura PHCC 85.60% 91.50% 16-Nov
11 Rautahat Sarmujwa HP 90.00% 96.80% 16-Nov

114 DoHS, Annual Report 2073/74 (2016/2017)


Family Health
Certificati Date of
S. N. District AFS sites Pre-score
on Score Certification
12 Sarlahi Bhaktipur HP 96.20% 98.40% 16-Nov
13 Sarlahi Achalgad PHCC 94.40% 96.90% 16-Nov
14 Sarlahi Pipariya HP 95.50% 98.40% 16-Nov
15 Saptari Hanumanagar HP 90.90% 96.80% 17-Nov
16 Saptari Bordhebarsain HP 91.50% 93.10% 17-Nov
17 Saptari Patthagada HP 91.50% 93.40% 17-Nov
Province 3
18 Kathmandu SPN Clinic, Putalisadak 100.00% 92.60% Aug-17
19 Sindhuli Belghari PHCC 87.20% 87.00% 15-Dec
20 Sindhuli Beseshwor HP 92.30% 96.00% 15-Dec
21 Sindhuli Shilapati HP 90.70% 97.00% 15-Dec
Province 4
22 Kaski SPN Clinic, Pokhara 95.00% 87.80% Aug-17
Province 5
23 Arghakanchi Thada PHC 96.00% 92.20% 17-Jan
24 Arghakanchi Hanspur HP 89.10% 92.20% 17-Jan
25 Dang Sashaniya HP 95.00% 94.70% 17-Jul
26 Dang Satbariya HP 95.00% 91.00% 17-Jul
27 Kapilvastu Gauri HP 83.00% 92.00% 16-Aug
28 Kapilvastu Tilaurakot HP 90.00% 98.00% 16-Aug
29 Kapilvastu Shivpur HP 98.00% 98.00% 16-Aug
30 Pyuthan Puranthanti HP 92.00% 95.00% 15-Dec
31 Pyuthan Okharkot HP 92.00% 95.00% 15-Dec
32 Pyuthan Bhingri PHC 92.80% 95.60% 17-Jul
33 Pyuthan Gothiwang HP 93.40% 89.70% 17-Jul
34 Rolpa Khumel HP 92.60% 96.20% 17-Nov
35 Rolpa Libang HP 94.70% 94.70% Dec-17
36 Rukum Sylakapha HP 94.70% 96.80% 16-Sep
37 Rukum Bafikot HP 96.00% 96.20% 16-Sep
38 Rukum Smiruti HP 96.00% 96.20% 16-Sep
Province 7
39 Achham Duni HP 91.80% 96.00% 15-Dec
40 Achham Kalika HP 85.10% 83.00% 15-Dec
41 Baitadi Bhunali HP 88.00% 97.00% 16-Dec
42 Baitadi Siddheswor HP 86.80% 90.60% 16-Dec
43 Bajhang Bhairavsthan HP 81.30% 85.00% 15-Dec
44 Bajhang Deulekh PHC 94.00% 97.20% 15-Dec
45 Bajhang Kharitadi 91.50% 98.00% 16-Dec
DoHS, Annual Report 2073/74 (2016/2017) 115
Family Health
Certificati Date of
S. N. District AFS sites Pre-score
score
on Score
ore Certification
46 Bajhang Chhana HP 83.70% 90.00% 16-Dec
Dec
47 Bajura Kaileshmandu HP 86.00% 98.30% 17-May
May
48 Bajura Jaguda HP 90.00% 95.00% 17-May
May
49 Dadeldhura Nawdurga 80.00% 93.10% 17-May
May
50 Dadeldhura Bagarkot HP 87.00% 93.10% 17-May
May
51 Dadeldhura Aalital HP 91.00% 87.80% 17-Jun
Jun

Figure 1: The National Standard wise total Score obtained by 51 certified AFS sites of 20 districts
(joint monitoring certification score)

Figure 1 illustrates that out of total nine national standards for joint monitoring and certification
process of ASRH services provided from AFS sites, average score of two indicators (number 7 & 9)
were found low in comparison to other indicators. So, major concern should be focused on life skill-
skill
based sexual and reproductive health education to adolescents and young people and improve and
sustain the quality of health services as a part of health management system strengthening.

116 DoHS, Annual Report 2073/74


207 (201
(2016/2017)
Chapter 4
Disease Control

Disease Control

4.1 Malaria
Background
Nepal’s malaria control programme began in 1954, mainly in the Tarai belt of central Nepalwith
support from the United States. In 1958, the National Malaria Eradication Programme was initiated
and in 1978 the concept reverted to a control programme. In 1998, the Roll Back Malaria (RBM)
initiative was launched for control in hard-core forests, foothills, the inner Tarai and hill river valleys,
which accounted for more than 70 percent of malaria cases in Nepal. Malaria is a greater risk in
areas with an abundance of vector mosquitoes, amongst mobile and vulnerable populations, in
relatively inaccessible areas, and during times of certain temperatures.

In Nepal, the first malaria micro-stratification was limited to district level where a district was
identified as the basic administrative unit. The population at risk of malaria was defined as the total
population of the district. The updated micro-stratification 2013 exercise (based on the number of
malaria cases, geo-ecology, vector breeding and vulnerability due to migration and population
movements), identified 54 VDCs to be high risk, 201 VDCs moderate risk and 999 VDCs low risk for
contracting malaria (Figure 4.1.1). The exercise identified 13 million people (47.9% of the
population) as living in malaria endemic VDCs, out of which around 1 million (3.62%) live in high risk
VDCs,2.66 million (9.8%) in moderate risk VDCs, and 9.38 million(34.5%) in low risk VDCs. A total of
14.13 million (52.1%) people are estimated to live in VDCs with no malaria transmission in Nepal.
The high risk areas are the foothills with river belts, forest fringe areas in the Tarai, hill river valleys
and inner Tarai areas. Low risk VDCs lie in the cultivated outer Tarai plains, mountains and mountain
valleys.The Global Fund to Fight AIDS, Tuberculosis and Malaria(GFATM) has supported the malaria
control programme since 2004.

EDCD has finished ward level micro stratification study on 2016 which was endorsement by
director general of DoHS. The results of this study were based on summation of scores of
each determinant that the ward received. The three determinants and their weight were -
disease burden with weight of 0.3, receptivity (geo-ecology) with weight of 0.5 and
vulnerability with weight of 0.2. Based on this analysis, a ward with a score of 75% or more
was categorized as high risk, a ward with a score of 60 % or more was categorized as a
moderate risk ward, a ward with a score of more than 20 % but less than 60% was
categorized as low risk, and a ward with a score of 20 % or less was categorized as no risk.
The study revealed that a total of 29,433 out of a total 31,550 wards were found to be at some level
of risk of transmission. Out of these, 54 wards in 28 VDCs of 12 districts were at found to be at high
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risk (0.17% of total risk wards), 370 wards (1.17% of total risk wards) across 127 VDCs of 27 districts
(including the 12 high risk districts) were categorized as moderate risk and 29,009 wards (91.94% of
total risk wards) were categorized as low risk wards whereas the remaining 2117 wards (6.70% of
total risk wards) came under no risk categories. Based on the latest population census, a total of
169,747 people (0.60%) live in high risk wards, similarly 1,357,723 people (4.83%) live in moderate
risk wards and 2,39,60,215 people (85.30%) live in low risk wards and 25,99,694 (9.25%) live under
no risk wards.At a Regional level approximately 85% of the High Risk Wards were found in Far
Western Development Region and Mid-Western Development Region. Among the 54 high risk
wards, 35 wards (64.81%) were in Far Western Development Region alone with the remaining 11
wards (20.37%) in Mid-Western Development Region, 5 wards (9.26%) in Central Development
Region and 3 wards (5.56%) in Western Development Region (WDR). The Eastern Development
Region did not have any high risk wards.

Due to reliability issues in the data reported through the HMIs as well as the non-availability of line
listing of all the confirmed cases several criteria was put in place. A ward where malaria information
of 2015 and 2014 was not available for review (eg. Baitadi district, Maharudra wards no.8), however,
there was an ongoing most recent transmission (i.e in 2016) or where a focal outbreak had occurred
was straight away classified as high risk because there was an ongoing transmission with API of most
recent year suggesting a focal outbreak in the ward. Wards with indigenous cases in all 3 years,
wards with indigenous case in 2 out of 3 years, and wards with imported cases with evidence of
probable introduced cases were categorized as moderate risk.A ward with a single indigenous case
in each of the three years was classified as moderate risk although it may have been a misclassified
case; yet since only 75 % – 80 % line listings were available and people seek care outside the public
health facility; it was more prudent to be over-cautious since the goal was getting to zero indigenous
case by 2020 (recently revised goal that the earlier 2022).

Figure 4.1.1:Ward Level Risk Classification Map (MS 2016)

Source: Malaria micro stratification report 2016

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Nepal’s National Malaria Strategic Plan (NMSP, 2014–2025) has shown in Box 4.1.1.

Box 4.1.1:National Malaria Strategic Plan (2014–2025)


Current National Malaria Strategic Plan (NMSP) 2014-2025 was developed based on the epidemiology of
malaria derived from 2012 micro-stratification, 2013 Mid –Term Malaria Program Review, and the updated
WHO guidelines, particularly for elimination in low endemic country. This plan has inherent Government of
Nepal’s commitment and seeks appraisal of external development partners, including the Global Fund, for
possible external funding and technical assistance. The aim of NMSP is to attain “Malaria Free Nepal by 2026”.

The strategic plan was divided into two phases: achieve Malaria Pre - Elimination by 2018 and attain Malaria
Elimination by 2026. Malaria pre-elimination targets were set to achieve and sustain zero deaths due to malaria
by 2015, reduce the incidence of indigenous malaria cases by 90%, and reduce the number of VDCs having
indigenous malaria cases by 70% of current levels by 2018. The baseline year was taken as 2012.

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

i) to strengthen strategic information for decision making towards malaria elimination


ii) to further reduce malaria transmission and eliminate the foci wherever feasible
iii) to improve quality of and access to early diagnosis and effective treatment of malaria
iv) to develop and sustain support through advocacy and communication, from the political leadership and
the communities towards malaria elimination and
v) To strengthen programmatic technical and managerial capacities towards malaria elimination.

Current Achievement
By 2016, National Malaria Program had achieved 54% reduction in indigenous malaria cases compared to 2012,
death was recorded in an imported case of malaria, and no foci have been cleared of malaria transmission.

Rationale for amending the NMSP


Nepal is primarily a low malaria endemic country with around 80% of malaria cases due to P. vivax and the
remaining burden due to P falciparum with occasional case reports of P. ovale or P. malariae mostly imported
from Africa. Vivax parasites have unique biological and epidemiological characteristics that pose challenges to
control strategies that have been principally targeted against Plasmodium falciparum.Infection with P.
vivaxtypically results in a low blood-stage parasitemia with gametocytes emerging before illness manifests,
and dormant liver stages causing relapses. As a consequence of low parasitemia, high prevalence of
asymptomatic infection and difficulty in detection of the parasites, ability to infect mosquitoes before
development of clinical symptoms, and appearance of relapse within months to years of the primary infection;
P vivax pose a great challenge to malaria elimination. Radical cure with at least 2 weeks of Primaquine is
required to clear the hypnozoites but the drug can only be given after a normal G6PD test. Besides, current
point of care rapid tests may not identify heterozygotes G6PD deficient female despite a normal rapid test and
such a case may hemolyze on exposure to Primaquine. P. vivaxtolerates a wider range of environmental
conditions and is more likely to lead to geographical expansion. Conventional control methods of minimizing
human contact with mosquito vectors through insecticide-treated mosquito nets and indoor residual spraying –
may be less effective against P. vivax. This is because, in many areas where P. vivaxpredominates, vectors bite
early in the evening, obtain blood meals outdoors and rest outdoors. In addition, vector control has no impact
on the human reservoir of latent hypnozoite stage parasites residing in the liver, which are responsible for an
appreciable proportion of morbidity.

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To recollect, National Malaria Strategic Plan has to address the following issues:

1. P. vivax is the overwhelmingly predominant parasite species in Nepal and strategy should reflect the
importance of P vivax in elimination programme and it should target P vivax with novel and innovative
interventions.
2. Traditional conventional interventions are neither effective for P vivax control nor elimination.
3. Novel interventions based on strong evidence are required to clear hypnozoites in the liver and prevent
relapse, point of care tests to detect asymptomatic and sub – microscopic infections, and new community
based testing and treatment methods to increase access to quality assured and quality controlled
diagnosis and prompt effective treatment. Ensure G6PD point of care test and roll out radical cure
treatment for P vivax infection.
4. Without interrupting P vivax (reduction will not be sufficient) transmission, achieving malaria elimination
is unlikely.

Process: National Strategy Updates


With this in mind, EDCD convened in January 2017 a multi-stakeholders meeting to draw a framework for
updating the NMSP (2014 – 2025). A core team was formed to review the existing strategic plan and suggest an
action framework for guiding the country towards malaria elimination. The framework was shared in the multi-
stakeholders meeting and each identified objectives were discussed in groups at length and a draft
presentation of the suggestions were collected. The suggestions of the meeting were aligned in the draft action
elimination framework and the final draft was shared with all the stakeholders. The feedback was discussed in
the core team meeting and relevant alignment was done and the final Malaria Elimination Action Framework
was shared in a meeting with EDCD and multi- stakeholders. The suggestions of the meeting were addressed in
the final Malaria Elimination Action Framework and the framework was presented to the Technical Working
Group/ Malaria for endorsement.

Elimination Framework: Objectives & Activities


The updated National Malaria Strategic Plan identifies the following key activities to implement in order to
achieve the vision of “malaria free Nepal” by 2025.

1. Strengthen strategic information for decision making and implement surveillance as a


core intervention towards malaria elimination

Malaria Burden
Progression towards malaria-free status is a continuous process, and not a set of independent stages.
As intervention coverage is increased and malaria incidence is reduced, the heterogeneity in
incidence and transmission rates is likely to further increase whereby malaria infection and disease
are more likely to be concentrated in a small proportion of individuals, such as small groups of
households, or hotspots that are at a substantially increased risk of malaria transmission. Hotspots
maintain transmission and targeting hotspots is a highly effective and efficient way to reduce malaria
transmission.
A key approach to ensure optimal responsewill be a structured malaria programme based on risk stratification
by malaria burden and an analysis of past malaria incidence, transmission risk determinants, the environment
and an analysis of access and use of health care services. The burden of malaria and the geographical area at
risk of malaria will be defined by evidence based on the micro stratification study, 2016. This will be validated

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by Malariometric Survey, 2017 and Health Facility Survey 2017.

Malaria risk is defined up to the smallest unit of community - the wards, which are classified as high risk wards,
adjoining wards to high risk wards, moderate risks, low risk, and no risk wards. Targeted interventions based on
risk stratification are likely to be more effective, efficient, and may add more value to money.

Malaria information from private sector is mostly unreported. Despite an estimated adjustment of additional 20
% to HMIS data based on the concept of free drug for malaria treatment in only public health facilities
throughout Nepal, yet actual private sector data is lacking and estimate of adjustment may be an
understatement.

Notification
A legal framework to notify each and every case of malaria in the public as well as private sectors should be in
place by 2018. National Malaria Elimination Steering Committee (NMESC) will develop the legal framework for
notification.

Web Based Reporting and Recording


Malaria Disease Information System (MDIS) should be implemented in both the public and private sectors
throughout the country. Only targeted districts are currently reporting through MDIS with minimal engagement
of private sectors. Private sectors inclusion and scale up of MDIS throughout the country should be operational
by 2018.

Case Based Surveillance


Each reported malaria case should undergo investigation to confirm and classify the case within 72 hours of
notification. Investigation should be conducted by local health facility with support from the district. Case
finding in the households and among the neighbours around an indigenous case should be conducted within 3
days of notification. An assessment to identify and classify the characteristics of malaria transmission in the
area (focus) and respond appropriately to clear the foci within 7 – 10 days of notification should be
implemented by 2017. A malaria data bank with detail line listing of all malaria cases should be operational by
2018 in the districts and the data should be compiled and collated in to a national data bank in NMETF/EDCD.

Foci Identification
Districts should identify, classify, respond and update malaria foci in their districts with support from the region
and canter. Although foci activity has just started recently, scale up of the activity will be implemented by 2017
to gradually achieve target coverage of 15% cleared foci by 2018, 35% cleared foci by 2019, 60% of cleared foci
by 2020, 80% of cleared foci by 2021, and 100% of cleared foci by 2022; and sustain it thereafter. Foci response
will target early quality diagnosis and effective treatment in the community using community testing, malaria
mobile clinics, and detection and treatment of asymptomatic and sub-microscopic malaria; achieving universal
coverage with LLINs distribution, and focal IRS spraying toclear the area from transmission of malaria. Mapping
hot spots and hot pops within a focus may be beneficial for more effective and efficient targeted interventions.

Drug Efficacy Study


Regular first line drug efficacy study will be conducted for ACT and Chloroquine. Although, the number of cases
may be difficult to enroll in the study from one study site, the use of multiple sites as one study site should be
helpful for the study.

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Operational Research
Map active foci with qPCR to identify asymptomatic and sub microscopic malaria and define hot spots and hot
pops for more effective and efficient targeted interventions by 2018.

Implement MDA in closed and isolated setting with MPPT for P. vivax after G6PD testing by 2017- 2018 and
disseminate the results by 2019-2020.

Imported Malaria
As countries move toward malaria elimination, imported infections become increasingly significant as theyoften
represent the majority of cases, can sustain transmission, cause resurgences, and lead to mortality. The
changing epidemiology of imported malaria in Nepal is a big challenge to malaria elimination. Imported malaria
is one of the main threats to achievement and maintenance of elimination, with greatest risk for countries
neighbouring high-endemic areas such as Nepal with an open border with India. Despite consistently low
reports of malaria cases, a major epidemiological shift is taking place within the country: imported cases have
risen from 16% of the total confirmed malaria cases in the country in 2004 to 45 % in 2016. Large `numbers of
Nepalese go to work in neighbouring malaria endemic states of India such as Assam, Gujrat, West Bengal and
Maharashtra and may return with malaria infection. Besides, seasonal migration for work for couple of months
during the peak malaria season to endemic states and home coming for celebrating major festivals is way of life
in Far West and Mid-West Regions. An operational research to map migrant and mobile population will be
conducted along with social networking, developing awareness through IEC about malaria prevention and
increase in early health seeking behaviours, enhanced surveillance and increase in health-care access through
Malaria Mobile Clinics in high and moderate risk areas from March to October. Reduction in malaria receptivity
in such high risk mapped areas by LLINs distribution and focal IRS spray and personal protection by distribution
of prevention package during transit will be promoted. Screening incentives will be explored at the border
entry with enhanced health seeking behaviours and target networks and use of mobile alerts and reminders on
return. Cross border collaboration needs to move away from just being an idea to be actually implemented with
concrete mechanisms and focal points to exchange data with the Indian National Vector Borne Disease Control
Programme (NVBDCP) and agreed chain of actions in areas where cases are originating. Such mechanisms and
agreement on actions to be undertaken in the affected areas (in both India and Nepal) require formal and
regular meetings with EDCD’s counterpart in India. WHO is best placed to hold/gather such meetings at a high
level to get firm commitment from India after the past failed attempts.

Mapping the Private Sector


Engagement of private sector will ensure reliable information on malaria burden and the state of diagnosis and
treatment in the sectors. An operational research to map and estimate private sector contribution to malaria
service will be conducted in 2017. This will be the basis of starting a dialogue process with the private sectors
targeted towards compliance with malaria case notification, recording & reporting, and also ensuring
compliance with NMTP 2016. But, In order to bring the private sector facilities aboard, a “win win“ strategy and
agreement based on 1) EDCD/MoH action and support to strengthen diagnostic and treatment capability and
quality of private facilities and 2) compliance of private facilities with notification, reporting and NMTP 2016,
will be rolled out by the end of 2017 (see objective 4.)

2. To further reduce & interrupt malaria transmission and eliminate foci.


Integrated Vector Management (IVM)
Integrated Vector Management (IVM) has been adopted as the key vector control strategy and IVM guidelines

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have been endorsed by TWG/malaria. IVM guidelines will be rolled out by 2017. The guidelines highlights
evidence based information on vectors, insecticides, and effectiveness and efficacy along with intersectoral
partnerships and collaboration and community engagement and participation.

Universal Coverage: LLINs

Universal coverage with mass LLINs distribution will be promoted in high risk wards and adjoining wards and
moderate risk wards. Continuous distribution of LLINs to pregnant women will be promoted in high risk wards
and adjoining wards and in moderate risk wards through ANC visit. Mass LLINs distribution by government
agency will be explored from 2018.

The coverage, use, and durability of LLINs after 3 -6 months of distribution will be tracked as a baseline and a
longitudinal study will be conducted after 12, 24, and 30 months. Operational research related to technical and
economic feasibility of using WHOPES-approved long lasting insecticide treatment of conventional nets
(IconMaxx) will be explored.

Vector Bionomics & Behaviours


A detail vector lists with their bionomics and behaviours should be prepared based on the geo-ecological strata
of the country. Updated vectors lists and their bionomics and behaviours in each of the geographical and
ecological strata where transmission of malaria is possible should be documented by 2017. Regular five yearly
updates will be sufficient in the coming years. Entomology study conducted in 2016 – 2017 may be identified as
the baseline year and may be of particular interest in framing the document since similar exercise was
conducted way back in the 1990S. A plan for strengthening entomology capability should be finalized by 2017
and it should be rolled out by 2018.

Vector Susceptibility Monitoring


Regular yearly sentinel site monitoring for vector susceptibility to insecticides should guide the use of
insecticides. This approach will be implemented as a core activity of an Integrated Vector Management (IVM).

Entomology Capacity Building


A long term plan to strengthen entomology capability in the country should start with a roll out of a
diploma/bachelor course in entomology by 2018. In the meantime, short term plan to conduct month long field
based training should continue with facilitation by national and international entomologists.

IRS
As outlined in the IVM guidelines, IRS will be conducted as follows:

- During malaria outbreak / epidemic


- During humanitarian crisis and national disasters in malaria endemic areas
- In areas where API is more than 1/1,000.
- As responsive measure to clear malaria foci

IRS will be conducted in an integrated manner to address other vector borne diseases such as Dengue and Kala-
azar.

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Interrupt Transmission:

Foci Identification and Delimitation


Each district will identify and classify malaria transmission foci in their district with support from region and
canter by the end of 2017. Foci are classified as Active, Non-active Residual, or Cleared. An active focus is
defined as an area with ongoing malaria transmission with locally acquired case(s) detected during the current
malaria season. A non-active residual focus denotes recent interrupted transmission meaning last locally
acquired case(s) was detected in last season or up to 3 years ago (1 – 3 years ago). A cleared focus denotes an
area with previous cases but no current transmission or within the last 3 years (only imported, induced or
relapsing case) detected this year. No locally acquired case detected up to 3 years earlier.

Each district willimplement foci response and delimit foci in the district as follows: (cumulative) – 15 % foci by
2018, 35 % by 2019, 60 % by 2020, 80% by 2021, and 100% of foci responded by 2022 and sustained it
thereafter. Foci identification will be conducted by DHO/DPHO with participation of local health facilities and
with active support from the center in the first year, but during foci updates in subsequent years DHO/DPHO
will conduct the exercise.

Appropriate response to delimit and eliminate the foci consists of early diagnosis and prompt complete
treatment (in addition to 3 days ACT, single low dose Primaquine for uncomplicated falciparum malaria and for
uncomplicated vivax malaria administer G6PD test and on normal test result treat with 3 days Chloroquine and
14 days Primaquine).

Increase access to diagnosis and treatment in the area is ensured through community test treat and track by
FCHVs (or modified approach) and Malaria Mobile Clinics. Universal coverage with LLINs and /or IRS spray will
ensure further reduction in transmission in the area. Case based surveillance along with detection of
asymptomatic and sub clinical malaria by PCR done at designated centers further drains the infectious pool of
reservoirs in the community. Foci will be mapped with PCR to target hotspots & hot population and implement
MMCs in the focus to increase early diagnosis and prompt complete treatment. Updated malaria foci, malaria
hot spots and hot pops information will be maintained at METF in the center.

3. Improve quality of and increase access to early diagnosis and effective and complete
treatment of malaria.

Quality Diagnosis
Quality malaria microscopy is a critical issue in National Malaria Programme. An external review of malaria
microscopy diagnosis in Nepal recommends roll out and scale up of quality assured and quality controlled
RDTs( capable to detect Pf &Pv- Combo) in most areas with establishment of designated strengthened
microscopy centers at strategic locations for cross check and quality control.

Community diagnosis and up to PHCs and private sectors malaria diagnosis should be done by Quality Combo
RDTs throughout the country. Trained microscopists if available in PHCs and private sectors may utilize
microscopy for diagnosis but quality assured and control guidelines should be in place. All positives and 10 %
negatives RDTs, should undergo cross checking and quality control. Prepare thick and thin slide of the sample
and each week send the slide for quality control to designated district microscopy center. Feedback should be
sent within a week. Conduct basic, refresher and competency assessment in malaria microscopy foras public
and private health care facilities, designated microscopy and referral centers respectively.

Equivocal slides and random sampling of positive and negative slides should be sent to the designated referral
centers for review. Feedback should be sent within a week.

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Drain Reservoirs in the Community


The spectrum of malaria infection is wide ranging from asymptomatic, sub-microscopic, symptomatic case,
relapse case, and recrudescent case. In order to reach elimination, strategy has to address this pool of
reservoirs in the community. Malaria Mobile Clinics (MMCs) using RDTs in the community will target proactive
case detection (malaria case and asymptomatic infection) in the community in areas of malaria transmission.
MMCs will be established through contracts with private health entities which will also involve Village Health
Workers operating in the communities. In addition, to interrupt malaria transmission, sub-microscopic and
asymptomatic malaria should be detected by qPCR (blood sample collected in DBS and transported to QA/QC
designated PCR centers in the regions) and treated as per the national guidelines. Three designated PCR centers
are in operation and scale up of further two centers would cover the country.

Disseminate NMTP 2016


NMTP 2016 should be disseminated to public and private health care providers by April 2017. The orientation
should target the following:

- Physicians & Medical Officers in public and private sectors


- Health Care Providers in public – AHWs, HAs/
- Drug dispensers in private sectors.

The big challenge is to comply with complete treatment particularly in vivax malaria treatment as per NMTP
2016. There is currently three treatment regimen in operation for P vivax treatment without G6PD testing: a.
chloroquine only; b. chloroquine and 5 days Primaquine; c. chloroquine and 14 days Primaquine. Drug
adherence, monitoring, and follow up are not implemented. A point of care test (RDTs) will be pre- positioned
by Malaria Programme by 2017. Although current point of care test will not address female heterozygotes for
G6PD and on exposure to Primaquine they may hemolyze, careful counseling and provision of FST facility in
each district may minimize the risk. It is envisioned that within a year, point of care test will address the issue of
female heterozygotes. Primaquine administration for 14 days for radical cure of P vivax malaria after a normal
G6PD test is the critical element in compliance with treatment protocol.

PSM/Logistics Plan
The Procurement and Supply Management plan requires new interventions that will foster an enable
environment for decision making based on evidence for 1) a more accurate forecasting of needs ofdrugs and
diagnostics commodities, 2) a more regular control of stock data reported to avoid stock-out, 3) a stronger
quality assurance system, and 4) a more robust plan for minimizing drug expiry and guarantee adequate waste
management.

Proposed activities include (but are not limited to):

- Establish and train a central forecasting committee for malaria commodities at EDCD comprising
members from Logistic Management Division (LMD), Save the Children (STC), WHO, Department of
Drug Administration(DDA), local USAID mission health section. The Terms of Reference for such
committee should be completed by July 2017.
- Set-up and conduct monthly meeting to cross-check data reported to LMD and EDCD (LMIS versus
MDIS, as well as data reported by VCIs, DHOs or other channels). A joint LMD-EDCD team will conduct
these meeting and produce reports to the TWG and NMESC.
- Develop product specifications, prepare cost estimates for procurement and validate the specifications
during an annual workshop with national stakeholders.

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- Develop updated SOPs on drug dispatch, drug receiving, inventory management, expiry handling, and
waste management and make them available to all district drug stores.
- Develop sampling protocols for collecting quality control samples of antimalarial commodities at
different points of supply chain. Conduct regular quality control operations.
- Obtain quotation for quality control tests from WHO – pre qualified laboratories and send samples for
quality testing

Case Management
Conduct malaria case management training for physicians, medical officers, and health care providers in public
and private sectors. Case management will focus on severe malaria in order to address increasing imported
cases of severe malaria seeking health care mostly in private sectors.

Community Test, Treat, and Track


Although FCHVs have been trained to recognize malaria on the basis of travel and symptoms yet community
testing has been implemented with a modified joint approach with support from local health facility. Early
diagnosis and prompt treatment in the community is a pre-requisite for limiting onward transmission from the
case. A review of current community test approach will be evaluated by 2017 with participation of all the
stakeholders. EDCD will build a strong case for community testing by FCHVs to be implemented in hard to reach
remote high and moderate risk districts. Although in the past TWG/Malaria rejected community testing by
FCHVs, but recent decision of NPHL to allow piloting the concept in HIV is encouraging. Community testing by
FCHVs in hard to reach, remote areas will be piloted in 2017 and the results shared with the stakeholders and
TWG/Malaria. If community testing by FCHVs is not recommended by the group then scale up of current
approach will be ensured with trained FCHVs sending SMS to the focal person in the local health facility. Focal
person respond within 24 hours and visit the community and with support from FCHV conducts community
testing and treatment in the community and FCHVs keep track of the case. Trained FCHVs ensure patient
adheres and complies with treatment and keeps track of the cases. Community testing is further augmented by
roll out of MMCs in high and moderate risk wards targeting proactive case detection and treatment.

4. Develop and sustain support through advocacy and communication, from the political
leadership and the communities towards malaria elimination
National Malaria Elimination Steering Committee (NMESC)
NMESC is required for policy, advocacy, and partnerships building. Such committed would include high level
representatives of the Ministries of Health, Education, Environment, Agriculture and Finance, as well as
representatives of Economic Development Partners (EDPs) such as WHO, USAID, UNICEF, DFID, GIZ, AFD, etc.

NMESC would meet annually to review progresses accomplished by the malaria program and examine the
current challenges, bottlenecks and requests for policy changes, support or funding.

Develop Private Sector Engagement Strategy


In order to bring the private sector facilities aboard, a “win win“ strategy and agreement based on 1)
EDCD/MoH action and support to strengthen diagnostic and treatment capability and quality of private facilities
and 2) compliance of private facilities with notification, reporting and NMTP 2016, will be rolled out by the end
of 2017.

As describe under objective 1), such strategy requires first a clear mapping of private facilities by legal

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registered status, size (visits), specialty of care, and location.

Private sector will report or comply if incentives mechanism (not monetary) or formal partnerships are
established including but not limited to:

- EDCD/MoH providing for free the full range of BCC materials, guidelines, protocol materials, RDTs and
drugs for quality diagnostic and treatment.
- EDCD providing training, mentoring and monitoring to private facilities staff.
- EDCD inviting private sector representative at District and Central Levels to regular coordination meetings.
- EDCD setting up a recognition system for best reporting/performing facilities (annual awards during
annual review of private sector data/achievements for instance).
- Private facilities reporting on a monthly basis the number of clinical cases, diagnosis results and treatment
provided following national treatment and case management protocol.
- Private facilities referring cases (severe or not) to recommended public facilities when not able to provide
necessary and appropriate services to patients.
- Private facilities offering testing and treatment for free when receiving commodities and training from
government.
- Private facilities participating in regular coordination meetings with district or national level authorities.

A national level meeting should be held with government authorities (EDCD, MOH, DHOs) and representative
of the private sector organizations/associations to agree on partnership conditions and review on a regular
basis the data generated from both sectors.

BCC targeting High Risk Groups


High risk groups (soldiers, forest guards, refugees, etc.) have not been targeted and received specific BCC
interventions and materials. There is a lack of data/evidence/documentation on the assumption of the
existence of such high risk groups. Studies identifying such groups by evidence are needed. Once identified,
specific BCC approaches and packages will be developed.

Cross Border Collaboration


In order to make collaboration with India effective, EDCD will develop a formal proposal to the Government of
India and its dedicated program (NVBDCP). Such proposal will list 1) the type of information that should be
shared by both countries in order to decrease the number of imported cases by targeting identified foci on both
side of the border, 2) the data transmission mechanism and focal points, and the 3) chain of actions/responses
to be undertaken by both partiesin affected districts/communities where imported cases are originating from.

It is expected that WHO would play the role of mediator to establish such collaboration but initially hosting a
bilateral high level meeting on that matter to introduce both parties to each other, recommend the
collaboration, assist EDCD to present its proposal and drive the discussion towards a formal commitment and
agreement framing on the collaboration.

In addition EDCD can unilaterally establish and test the relevance of health/check posts at the border of high
risk districts which would provide on-site testing, communication materials and prevention commodities
packages (prophylaxis, LLINs, repellants, etc.) to targeted migrant workers/populations.

5. Strengthen programmatic technical and managerial capacities towards malaria


elimination

Malaria Elimination Task Force

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A Malaria Elimination Task Force will be established by 2017 and will function as a gateway for malaria data
banking and management; document success and failures monitor and evaluate the progresses made toward
malaria elimination. METF will present the updated progress, success and failures, constraints and challenges in
malaria elimination programme to TWG/Malaria for guidance, approval or support. Monthly reports will be
sent from the METF to the TWG/M members.

Because the METF staff will be dedicated to the Malaria Program to fully focus on this disease, EDCD will
develop specific Job Description for these position, describe the level term of references, responsibilities and
authority of the METF, and will internally restructure/shift its organigram to include this team while keeping the
same number of employees.

Technical Working Group


Malaria Technical Working Group (TWG/M) will guide the malaria programme towards elimination. The TWG/M
will meet upon request from the METF as needed to provide programmatic, technical or strategic guidance, to
approve new interventions or changes in the work plan, and to seek additional political, financial or technical
support as needed.

Malaria Programme Review

An internal Malaria Programme Review should be conducted in 2017, 2020 and 2022 to review and measure
progresses made toward elimination and update as needed the NMSP.

Annual Work Plan

To ensure that all interventions are planned and budgeted in a timely fashion and that activities follow a clear
roadmap, the METF will develop every year a work plan that will be reviewed and approved by the TWG/M.

Major activities in 2073/74


 413403 LLIN was distributed as mass distribution and 55919 LLIN was distributed to pregnant
women at their first ANC visits.
 Conducted the ward-level micro-stratification of malaria cases in 44 districts.
 Introduced case-based surveillance system, including web-based recording and reporting
system for districts. The MDIS is now fully operational.
 Conducted a national malaria vector survey.
 Orientated district and peripheral level health workers on case based surveillance and response.
 Carried out detailed foci investigation at more than four sites.
 Conducted G6PD deficiency prevalence study across 30 wards in 54 high risk VDCs.
 Revitalized the malaria microscopy quality assurance system with collaboration between the
Epidemiology and Disease Control Division (EDCD) and VBDRTC, with technical assistance from
WHO.
 Orientated district health workers and FCHVs on the government’s malaria elimination initiative
and their role in detecting cases and facilitating early treatment.
 Orientated mother groups and school children on malaria prevention and the need for early
diagnosis and prompt treatment.
 Conducted quarterly and annual review meetings for district and central level staff. Participants
reviewed data from peripheral facilities and revised it based on suggestions.
128 DoHS, Annual Report 2073/74 (2016/17)
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 Conducted operational research on malaria vector behaviour and insecticide resistance.
 Conducted regular vector control (indoor residual spraying) biannually across high and
moderate risk districts.
 Conducted detailed case based investigation and fever surveys around positive index cases.
 Conducted integrated entomological surveillance around twelve different site of thought-out
the country.
 Celebrated World Malaria Day on 25 April.

Achievements
Nepal achieved MDG 6 ahead of time by reducing malaria morbidity and mortality rates by more
than 50 percent in 2010.Despite political instability, Nepal’s malaria programme has successfully
implemented planned interventions to eliminate the remaining active malaria foci (VDCs). MoH, with
support from its EDPs, has implemented a strong malaria control programme, steadily improving the
coverage and quality of indoor residual spraying, introducing long lasting insecticide-treated nets,
and increasing access to rapid malaria diagnosis and powerful artemisinin-based combination
treatments.

Data generated by public health care facilities in the HMIS, the Early Warning and Reporting System
(EWARS) and from studies including malaria micro-stratification show a substantial decline over the
last six years in clinical and laboratory confirmed Plasmodium falciparum and P.vivax cases. The
findings of the micro-stratification exercise (2013) reduced the number of high and moderate risk
district from 31 to 25 and identified 1,254 VDCs (out of 3,972) as presenting a risk of contracting
malaria. In 2073/74 (2016), micro stratification was done to assess the risk at ward level. The result
was published.

The trends of the malaria epidemiological situation between 2071/72 and 2073/74 show a slightly
increasing trend of confirmed cases and 3 deaths (Table 4.1.1):
 Confirmed malaria casesincreased from 991 in 2072/73 to 1128 in 2073/74. The proportion of
P. falciparum infections slightly decreased and accounted for 13.1 percent of all cases in current
year although the proportion is still high, which may be due to high number of imported P.
falciparum cases.
 During 2004–2007, the annual parasite incidence (API) remained stable (0.26-0.27 per 1000
population countrywide), and thereafter gradually declined to the lowest level ever recorded (in
2073/74) of 0.08/1000 at risk population (calculated based on denominator set after micro-
stratification, 2016).
 The trend of clinically suspected malaria cases is also decreasing, mainly due to the increased
coverage of RDT, microscopic laboratory service at peripheral level and regular orientation and
onsite coaching of service providers. A total of 3904 probable/clinical suspected malaria cases
treated by chloroquine were reported in 2073/74.
 There was a sharp decrease in the number of indigenous P. falciparum cases with slowly
decreasing trend of indigenous P.vivax cases. But cases being identified in new areas, especially
in hilly terrain, suggest that P.vivaxmalaria remains a challenge for the elimination of malaria in
Nepal. This raises the need for new country specific elimination strategies.

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Table 4.1.1: Malaria epidemiological information (2071/72–2073/74)
Items /indicators 2071/72 2072/73 2073/74
Total population 13,455,000 13,767,000 14944174
Slide Collection Targer 150,000 150,000 150,000
Total slide examined 101,377 116,276 118165
Total positive cases 1,352 991 1128
Total indigenous cases 683 506 492
Total imported cases 669 485 636
Total P. falciparum (Pf) cases * 274 162 148
% of Pf of total cases* 20.26 16.34 13.1
Total indigenous Pf cases * 101 70 52
% indigenous Pf cases * 36.86 43.21 35
Total imported Pf cases * 173 92 96
% imported Pf cases 63.13 56.79 65
Total P. vivax(Pv)cases 1078 829 980
Total indigenous Pv cases 570 436 440
% indigenous Pv cases 42 52.6 44.9
Total imported Pvcases 508 393 540
% imported Pv cases 37.57 47.4 55.1
Annual blood examination rate 0.75 0.84 0.79
Annual parasite incidence 0.1 0.07 0.08
Annual Pf incidence 0.02 0.012 0.01
Slide positivity rate 1.33 0.85 0.95
Slide Pf positivity rate * 0.27 0.14 0.13
Probable/clinical suspected malaria
cases (not tested but treated by 20,861 10642 3904
chloroquine)

Source: EDCD

The trend of the national malariometric indicators (Table 4.1.1) indicates that Nepal has entered the
elimination phase. Despite district variance including on number of cases, the API and slide positivity
rates (SPR) and the zero indigenous cases from districts such as Kavre and Sindhupalchok over the
last three years suggests a paradigm shift. The highest number of confirmed cases were reported
from Kailali district (267), followed by Dhanush (78), Baitadi (75), Kanchanpur (75, Kap) and
Kaplbastu (72). This shows substantial progress towards elimination targets (bearing in mind that
data are only generated by public health care facilities and require continuous attention for
improvement).

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Table: Province wise Malaria epidemiological information of 2073/74
Annual Blood Malaria annual Percentage of Percentage of Slide positivity
Examination parasite Plasmodium imported cases rate of malaria
rate of malaria incidence per falciparum among positive among high risk
Province in high risk 1000 cases in high cases of malaria districts
districts population at risk districts
high risk
districts
Province 1 0.44 0.02 24.5 77.6 0.39
Province 2 0.51 0.04 19.9 28.1 0.83
Province 3 0.42 0.03 28.9 37.8 0.63
Province 4 0.87 0.03 10.3 72.4 0.32
Province 5 1.07 0.08 16.19 74.5 0.77
Province 6 0.7 0.13 5.3 74.7 1.7
Province 7 1.6 0.3 8.3 50.6 1.6

Confirmed malaria is slightly increased due to active surveillance and others many factors may have
contributed to the decline of clinical and the decline of the number of endemic districts (and
probably of the number of active foci):
 Overall improvements in the social determinants of health (for example, less than 20% of
Nepalese people now live below the poverty line against more than 40% in 2000).
 Increased access to simple diagnostic tools like (combo) RDTs.
 The availability of powerful antimalarial medicine(ACTs) in all public health facilities.
 The distribution of around 5 million LLINs in endemic areas.

The large financial support from the GFATM since 2004 has played a major role by allowing the
programme and partners to scale up essential interventions and malaria control tools to the most
peripheral level. Data reported by the districts via HMIS and reports received by the programme may
differ for various reasons such as lack of orientation of staff who generate data and statistical
officers who enter the data as per the suggestion of vector control officers at district and regional
levels. The involvement of the vector control inspector (VCI), statistical officers and lab personnel
from districts and regions on data quality coupled with rigorous on-site coaching and support by the
central EDCD team (comprising government and contracted staff from Save the Children working at
the programme management unit) have paid dividends in helping decrease errors.

Crucial concerns remain to be addressed to improve the reliability and precision of data. In
particular, there is a need to increase the capacity of EDCD and district teams to analyse data
generated by public health facilities and progressively include and analyse data generated by all
private health institutions including NGOs that run community activities and support refugees and
migrants.

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Table 4.1.2: Recommendations from regional and national reviews in 2072/73 and actions taken
in 2073/74
Problems and
Action to be taken Action taken
constraints
 Increased number of malaria
Confirmation of  Malaria microscopy microscopy trainings run at
suspected and trainings of all untrained VBDRTC and in other regions
probable malaria cases lab personnel including lab personnel from
across the country
 Availability of RDT at non  Database created that lists
microscopic sites untrained and trained personnel
since 2004. It aims to reduce
 Orientation of service
repetition before two years of
providers, clinicians, basic malaria microscopy training
health workers and to provide equal opportunities
private practitioners  Regular periodic validation of
HMIS data by EDCD in
 Validation of probable coordination with DPHOs
malaria case through  Decentralized training centres
cases investigation established in mid and far west to
train more lab personnel on
malaria microscopy

Low blood slide  Train health workers on  Supplied RDT at community level
examination rates for RDT and microscopy in
 Trained health workers from
malaria elimination malaria reported districts
malaria reported districts
programme

Orientation on malaria  Run training programmes  Ongoing basic and refresher


programme to health with GFATM support trainings on malaria microscopy
workers for lab technicians and assistants
at peripheral facilities

 Oriented RHD and DHO finance


and storepersons on malaria
programme

 Oriented FCHVs on malaria

Malaria case reporting  Orient district and  District and peripheral level staff
and case investigation peripheral staff on case oriented on case investigation,
investigation and reporting surveillance, foci investigation and
reporting.

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Insufficient variables  EDCD to address the  Discussed with HMIS section and
in HMIS tool (for e.g. insufficient variables agreed to rectify at next revision
slide and RDT during HMIS tools revision
classification)

Malaria cases  Programme should  Programme will be added next


increasing in non- address non-endemic year to also target non-endemic
endemic district districts districts.

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4.2 Kala-azar

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

The government committed to the regional strategy to eliminate kala-azar and signed the
memorandum of understanding that was formalized at the World Health Assembly in 2005, with the
target of achieving elimination by 2015. In 2005, the EDCDformulated a National Plan for
Eliminatingkala-azar across preparatory (2005-2008), attack (2008–2015) and consolidation (2015
onwards) phases. See Box 4.2.1 for the plan’s goals, objectives and strategies. The expected outputs
of the plan are related to the components of the system that need strengthening. One is to develop
a functional network that provides diagnosis and case management with special outreach to the
poorest people.

Box 4.2.1: Goal, objectives and strategies


Goal — To improving the health status of vulnerable groups and at risk populations living in kala-
azar endemic areas of Nepal by eliminatingkala-azar so that it is no longer a public health problem.

Target — Reduce the incidence of kala-azar to less than 1 case per 10,000 populations at district
level.

Objectives:
 Reduce the incidence of kala-azar in endemic communities including poor, vulnerable and
unreached populations.
 Reduce case fatality rates from kala-azar.
 Treat post-kala-azar dermal leishmaniasis (PKDL) to reduce the parasite reservoir.
 Prevent and treatkala-azar and HIV–TB co-infections.

Strategies — Based on the regional strategy proposed by the South East Asia kala-azar technical
advisory group and the adjustments proposed by the Nepal expert group discussions, MoH has
adopted the following strategies for the elimination of kala-azar.
 Improve programme management
 Early diagnosis and complete treatment
 Integrated vector management
 Effective disease and vector surveillance
 Social mobilization and partnerships
 Clinical, implementation and operational research.

The national plan was revised in 2010 as the National Strategic Guideline on Kala-Azar Elimination in
Nepal that recommended rK39 as a rapid diagnostic test kit and miltefosine as the first line of

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treatment in kala-azar in most situations. The further revised national guidelines(2014)
recommended introducing Liposomal Amphotericin B and a combination regimen for kala-azar and
PKDL treatment in Nepal.

Over the last decade, there have been significant advances in the diagnosis and treatment of kala-
azar. Nepal’s national programme made the rK39 dipstick test kit (a rapid and easily applicable
serological test) available to PHCC level in programme districts.

Major activities in 2073/74


Case detection and treatment — Early case detection and complete and timely treatment is the
mainstay of eliminating kala-azar. Kala-azar related diagnostic and treatment services are provided
at PHCC and above levels of health facilities while awareness, health education, follow-up for
treatment compliance, identification and referral of suspected cases are also offered at health posts.

Indoor residual spraying in priority affected areas — In 2073/74 two rounds of selective indoor
residual spraying were carried out in prioritised kala-azar affected areas of endemic districts based
on the national IRS guideline. IRS is carried out only in villages where kala-azar cases were recorded
in the previous year or in areas with an outbreak in the recent past. The kala-azar programme also
benefits from IRS for the prevention of malaria.

Introduction of liposomal amphotericin-B — The WHO Expert Committee on Leishmaniasis in 2010


and the Regional Technical Advisory Group (RTAG) for the kala-azar elimination programme in 2011
recommended Liposomal Amphotericin B (L-AmB) as the first line regimen during the attack phase in
the Indian subcontinent. Taking into consideration its high efficacy, safety, ease of use and
assuredcompliance, the results of a phase 3 trial evaluating three regimens for combination therapy
showed excellent efficacy and safety across all three regimens. The combination regimens have been
recommended as second line regimens for the Indian sub-continent in the attack phase. In the long
term, combination regimens are the best way to protect individual drugs from developing resistance.
Monotherapy with miltefosine or paromomycin is a fourth choice (after Amphotericin B) in the
expert committee’s recommendations.

L-AmB was introduced in Nepal in December 2015 after training about 60 doctors and nurses from
endemic districts. The therapy should be directly observed and patients should be hospitalized for
the full duration of the therapy.L-AmB needs a cold chain (<25oCelsius) for storage; and therefore
should be made availableonly in hospitals where proper storage is ensured.

Training on revised national guidelines and treatment protocol — Medical officers, nursing staff,
laboratory staffs and other paramedics were trained on the revised national kala-azar guidelines and
treatment protocols.

Kala-azar review meeting — A review meeting was held with DHO and district hospital personnel
and the focal persons of all kala-azar endemic and non-endemic districts focusing on data
verification, line listing update and the revised treatment protocols.

Disease surveillance— Kala-azar tends to be underreported as most data is obtained through passive
case detection especially from government hospitals. During 2073/74, active case detection was
carried out in endemic VDCs. This was done through the camp approach. The VDCs were selected
based on the number of new cases reported in the previous and running fiscal year. Community-

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based house to house searches were carried out by FCHVs for suspected kala-azar and PKDL cases.
Suspected cases were then screened clinically and by rapid diagnostic kits (rK39) at health facilities
by doctors, laboratory persons and other health workers. rK39 positive cases were referred to
district or zonal hospitals for further confirmation and management.

Trend of kala-azar cases


The number of Kala-azar cases has decreasing significantly in recent years. A total of 220 cases were
reported in 2071/2072 of which 177 were native cases. Of the native cases 220 (80%) were from the
18 programme districts. EDCD extended the elimination programme to Okhaldhunga, Surkhet, Palpa,
Makawanpur, Kailali and Bhojpur districts in 2071/72 .

In 2072/2073, 267 kala-azar cases were reported, an increase from the previous year (Table 4.2.1).
The most cases were reported from Morang (50), Siraha (23) and Mahottari (18) while the
programme districts of Parsa reported no cases. Thirty two non-programme districts reported 69
cases in 2072/73 (Achham, Arghakhanchi, Baitadi, Bajhang, Bajura, Banke, Bardiya, Dailekh, Dang,
Darchula, Dhading, Dhankuta, Dolpa, Doti, Gulmi, Humla, Ilam, Jajarkot, Kalikot,Kanchanpur,
Kathmandu, Khotang, Mugu, Nawalparasi, Nuwakot, Pyuthan, Ramechhap, Rolpa, Rukum, Salyan,
Sindhupalchowk and Syangja). This epidemiological shifting indicates that the programme should
conduct a vector survey to map the presence of the vector and the indigenous transmission of the
disease.

In 2073/2074, 151kala-azar cases were reported, decreased from the previous year (Table 4.2.1).
The most cases were reported from Sarlahi (24), Morang (21) and Malpa (16) while the programme
districts of Parsa reported no cases. Twenty five non-programme districts reported 80 cases in
2073/74 (Achham, Argrakhachi, Bajura, Banke, Bardiya, Dailekh, Dang, Dhankutta, Doti, Humla,
Kalikot, Kanchanpur, Kapilbastu, Kathmandu, Kavre, Lalitpur, Mugu, Pyuthan, Ramechape, Rukum,
Rupandehi, Salyan, Sindhuli, Synajha and Tanahu)

Table 4.2.1: Trend of kala-azar cases (FY 2071/72 to 2073/74)


2071/2072 2072/2073 2073/2074
Province Districts
Native Foreign Native Foreign Native Foreign
Jhapa 6 0 11 0 6 0
Morang 48 0 50 0 21 0
1 Sunsari 18 0 14 0 6 0
Okhaldhunga 1 0 0 0 2 0
Bhojpur 6 0 2 0 6 0
Udayapur 2 0 3 0 2 0
Dhanusha 16 0 8 4 15 1
Siraha 17 0 23 0 15 1
Mahottari 18 0 18 7 11 0
2
Sarlahi 13 4 10 6 24 4
Saptari 9 1 16 0 6 0

136 DoHS, Annual Report 2073/74 (2016/17)


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2071/2072 2072/2073 2073/2074
Province Districts
Native Foreign Native Foreign Native Foreign
Rautahat 0 0 1 0 1 0
Bara 1 0 2 0 1 0
Parsa 0 0 0 0 1 0
3 Makwanpur 4 0 1 0 5 0
5 Palpa 3 0 9 0 16 0
6 Surkhet 9 0 10 0 11 0
7 Kailali 6 0 3 0 2 0
Total cases of programme
177 0 181 0 151 6
districts
Other districts 43 0 69 0 74 0
Total cases 220 5 250 17 225 6
Source: HMIS/EDCD

The incidence of kala-azar at national and district level has been less than 1/10,000 population since
2013. The incidence at district level in 2071/72 ranged from 0.47/10,000 in Morang to 0.01 in Kailali
district and in 2072/73 from 0.47 in Morang to 0.01 in Bara. In 2073/74, the district level incidence
per 10,000 people in areas at risk ranged from 0.72, 0.64, 0.28, 0.28 in Humla, Palpa, Sarlahi and
Surkhet respectively to 0.01 in Kathmandu, Nawalparasi and Rautahat with an average incidence of
0.16 per 10,000 in the 18 programme districts and 0.11 at the national level (excluding 6 foreign
cases) (Table 4.2.2). The case fatality rate was 3.s1 percent in 2073/2074. 18 endemic districts
reported kala-azar cases in 2073/74.

Note that kala-azar cases reported from DHOs and DPHOs via the HMIS and case reports received by
the programme sometimes vary. The HMIS usually receives raw data from districts while the
programme proactively collects data from hospitals and other health facilities, DHOs and DPHOs
through EWARS. EDCD verifies data with the help of line listing report of all cases (EDCD started to
line list all kala-azar cases in 2012). EDCD also receives case reports done at central and district levels
with the line listing of cases.

Table 4.2.2: Kala-azar cases and incidence (2071/72 to 2073/74)

Cases Incidence
Districts 2071/72 2072/73 2073/74 2071/72 2072/73 2073/74
Jhapa 6 11 6 0.07 0.12 0.07
Morang 48 50 21 0.47 0.48 0.2
Sunsari 18 14 6 0.22 0.16 0.07
Saptari 8 16 6 0.14 0.23 0.09
Udayapur 2 3 2 0.06 0.09 0.06
Siraha 17 23 15 0.26 0.34 0.22

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Cases Incidence
Districts 2071/72 2072/73 2073/74 2071/72 2072/73 2073/74
Dhanusha 16 8 15 0.2 0.1 0.19
Mahottari 18 18 11 0.27 0.27 0.16
Sarlahi 9 10 24 0.16 0.12 0.28
Rautahat 0 1 1 0 0.01 0.01
Bara 1 2 1 0.01 0.03 0.01
Parsa 0 0 1 0 0 0.01
Okhaldhunga 1 0 2 0.07 0 0.13
Surkhet 8 10 11 0.21 0.26 0.28
Palpa 3 9 16 0.12 0.35 0.63
Bhojpur 6 2 6 0.35 0.12 0.36
Kailali 6 3 2 0.07 0.03 0.02
Makwanpur 4 1 5 0.09 0.02 0.11
Other districts 44 69 74 0 0.07 0.03
Total 215 250 225 0.25 0.12 0.11
Source: HMIS,

Table 4.2.3 summarises the progress in 2073/74 against recommendations made at regional and
national reviews in the previous year.

Table 4.2.3: Recommendations at regional and national reviews of 2072/73 and actions in
2073/74

Issues Recommendations Responses


Early case detection and  Orientation and training of  Health workers oriented
complete treatment of kala- health workers on new guidelines
azar  Regular supply of kala-azar  Reactive case detection
test kits and drugs based on index cases in
 Active case detection in endemic district
endemic districts
Early detection and case  Case based surveillance  Budget allocated to
investigation  Reporting with line listing of districts for case based
cases surveillance and case
investigations
 Initiated line listing of
cases
Cases increasing in non-  Extend programme to other  EDCD extended
endemic districts non-endemic districts programme to these
districts in 2071/72

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4.3 Lymphatic Filariasis
Background
Lymphatic filariasis is a public health problem in Nepal. Mapping of the disease in 2012 using ICT
(immune-chromatography test card) revealed 13 percent average prevalence of lymphatic filariasis
infection in Nepal’s districts, ranging from <1 percent to 39 percent. Based on the ICT survey,
morbidity reporting and geo-ecological comparability, 61 districts were identified as endemic for the
disease (Figure 4.3.1). The disease has been detected from 300 feet above sea level in the Terai to
5,800 feet above sea level in the Mid hills. Comparatively more cases are seen in the Terai than the
hills, but hill valleys and river basins also have high disease burdens. The disease is more prevalent in
rural areas, predominantly affecting poorer people. Wuchereriabancrofti is the only recorded
parasite in Nepal, The mosquito Culexquinquefasciatus, an efficient vector of the disease, has been
recorded in all endemic areas of the country.

Figure 4.3.1: Lymphatic filariasis endemicity, Nepal

LF MDA Status, Nepal: 2017


Total endemic districts: 61
HUMLA

DARCHULA
Average prevalence: 13%
BAJHANG
MUGU
MDA stopped districts: 31
BAITADI
BAJURA
Total at risk population: 25 million
N
DADEL- JUMLA
DHURA
DOTI ACHHAM KALIKOT DOLPA

MUSTANG
KANCHAN-
PUR DAILEKH
JAJARKOT
KAILALI

SURKHET
RUKUM MANANG E
MYAGDI
SALYAN
BARDIYA GORKHA
ROLPA KASKI
LAMJUNG
PARBAT RASUWA
BANKE PYUT-
HAN GULMI

Index
DANG
ARGHAK SYANGJA TANAHU SINDHU-
HACHI NUWAKOT PALCHOK
PALPA DOLAKHA
DHADING KATHM
KAPIL- NAWAL SULUK-
Non endemic districts (14) BASTU RUPAN-
DEHI
PARASI
CHITWAN MAKAWAN- LALIT KAVRE
HUMBU
SANKHUWA-
SABA
TAPLEJUNG

MDA stopped (31 Districts) OKHAL-


DHUNGA

Eight rounds completed (5 Districts)


PARSA
SINDHULI KHOTANG TERHA-
BHOJ- THUM
BARA RAUT- PUR
Seven rounds completed (4 Districts) AHAT SARLAHI
MAHO-
TARI
UDAYAPUR DHAN-
KUTA

Six rounds completed (10 Districts)


DHA ILAM
NUSA SIRAHA

SUNSARI MORANG

Five rounds completed (10 districts)


SAPTARI JHAA

TAS failed district (Nine rounds completed 1 district)

Government of Nepal
Ministry of Health
Department of Health Services

Progress towards elimination


The EDCD formulated a National Plan of Action for the Elimination of Lymphatic Filariasis in Nepal
(2003–2020) (Box 4.3.1) by establishing a National Task Force. The division initiated mass drug
administration (MDA) in Parsa district in 2003, which was scaled up to all endemic districts by
2069/70 (2013). As of 2073/74, MDA has been stopped (phased out) in 31 districts, post-MDA
surveillance initiated in 20 districts and morbidity management partially initiated in all endemic
districts. All endemic districts will complete the recommended six rounds of MDA by 2018. The
elimination programme has indirectly contributed to strengthening the system through trainings and
capacity building. Since 2003, surveys have been carried out including mapping, baseline, follow up,

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post MDA coverage and transmission assessment surveys. The transmission assessment survey in 31
districts in 2016 found that the prevalence of infection had significantly reduced. Since 2003 more
than 100 million doses of lymphatic filariasis drugs have been administrated to at-risk population.

Box 4.3.1: Goal, objectives, strategies and targets of lymphatic filariasis elimination programme

Goal — The people of Nepal no longer suffer from lymphatic filariasis

Objectives:
 To eliminate lymphatic filariasisas a public health problem by 2020
 To interrupt the transmission of lymphatic filariasis
 To reduce and prevent morbidity
 To provide deworming through albendazole to endemic communities especially to children
 To reduce mosquito vectors by the application of suitable available vector control measures (integrated
vector management).

Strategies:
 Interrupt transmission by yearly mass drug administration using two drug regimens (diethylcarbamazine
citrate and albendazole) for six years
 Morbidity management by self-care and support using intensive simple, effective and local hygienic
techniques.

Targets:
 To scale up MDA to all endemic districts by 2014
 Achieve <1% prevalence (microfilaraemia rate) in endemic districts after six years of MDA by 2018.

Major activities in 2073/74

Mass drug administration


MDA was continued in 30 districts in 2073/74. 10 districts completed five, 10 districts completed six,
4 districts completed seven, 5 districts completed eight and 1 district completed nine rounds of MDA
in this year. A total of 7,870,784 (72.7%) of the targeted 10,827,093 people in 30 districts were
treated this year and more percentage of people were treated than in previous years. The campaign
was conducted in two phases in March/April 2017 with the first phase in twenty five districts and the
second phase in 5 districts. The campaign mobilized 10,449 health workers and 54,665 trained
volunteers to reach the target populations and for monitoring campaign activities. The main MDA-
related activities are listed in Box 4.3.2.

More than 12,000 adverse events (mostly mild headaches, dizziness, stomach aches) were reported
after MDA. Health workers and volunteers mobilized for the campaign reported nearly 8,000 new
cases of morbidity due to or suspected to be due to lymphatic filariasis. More than 30,000 cases of
lymphedema of the lower and upper limbs, breast swelling and hydrocele were reported from
endemic districts during previous MDA campaigns.

The progress and coverage of the MDA campaign is shown in Table 4.3.1.

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Table 4.3.1: Scaling-up and coverage of MDA campaigns
MDA MDA At risk Treated Epidemiological
Remarks
Year districts population population coverage %
2003 1 505,000 412,923 81.77
2004 3 1,541,200 1,258,113 81.63
2005 5 3,008,131 2,509,306 83.42
2006 3 2,075,812 1,729,259 83.31
2007 21 10,906,869 8,778,196 80.48
2009 21 10,907,690 8,690,789 79.68
2010 30 14,162,850 11,508,311 81.26 MDA stopped in 1 district
2011 36 15,505,463 12,276,826 79.18 MDA stopped in 4 more districts
2012 46 20,017,508 13,546,889 67.68
2013 56 21,852,201 16,116,207 73.75
2014 41 15,874,069 10,929,305 68.90 MDA stopped in 15 more districts
2015 41 15,981,384 11,117,624 69.60
2016 35 12,470,213 8,887,666 71.3 MDA stopped in 5 more districts
2017 30 10,827,093 7,870,784 72.7 MDA stopped in 6 more districts
Source: EDCD

Box 4.3.2: MDA related major activities


National level activities — National task force committee meetings; interactions with the media,
professionals, organizations and civil society; monitoring and supervision; procurement and supply;
and advocacy and IEC/BCC activities.

Regional level activities — Regional level planning meetings in Butwal, Dhangadhi and Biratnagar;
regional coordination meetings and monitoring and supervision.

Implementation unit and district level activities — Planning meetings, training of health workers,
advocacy, social mobilization, IEC/BCC, monitoring and supervision, interactions with the media,
interactions with multi-sector stakeholders and logistics supply.

Community level activities — Volunteers orientations, advocacy, social mobilization, IEC/BCC,


implementation of MDA activities and monitoring and supervision.

Social mobilization activities — The production of revised IEC materials, checklists, reporting,
recording, and guidelines for MDA campaign; media mobilization and advertisement of MDA;
coordination and collaboration with stakeholders and school health programmes and interactions in
schools on the disease and MDA.

Monitoring — Monitoring and management of post-MDA complications and adverse events.

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Transmission Assessment Survey (TAS)— After completion of six round of MDA with pre-TAS
passed, six districts(Rukum, Rolpa, Salyan, Siraha, Saptari and Okhaldhunga) carried out TAS I and
fifteen districts ( Bara, Dhading, Dhanusha, Gorkha, Kavrepalanchok, Mahottari, Nuwakot, Palpa,
Ramechhap, Sarlahi, Sindhuli, Sindhupalchok, Syangjha, Tanahun and Rautahat ) completed TAS II
with supported of RTI/ENVISION. All the districts passed TAS.

Morbidity management and disability prevention


Morbidity management and disability prevention is the second strategy adopted by the national
elimination programme to reduce suffering in infected people living with chronic and morbid
conditions including elephantiasis, lymphedema and hydrocele. This strategy includes activities and
interventions ranging from home-based self-care by people living with lymphedema and
elephantiasis to hospital-based management and surgical corrections of hydroceles.

The following activities were carried out in 2073/74:


 2172 hydrocele surgeries have been performed in year 2073/074. This surgery is included in
the Red Book and is regularly done in hospitals in endemic districts.
 Morbidity mapping in Saptari and Okhaldhunga districts.
 All health workers and FCHVs in Saptari and OKhaldhunga were trained on patient self-care.
 BPKIHS and PAHS were recognized as referral hospitals for lymphatic filariasis morbidity
management.
Post MDA surveillance
Post MDA surveillance is ongoing in MDA stopped (phased out) districts. The monitoring of
microfilaria in human populations was done in five MDA-stopped districts(Parsa, Makawanpur,
Chitwan, Nawalparasi and Rupandehi ) by collecting night blood samples and performing smear
examination for lymphatic filariasis microfilaria. The results were encouraging showing no or low
infections.
Challenges and ways forward

The major challenges that remain that need addressing to consolidate the achievements are
ensuring quality MDA including achieving high coverage in urban areas and some specific
communities, and adverse event management, sustaining low prevalence in MDA phased out
districts, expanding morbidity management and disability prevention, and post MDA surveillance.
The biggest challenge is the persistent high prevalence in some districts despite completing the
recommended rounds of MDA.
The following are the major programme recommendations:
 Continue MDA at least for the next years to complete the recommended six rounds in all
endemic districts, and carry out transmission assessment, periodic surveillance and follow up
surveys to monitor progress towards elimination.
 Strengthen the capacity of the health system and service providers on morbidity management
and disability prevention and post-MDA surveillance.
 Carry out operational research, studies and programme reviews.
 Consolidate all documents related to the programme in a dossier for the later validation and
verification of elimination.

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4.4 Dengue

Background

Dengue is a mosquito-borne disease that occurs in Nepal as dengue fever, dengue haemorrhagic
fever (DHF) and dengue shock syndrome (DSS). The earliest cases were detected in 2005. Sporadic
cases and outbreaks occurred in 2006 and 2010. Initially most cases had travelled to the
neighbouring country (India), although lately indigenous cases are also being reported.

The affected districts are Chitwan, Kanchanpur, Kailali, Banke, Bardiya, Dang, Kapilvastu, Parsa,
Rupandehi, Rautahat, Sarlahi, Saptari and Jhapa, reflecting the spread of the disease throughout the
Tarai plains from west to east. In 2011, 79 confirmed cases were reported from 15 districts with the
highest number in Chitwan (55).

Aedesaegipti (the mosquito-vector) was identified in five peri-urban areas of the Tarai (Kailali, Dang,
Chitwan, Parsa and Jhapa) during entomological surveillance by EDCD during 2006–2010, indicating
the local transmission of dengue.

Studies carried out in collaboration with the Walter Reed/AFRIMS Research Unit (WARUN)in 2006 by
EDCD and the National Public Health Laboratory (NPHL)found that all four sub-types of the Dengue
virus (DEN-1, DEN-2, DEN-3 and DEN-4) were circulating in Nepal. Details of Nepal’s Dengue Control
Programme are given in Box 4.4.1.

Box 4.4.1: Nepal’s Dengue Control Programme

Goal — To reduce the morbidity and mortality due to dengue fever, dengue haemorrhagic fever (DHF) and
dengue shock syndrome (DSS).

Objectives:
 To develop an integrated vector management (IVM) approach for prevention and control.
 To develop capacity on diagnosis and case management of dengue fever, DHF and DSS.
 To intensify health education and IEC activities.
 To strengthen the surveillance system for prediction, early detection, preparedness and early response
to dengue outbreaks.

Strategies:
 Early case detection, diagnosis, management and reporting of dengue fever,DHF and DSS.
 Regular monitoring of dengue fever, DHF and DSS cases and surveillance through the EWARS.
 Mosquito vector surveillance in municipalities.
 The integrated vector control approach where a combination of several approaches are directed
towardscontainment and source reduction

Major activities in 2073/74


 Trained physicians, nurses, paramedics and laboratory technicians on dengue case detection,
diagnosis, management and reporting.
 Orientated municipality stakeholders in 25 programme districts.
 Supplied rapid diagnostic test kits (IgM).

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Disease Control
 Dengue case monitoring and vector surveillance.
 Search and destruction of dengue vector larvae (A. aegypti) in 25 programme districts.
 Developed and disseminated health education messages.

Achievements
A total of 1527 dengue cases were reported from 42 districts in 2073/74 (Table 4.4.1). The most
were from Chitwan (687) followed by Jhapa and Rupendehi. And there was one confirmed deaths
due to Dengue —in Chitwan.

The number of reported dengue cases has decreased significantly since 2010 (Figure 4.4.1) with high
percent increase in the last three years from 302 to 134 to 1527 in the current year. The majority of
cases have been reported from Chitwan, Jhapa and Rupandehi with more than 46 percent of
2073/74 cases from Chitwan.

Table 4.4.1: Dengue positive cases (2071/72–2073/74)


Total positive
SN Districts
2071/72 2072/73 2073/74
1 Bara 0 2 4
2 Bhaktapur 1 1 0
3 Bhojpur 0 2 0
4 Chitwan 119 70 687
5 Dadeldhura 1 0 0
6 Dang 0 3 8
7 Doti 1 0 0
8 Gorkha 0 2 0
9 Gulmi 0 1 0
10 Ilam 0 0 0
11 Jhapa 8 2 405
12 Kailali 9 1 14
13 Kanchanpur 15 4 2
14 Kapilbastu 0 2 3
15 Kaski 0 1 1
16 Kathmandu 1 1 5
17 Kavre 0 1 2
18 Mahottari 0 0 3
19 Makwanpur 20 2 82
20 Nawalparasi 3 12 3
21 Palpa 0 4 0
22 Parsa 114 12 7
23 Pyuthan 0 1 1
24 Rautahat 0 0 0
25 Rupandehi 10 2 164

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4.5 Zoonosis

Background
The Epidemiology and Disease Control Division (EDCD) is responsible for responding to poisonous
snake bites, and the control and prevention of rabies and other zoonosis in coordination and
collaboration with the general public and non-governmental and private partners

See Box 4.5.1 goals and objectives of the national zoonosis control programme.

Box 4.5.1: Goals and objectives of national zoonosis control programme

Goals:
 No Nepalese dies of rabies or poisonous snake bites due to the unavailability of anti-rabies vaccine (ARV)
or anti-snake venom serum or timely health care services.
 To prevent, control and manage outbreaks and epidemics of zoonosis.

Objectives:
 To strengthen the response and capacity of health care service providers for preventing and controlling
zoonoses.
 To improve coordination among and between stakeholders for preventing and controlling zoonoses.
 To enhance the judicious use of tissue culture, ARV and ASVS in health facilities.
 To reduce the burden of zoonotic diseases (especially rabies and six other priority zoonoses) through
public awareness programmes.
 To provide tissue culture ARV as a post-exposure treatment to all victims bitten by suspicious or rabid
animals.
 To reduce the mortality rate in humans by providing ASVS and ARV.
 To train medical officers and paramedics on snake bite management and the effective use of ARS.
 To reduce the number of rabid and other suspicious animal bites.
 To reduce the annual death rate due to rabies.

Rabies— almost half of Nepal’s population is at high risk and a quarter at moderate risk of
rabies.Around 30,000 cases in pets and more than 100 human rabies cases occur each year with the
highest risk are in the Tarai (Figure 4.5.1). Latent infectionshave been reported in dogs and cats and
rabies has also been reported in bats.Very few patients take rabies immune globulin (post-exposure
prophylaxis). Surveillance is passive. Recent progress has seen the Arctic Fox rabies genome type
virus isolated and laboratories strengthened for ARV production.

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Figure 4.5.1: Rabies risk zones in Nepal

Activities and achie


achievements
vements in 2073/74 in Rabies control Programm
The following activities were carried out in 2073/74 for the control of rabies cases:
 Stray dog sterilization program and awareness program were conducted for the control of
rabies
 Orientation program to Medical officers
officers, nurses and paramedics was conducted on theproper
proper
use of ARV.
 Procurement of cell culture ARV vaccine for almost 6000 people of high risk area

In 2073/74, 37226 cases animal bites were reported (Table


Table 4.5.1). The number of reported animal
bite cases has fluctuated in recent years but tthe
he number of rabies deaths has increased in line with
the decreasing
creasing administration of ARV.

Table 4.5.1: Status of reported dog bites and rabies in Nepal


No of cases of No. of cases of
No. of cases of animal No. ofARV vials
Fiscal year dog bites other animal Deaths
bites (dog+ other animal) consumed
bites
2065/66 24,005 2,571 26,576 145,978 97

2066/67 23,517 2,145 25,662 168,194 89

2067/68 24,269 2,197 26,466 167,663 83

2068/69 29,102 2,211 31,313 229,851 76

2069/70 31,937 2,996 34,933 219,651 68

2070/71 31,976 2,540 34,516 195,868 10

146 DoHS, Annual Report 2073/74


207 (201
(2016/17)
Disease Control
No of cases of No. of cases of
No. of cases of animal No. ofARV vials
Fiscal year dog bites other animal Deaths
bites (dog+ other animal) consumed
bites
2071/72 17,320 3,290 20,610 273,000 13

2072/73 20,133 2,494 22,627 320,139 6

2073/74 37,226 2,518 39,744 227,639 8


Source: HMIS/EDCD

Snake bites
Poisonous snake bites — Twenty-one of the 79 species of snakes found in Nepal are poisonous (11
pit viper species, 5 krait species, 3 cobra species and 1 each coral and Russel’s viper species). Around
15,000 snake bite cases occur annually of which about 10 percent are poisonous bites. The mortality
rate is about 10 percent among poisonous bite cases. The 26 Tarai districts are highly affected. In the
last eight years between 1 and 131 deaths have been reported from poisonous snake bites each
year. The free distribution of anti-snake venom serum (ASVS) began in 1999/2000. Indian
quadrivalent ASVS is used.

The following activities were carried out in 2073/74 for the control and management of poisonous
snake bites:
 Guideline for snake bite was published
 orientation program to Medical officers, nurses and paramedics was conducted on the proper
use of Anti snake venom
 Procurement of cell culture ASV for almost 2000 people of high risk area
 Research was done for the production of anti-snake venom within the country.

In 2073/74, 6,121 snake bite cases were reported in Nepal (Table 4.5.2). A total of 912cases were
poisonous resulting in 33 deaths. Table 4.5.3 summarises progress in 2073/72 against previous years
data.

Table 4.5.2: Snake bite cases and deaths, Nepal (2065/66–2073/74)


Fiscal year Total cases Non-poisonous Poisonous Cure No. deaths % deaths
2065/66 13,017 11,883 1,134 1,006 128 11.3

2066/67 17,163 15,844 1,319 1,188 131 9.9

2067/68 18,204 17,121 1,083 965 118 10.9

2068/69 14,768 13,789 979 890 89 9.1

2069/70 14,329 13,462 867 788 79 9.1

2070/71 5,143 4,145 998 988 10 1.0

2071/72 4,128 3,461 667 666 1 0.14

2072/73 3,268 2,605 663 643 20 3.0

2073/74 6,121 5209 912 879 33 3.6


Source: HMIS/EDCD

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Table 4.5.3: Issues, recommendations from reviews and actions taken—control of zoonoses
Issues Recommendations Action taken
The under reporting of cases and Develop a regular reporting mechanism Increased supervisory
deaths from dog and snake bites visit to reporting sites

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4.6 Leprosy
Background
The establishment of the Khokana Leprosarium in the nineteenth century was the beginning of
organized leprosy services in Nepal. Key leprosy control milestones since 1960 and the goal, objectives
and strategies of the national Leprosy Control Programme are:

Evolution and milestones of leprosy control programme in Nepal


Year Landmarks
1960 Leprosy survey by Government of Nepal in collaboration with WHO
1966 Pilot project to control leprosy launched with Dapsone monotherapy
1982 Introduction of multi-drug therapy (MDT) in leprosy control programme
1987 Integration of vertical leprosy control programme into general basic health
services
1991 National leprosy elimination goal set
1995 Focal persons (TB and leprosy assistants [TLAs]) appointed for districts and regions
1996 All 75 districts were brought into MDT programme
1999/2000–2001/02 Two rounds of National Leprosy Elimination Campaign (NLEC) implemented
2008 Intensive efforts made for achieving elimination at the national level
2009 and 2010 Leprosy elimination achieved and declared at the national level
2011 National Leprosy Strategy (2011–2015)
2012-2013 Elimination sustained at national level and national guidelines, 2013 (2070)
revised
2013-2014 Mid-term evaluation of implementation of National Leprosy Strategy (2011-2015)
2014-2015 Ministry of Health designated LCD as the Disability Focal Unit
2017 Policy, Strategy and 10 Years Action Plan on Disability Management (Prevention,
Treatment and Rehabilitation) 2073-2082 developed and disseminated

Goal, objectives, strategies and targets of the leprosy control programme


Vision: Leprosy free Nepal
Goal : End the consequences of leprosy including disability and stigma
Guiding principles
 Stewardship and system strengthening
 Expedite the elimination process in high prevalence districts
 Collaboration, coordination and partnership
 Community involvement
DoHS, Annual Report 2073/74 (2016/17) 149
Disease Control
 Integration, equity and social inclusion
 Linkages with Universal Health Coverage and Sustainable Development Goals

Objectives:
1. Achieve elimination status in all districts by 2019
2. Expand services for early detection of leprosy cases at health facility, especially in high
prevalence districts through Enhancing selected diverse approaches (ISDT)
3. Strengthen cases-based reporting and surveillance by 2017
4. Initiate Post-Exposure Leprosy Prophylaxis to family members and neighbors
5. Achieve the surveillance performance indicators

Strategies

1. Expand and Enhance early case detection through selected diverse approaches (ISDT)
2. Strive to achieve the surveillance performance indicators
3. Modernize and intensify the service delivery pathways for ensuring quality services
4. Heighten the collaboration and partnership for Leprosy-Free Nepal
5. Enhance support mechanism for people infected and affected by leprosy

Activities and achievements in 2073/74


MDT service delivery — In 2073/74, 3215 new leprosy patients were detected and put under multi-drug
therapy out of whom 2,626 cases were under treatment at the end of the fiscal year. During the year,
3,400 patients completed treatment and were released from treatment. Secondary and tertiary care
services were provided to needy and leprosy-affected patients through the existing network of referral
centres with partner support. MDT drugs (that are made available by the Novartis Foundation through
WHO) and anti-reaction drugs were freely available and the supply remained uninterrupted throughout
the year.

Capacity building — The Leprosy Control Division (LCD) ran the following capacity building programmes
in 2073/74:
 The Comprehensive Leprosy Training especially for Female Health Workers of took places in two
batches July 24 – Augusts 28 and 2016 and July 31st – August 4th 2016 and witnessed 40 participants
from 20 leprosy endemic districts.
 One day leprosy orientation programmes for media persons, village health promoters, social
workers, nursing staff, lab staff and MBBS and elective medical students.
 The 5-days comprehensive leprosy training (CLT) course for health workers.
 The 6 days basic leprosy training (BLT) course for medical officers
 Comprehensive Leprosy Training to 20 Health workers (HA & AHW) of 10 districts from 17-21
October 2016

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These trainings are being conducted with support from The Leprosy Mission Nepal- Anandaban Hospital,
International Nepal Fellowship, Nepal Leprosy Trust, Lalgadh and WHO.

IEC and advocacy — In order to enhance community awareness, passive case detection, voluntary case
reporting and to reduce stigma, IEC activities were regularly undertaken using electronic and print
media. Posters highlighting the diagnosis, reactions, treatment and free leprosy services were produced
and distributed for display at health facilities in all 75 districts and for raising public awareness. Two
infomercials and one music video were produced and broadcast. Leprosy messages were also
broadcasted in coordination with Nepal TV and FM radio programmes highlighting the World Leprosy
Day. Moreover, as LCD as been designated as the Disability Focal Unit by Ministry of Health in 2071 B.S,
short promotional video related to disability was produced and broadcasted from NTV.

World Leprosy Day—World Leprosy Day which is celebrated on the last Sunday of in the month of
January internationally, similarly 64th World Leprosy Day was commemorated on 29th January 2017 in
Nepal by conducting various activities at national, regional and district levels. On the same day a media
interaction programme was arranged at DoHS in presence of the Director General, warm clothes
distribution programme was undertaken for leprosy affected people of Narayanthan on the same day.

Reviews — Regular trimester review meetings were held at district and regional levels where
aggregated data, administrative issues and accomplishments were presented and discussed and future
plans discussed. Three central trimester review workshops were held to assess the outcome and
monitoring of the programme. Regional TB-Leprosy Officers (RTLOs) presented and shared information
and issues on the leprosy programme in their regions. Regional medical store chiefs also presented the
MDT drugs situation and informed that MDT supply had been uninterrupted over the year.

Early case detection— A focal campaign for active case detection was run in the three high leprosy
endemic districts of Kapilvastu, Rupandehi and Bara districts. Forty-five health workers, 135 FCHVs and
90 leprosy affected people were oriented on performing house-to-house searches. The searches were
then carried out. Leprosy officers, supervisors and partner personnel then supported health facilities to
diagnose and manage identified cases. In addition, a week long active case detection programmes was
also run in urban slums of Mahottari in coordination with the DHOs, district TB and leprosy officer
(DTLOs), FCHVs, health workers and additional support from partner organisations.

Contact examination — Contact examination is an index case-based approach where health workers
and FCHVs visit every household around a newly detected leprosy case using the pictorial card and
search for any signs and symptoms of leprosy and refer suspected cases to the nearest health facility for
confirmation and treatment. This programme was undertaken in VDCs of Dhanusa, Saptari and Rautahat
districts with the family and neighbours of 136 index cases. Twenty six new cases were diagnosed in the
contact/neighbours examination conducted from 30 Sep. - 27 Nov. 2016 (14 Ashwin - 12 Mangsir 2073).

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Disease Control
Diagnosed Cases

Total cases

G2D cases
No. of

% of MB

Female

Female
No. of

cases

% of

% of
G2D
Districts Municipality/ Child
index Adult
VDC (>14 yr)
cases MB PB MB PB
Saptari 10 25 2 2 0 3 7 29 5 71% 2 29%
Dhanusha 20 75 1 7 1 3 12 17 3 25% 0 0%
Rautahat 19 36 2 3 0 2 7 29 4 57% 1 14%
Total 49 136 5 12 1 8 26 23 12 48% 3
12%

District Level Mini Leprosy Elimination Campaign (MLEC) –Despite the fact that Nepal attained an
elimination status in 2010, every year the prevalence of leprosy is still greater than 1 per 10,000
population in 18-20 Terai districts. Hence, in order to achieve the elimination status in sub-national
level, MLEC was carried out in Banke and Bardiya district in support from Sasakawa Memorial Health
Foundation. The package of MLEC included sensitization, advocacy, IEC, awareness, door to door case
search and stigma reduction activities. Altogether, 2400 people were oriented regarding leprosy, six
lakhs population were screened and 282 (145 Bardiya/137 Banke) new cases were identified and put
under MDT.

Continued medical education— A one day medical education event was run for neurologists, surgeons,
dermatologists, physicians and other medical officers in Biratnagar, Chitwan, Butwal, Nepalgunj and
Dhangadi from 22nd -26th Ashad 2073. The events highlighted the roles of clinical specialists in leprosy
control, reducing disease burden and stigma prevention and provided up-to-date information on leprosy
management.

Transport support to released-from-treatment cases — The LCD provided grants of NPT 1,000 to 3040
patients released from treatment to cover their transport costs after completing MDT treatment. The
treatment regularity rate of patients is increasing partly due to the provision of this incentive.

Recording, reporting, update and leprosy case validation— Recording and reporting update and case
validation was carried out in Dhanusa district to verify data and records of cases in health facilities, to
validate cases diagnosed by health facilities and to strengthen recording and reporting and the release
of cases from treatment. This was carried by a joint team of LCD, RHD, DHO, DPHO, WHO and TLMN.

Publications — The annual report 2073/74 (2015/16) was published and programme operational
guideline containing technical and financial information for implementing and conducting leprosy
control activities was developed and printed that were distributed to DHOs/DPHO/RMS. Besides, Policy,
Strategy and 10 Years Action Plan on Disability Management 2073-2082, Leprosy Handbook and Bulletin
were also published and disseminated.

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Accessibility programme — A one day orientation was conducted in district level to raise the awareness
of disadvantaged and unreached communities about the signs and symptoms of leprosy. The
communities were also educated on stigma reduction and encouraged to take part in leprosy control
activities. A few of the programmes led to participants identifying suspected cases and referring them to
health facilities.

Supervision and monitoring — Regular supervisory visits were undertaken by LCD staff to guide health
workers at peripheral health facilities and to DHOs, DPHOs and RHDs. Additional funds for this were
provided by WHO and Netherlands Leprosy Relief (NLR).

Involvement of people affected by leprosy— LCD has been supporting a networks of people affected by
leprosy and empowered them to widen the involvement and participation of leprosy affected people in
leprosy related awareness raising and income generation activities. This is highly appreciated by the
people affected with leprosy and the partners working in leprosy control activities in Nepal.

Review, planning and interaction programmes — Review, planning and interaction programmes were
organized in the 19 high endemic Terai district each trimester to identify and resolve technical issues
and for updating and verifying records in the presence of DHOs, DPHOs, TBLOs, statistical officers, other
health workers and leprosy affected people.

Coordination with partners — LCD organized coordination meetings among the partners working in the
leprosy control and disability prevention sector. Three meetings were held with the participation of
WHO, NLR, Leprosy Mission Nepal (LMN), Nepal Leprosy Trust (NLT), International Nepal Fellowship
(INF), BIKASH Nepal, Partnership for New Life (PNL), Nepal Leprosy Fellowship (NLF), Nepal Leprosy
Relief Association (NELRA), Sewa Kendra, Shanti Sewa Griha, Rehabilitation, Empowerment and
Development (READ) Nepal, and IDEA Nepal. The meetings were held to share regular updates on
activities, to have common approach to celebrate World Leprosy Day and to develop programme
guidelines.

Surveillance for preventing disability— The surveillance of leprosy cases was carried out in seven health
facilities (Koshi Zonal Hospital, Anandaban Hospital, Lalgadh Hospital, Seti Zonal Hospital, Butwal Clinic,
Patan Clinic and INF-Banke Clinic. Detail information was collected about 200 under treatment cases was
collected. Further strengthening of this system is needed to collect timely and quality information with a
plan to collect it every three months.

Post exposure prophylaxis —Leprosy post-exposure prophylaxis (LPEP) in which the single dose
Rifampicin is given to contacts of newly diagnosed leprosy patients to decrease their risk of developing
leprosy, is now extended to Kailali, Dhanusa, Kapilvastu and Rupandehi districts from the initial pilot
districts: Parsa, Morang and Jhapa. This programme is being implemented in government as well as
partners (The Leprosy Mission Nepal, Netherland Leprosy Relief & Nepal Leprosy Trust) support. The
updates on LPEP till Chaitra 2073 is as followed:

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Disease Control
No. of index Contact No. of No. of contact New case finding
Districts
cases Searched contact excluded Leprosy TB
Jhapa 650 490 12718 306 70 17
Morang 542 562 11044 686 39 2
Parsa 381 300 7874 295 49 1
Sub Total 1573 1352 31636 1287 158 20
Dhanusa 89 89 3533 1864 41 0
Kapilvastu 148 145 5364 373 20 2
Rupandehi 24 24 738 118 0 0
Sub Total 261 258 9635 2355 61 2
Grand Total 1834 1610 41271 3642 219 22
Note: LPEP is being implemented in Kailali recently, hence the district update is not included in the table.

Grant to leprosy affected persons— Every year a grant is provided to support leprosy affected residents
in the Khokana and Pokhara leprosy ashrams through the Nepal Leprosy Relief Association (NELRA). The
grant goes to provide fuel, blanket, food and incentives to approximately 175 leprosy affected people.
The amount of grant has increase from NRs. 1 million to 1.2 million in the current year.

Injury/Trauma Management Training, Orientation and Empowerment of Disability Stakeholders

3 days Injury –Trauma Management Training was carried out targeting 22 health professionals
(Health assistants, nurses and medical officers) of 7 provinces from Ashad 25-27, 2074 at
Sukraraj Tropical Infectious Disease Hospital.
Activities regarding Orientation and Empowerment of Disability Stakeholders were carried out in
Kathmandu, Hetuada and Surkhet for members of Disability Peoples Organization in Jestha and Ashad
2074.

Dissemination of Policy, Strategy and 10 Years Action Plan on Disability Management (2073-
2082)
After rigorous discussions and meetings with disability partners, stakeholders and disability
peoples' organizations, Policy, Strategy and 10 Years Action Plan on Disability Management
(2073-2082) was developed. The dissemination of the Action Plan took place on Jeatha 4, 2074
(18th May 2017) in presence of former Honorable Health Minister: Gagan Kumar Thapa and
Honorable State Minister of Health: Tara Man Gurung.

ACTIVITIES SUPPORTED BY PARTNERS


In 2073/74, WHO supported the supply of MDT drugs, provided technical support for the leprosy control
programme, assisted in supervision and monitoring, and supported capacity building, active case
detection and the community awareness programme

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The Netherlands Leprosy Relief, Leprosy Mission Nepal, Nepal Leprosy Trust and International Nepal
Fellowship supported the following activities in high endemic districts:
 Community awareness and participation programme
 Orientation of community members
 Provision of primary, secondary and tertiary care at referral centres
 Capacity building activities for government health workers
 Technical support through joint supervision and monitoring
 Prevention of disability in leprosy and rehabilitation service
 Formation, implementation and support of self-care and self-help groups operated by people
affected by leprosy and people living with disabilities due to leprosy
 Support for Post-Exposure Prophylaxis Programme

Prevalence
Overall prevalence
At the end of FY 2073/74 (2016/17), 2626 leprosy cases were receiving MDT in Nepal, which makes a
registered prevalence rate of 0.92 case per 10,000 population at the national level. This rate is below the
cut-off point of 1 case per 10,000 population set by WHO to indicate the elimination of leprosy as a
public health problem. This shows that Nepal’s elimination status from 2009 is being sustained. The
prevalence rate has slightly increased than the previous year. Out of 77 districts, 6 districts reported
zero prevalence, 54 districts had a prevalence rate <1 and 17 districts had a rate of more than 1.

Figure : Leprosy prevalence in Nepal, 2073/74 (2016/17)

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Disease Control
The highest number of leprosy cases under treatment was reported from Province-2 (890 cases, 34% of
total) followed by Province-5 (764 cases, 29% of total) (Table 4.6.1). The registered prevalence rate was
the highest in Province-5 (1.57 case per 10000 population) followed by Province-2 and lowest
prevalence was reported at Province-6 (0.62 case per 10,000 population).

Table : Distribution of registered cases and prevalence rate in 2073/74


Provinces No. of registered prevalence cases at the end of the year
Total cases Percentage Reg. prevalence rate / 10,000 population
Province-1 394 15% 0.82
Province-2 890 34% 1.50
Province-3 157 6% 0.26
Province-4 116 4% 0.47
Province-5 761 29% 1.56
Province-6 110 4% 0.64
Province-7 198 8% 0.71
National 2626 100% 0.92
Source: LCD

The number of districts reporting a prevalence rate of more than 1 per 10,000 population decreased to
16 from 18 in the previous year (Figure). Fifteen of the 17 districts are in the Terai belt whereas Jajarkot
falls in the hilly region. Banke reported the highest prevalence rate (4.67 per 10,000 population).

Figure: Districts with leprosy prevalence rate above 1 per 10,000 population

Banke 4.67
Bardiya 4.53
Dhanusa 2.03
Parsa 1.6
Bara 1.59
Sarlahi 1.58
Mahottari 1.45
Jhapa 1.37
Morang 1.36
Rautahat 1.32
Siraha 1.3
Jajarkot 1.28
Kailali 1.2
Nawalparasi-East 1.13
Chitwan 1.12
Kapilvastu 1.11
Nawalparasi-West 1.06

0 1 2 3 4 5

156 DoHS, Annual Report 2073/74 (2016/17)


Disease Control
NEW CASE DETECTION

The detection of new cases signifies ongoing transmission with the rate measured per 100, 100,000
000
population. A total of 3215 new leprosy cases were detecte
detectedd in 2073
2073/74 with the 36% of new cases in
Province (1,170 cases
Province-2 cases).. Meanwhile, Province
Province-4 and 6 have the lowest new case detection (as
as shown in
the figure).
igure). The ne
neww case detection rate (NCDR) per 100,000 populations for FY 2072073/744 was 11.23
23
nationally
nationally.

Eight districts (Dhankuta,


Dhankuta, Dolpa, Humla,
Humla Manang, Mustang, Panchthar, Rukum-
Rukum-East
East and Sindhupalchok)
Sindhupalchok)
reported no new cases this year while 221 districts had case detection
detection rates more than 10 (Figure
(Figure)) of
which Banke had the highest rate (51. (51.83
83) followed by Bardiya (51.14). District level mini leprosy
elimination campaigns were conducted in these two districts scanning the 60% of the whole district
population which resul
resulted
ted in the tremendous increase in NCDR as compared to previous year rate of
34.91 and 26.11 respectively
respectively.

Figure: Province-wise
Province wise new leprosy cases, 2073/74

209
115 501

Province
Province-1
880
Province
Province-2
Province
Province-3
Province
Province-4
1170
Province
Province-5
125 Province
Province-6
215
Province
Province-7

DoHS, Annual Report 207


2073/74 (2016/17)
(201 157
Disease Control
Figure: Districts with more than 10 new case detection rate per 100,000 population, 2073/74

Sunsari 10.42
Nawalparasi West 10.6
Nawalparasi East 10.98
Rupandehi 12.18
Saptari 13.75
Udaypur 13.77
Chitwan 13.82
Kailali 13.96
Siraha 15.62
Rautahat 16.77
Jajarkot 17.03
Kapilvastu 17.43
Parsa 17.46
Jhapa 17.8
Morang 18.01
Bara 18.88
Mahottari 20.21
Sarlahi 20.81
Dhanusa 32.53
Bardiya 51.14
Banke 51.83

0 10 20 30 40 50 60

Fifty two percent of new cases were multibacillary (MB) and the rest were paucibacillary (PB). This
proportion has remained around fifty percent for the last few years. More than one third (42.33%) of
the new cases were among females. The female proportion has remained in the range of 30-40 percent
for the last five years. 6.84 percent of new cases were detected among children. The stagnant indicator
of child cases signifies that transmission is still prevalent among children. However, the Grade-2
Disability (visible disability) has decreased to 2.71% from 3.57%.

Table: Details of new leprosy cases (2073/74)

Provinces Total New Cases NCDR

Province-1 501 10.57


Province-2 1170 19.77

Province-3 215 3.54

Province-4 125 5.05

Province-5 880 18.09

Province-6 115 6.70

Province-7 209 7.51

National 3215 11.23


Source: LCD
158 DoHS, Annual Report 2073/74 (2016/17)
Disease Control
TREND IN PREVALENCE, CASE DETECTION AND RELAPSE CASES
There has been little change in new case detection and the number of registered cases in the last eight
years. The prevalence decreased in 2066/67 when elimination status was declared and has been under
the elimination rate since then but the prevalence has increased this year. However, the new case
detection rate has remained around 11. The number of relapse cases increased from 12 cases in the
previous year to 15 in 2073/74.

Figure: Trend in new leprosy case detection rate and prevalence rate from 2067/68-2073/74
1 0.92 20
0.89 0.89
0.85 0.84 0.83
0.79

NCDR/1,00,000 Population
0.8
PR/10,000 Population

15

0.6
12.2 11.9 11.8 10
11.2 11.01 11.23
10.67
0.4

PR/10,000 Population NCDR/1,00,000 Population 5


0.2

0 0
2067/68 2068/69 2069/70 2070/71 2071/72 2072/73 2073/74

Figure: Trend in relapse cases from 2067/68- 2073/74

30
27
25
20 20
15 15
11 12
10
8
5 5
0
2067/68 2068/69 2069/70 2070/71 2071/72 2072/73 2073/74

DISABILITY CASES
Leprosy cases that are not detected early on or in a timely and complete may results in disabilities. Early
detection and timely and complete treatment is crucial for preventing disabilities. The Proportion of
Grade 2 Disability (G2D) among new cases and the rate per 100,000 population are major monitoring
indicators of early case detection. During 2073/74, 87 cases of visible disability (G2D) were recorded
with a proportion among new cases of 2.71% nationally.

DoHS, Annual Report 2073/74 (2016/17) 159


Disease Control
CHILD CASES
A total of 220 new child cases were diagnosed in 2073/74 resulting to 6.84% of new cases. This was a
decrease from the previous year although the trend is fluctuating (Figure).

45 42.33
38.28
40 35.46 36.03
35 31.6 30.86
28.39
30
25
20
15
10 7.73 7.2 6.84
6.26 6.33
5.19 4.18
5 4.42
3.57 3.16 2.89 3.38 3.57 2.71
0
2067/68 2068/69 2069/70 2070/71 2071/72 2072/73 2073/74

G2D among new Female among new Child among new

Conclusions
The elimination status was maintained at the national level as the prevalence rate remained below 1
case/10,000 population this year although the rate was still high in 17 districts compared to 18 districts
last year. The increased proportion of female and child cases could be a result of more early and active
case detection activities. Finally, there is good coordination and partnerships with partners.

The figures for the main indicators of leprosy control for the last eight years are summarised in Table
while the main strengths, weakness and challenges of the leprosy control programme are listed.

160 DoHS, Annual Report 2073/74 (2016/17)


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Table : Comparison of leprosy indicators (2066/67–2073/74)

(2009/10)

(2010/11)

(2011/12)

(2012/13)

(2013/14)

(2014/15)

(2015/16)

(2016/17)
2066/67

2067/68

2068/69

2069/70

2070/71

2071/72

2072/73

2073/74
Indicators

New patients 3,157 3,142 3,481 3,253 3,223 3,053 3,054 3215
New case detection rate 11.5 11.2 12.2 11.9 11.18 11.01 10.67 11.23
Under Treatment cases at the end 2,104 2,210 2,430 2,228 2,271 2,461 2,559 2626
PR/10,000 population 0.77 0.79 0.85 0.82 0.83 0.89 0.89 0.92
No. new child cases 212 163 218 136 204 236 220 220
Proportion child cases 6.71 5.19 6.26 4.24 6.33 7.73 7.20 6.84
New G2D cases 86 109 110 94 109 135 109 87
Proportion G2D cases 2.72 3.47 3.16 2.89 3.38 4.42 3.57 2.71
G2D rate/100,000 0.31 0.39 0.39 0.35 0.40 0.49 0.38 0.33
New female cases 1,030 892 1,100 1,004 1,143 1,100 1,169 1361
Proportion female cases 32.6 28.4 31.6 30.8 35.46 36.03 38.28 42.33
Released from treatment 3,844 2,979 3,190 3,374 3187 2,800 2,902 3040
No. Defaulters 25 31 24 43 24 38 44 57
No. relapse cases 18 20 25 14 11 8 12 15
Source: LCD

Table 4.6.5: Strengths, weakness and challenges for the leprosy control programme
Strengths Weaknesses Challenges
 Commitment from political level  Low priority for leprosy  To sustain the elimination
–government's commitment to programme at periphery achieved at national level and
Bangkok Declaration for Leprosy  Low motivation of health elimination at district level
 Accessible of leprosy service workers  To maintain access and quality of
 Free MDT, transport service for  Very few rehabilitation services in low endemic mountain
released from treatment cases activities and hill districts
and other services for treating  Inadequate training and  To strengthen surveillance,
complications orientation for newly logistic, information, and job
 Uninterrupted supply of MDT recruited health workers and oriented capacity-building for
refresher trainings for focal general health workers, and an
 Good communication and
persons and managers efficient referral network
collaboration among supporting
partners  Poor institutional set-up and  To assess the magnitude of
 Improving participation of inadequate human resources disability due to leprosy
leprosy affected people in  Problem for reaction and  To further reduce stigma and
national programme complication management at discrimination against affected
persons and their families
 Steering, coordination and periphery level
technical committees formed  Poor result-based output,  Insufficient activities in low

DoHS, Annual Report 2073/74 (2016/17) 161


Disease Control
and conducting meeting in recording and reporting of endemic districts for reducing the
regular basis contact examination activities disease burden
 Contact examination/  Poor coverage and monitoring  To maintain access and quality
surveillance of patient, family of LPEP in implementing service at HF level
members and neighbours districts  Strengthening of index case &
 Introduction of Leprosy Post- contact surveillance, recording and
Exposure Prophylaxis in 7 of the reporting system
high

Future course of action and opportunities


 Implement the national strategy 2016-2020 within MoH and through partners.
 Use and follow national operational guideline as per the new strategy.
 Intensify IEC activities to raise community awareness on early diagnosis and treatment, the
prevention of disability, rehabilitation and social benefits.
 Strengthen early case detection by focusing on pocket areas of high endemic districts.
 Develop an intensified case search activity for the district level elimination
 Promote community participation in the National Leprosy Elimination Programme.
 Improve the access of unreached, marginalized and vulnerable groups to leprosy services.
 Strengthen the involvement of people affected by leprosy in leprosy services and programmes.
 Build the capacity of health workers for early case detection, management and community based
rehabilitation.
 Carry out operational research in high endemic districts and pockets on specific issues for quality
services.
 Expand chemoprophylaxis and immuno-prophylaxis (one, either or both) to protect contacts and
break transmission.
 Intensify vocational education and income generation activities for people affected by leprosy.
 Ensure resource mobilization, partnership and participation of local government and collaboration
with new partners, institutions and individuals for leprosy services and rehabilitation.
 Strengthen the capacity of LCD for effectively implementing national policies and strategies.
 Strengthen surveillance in low endemic districts and areas.
 Strengthen the evidence-based (laboratory confirmed) reporting of relapse cases.
 Address cross-border issues.
 Sustain the newly initiated programme and services e.g. satellite services, interactions with medical
college hospitals, joint monitoring, training and observation in partnership approach.
 Strengthen referral hospital (efficiency, quality service in handed over zonal hospitals) and proper
referral mechanism.

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4.7 Tuberculosis
Background
Tuberculosis (TB) is a public health problem in Nepalthat affects thousands of people each year and
is the sixth leading cause of death in the country. WHO estimates that 44,000 people develop active
TB every year and out of them 20,500 have infectious pulmonary disease and can spread the disease
to others. The achievement of the global targets of diagnosing 70 percent of new infectious cases
and curing 85 percent of these patients will prevent 30,000 deaths in Nepal over the next five years.

In 2073/74, the National Tuberculosis Programme (NTP) registered 31,764 TB cases. Among them
16,927 (53.28%) were new and relapse pulmonary smear positive TB cases, 427 (1.34%) were smear
positive retreatment cases, 5,216 (16.42%) were sputum smear negative and 9,194 (28.94%) were
extra-pulmonary TB cases. Of all registered cases20,364 (64.1%) were male and 11,400 (35.9%)
female.

According to the latest WHO data (May 2016), tuberculosis deaths in Nepal reached 5,506, 3.5
percent of all deaths. The age adjusted death rate was 27.80 per 100,000 of population, which ranks
Nepal as the forty-third most affected country. There were 971(296 female and 675 male) reported
deaths from TB in 2073/74. Most TB cases and deaths occur among men in a ratio of 2 male cases
for every female case. TB mortality is unacceptably high given that most deaths are preventable if
proper diagnosis and treatment are provided.

The Directly Observed Treatment Short Course(DOTS)has been implemented throughout the country
since April 2001. The NTP has coordinated with the public sector, private sector, local government,
I/NGOs, social workers, educational institutions and other sectors to expand DOTS and sustain the
good progress achieved by the NTP. There are 4,344 DOTS treatment centres in Nepal and the NTP
has adopted the global End TB Strategy and the achievement of the SDGs as the country’s TB control
strategy. Box 4.7.1 lists the aims of the national programme.

Box 4.7.1: Vision, goal, strategy and target of the National TB Programme
Vision: Nepal free of tuberculosis.

Long term goal: End the tuberculosis epidemic by 2050.Short term goal: Reduce TB incidence by 20%
by 2021 compared to 2015 and increase case notifications by a cumulative total of 20,000 from July
2016 to July 2021.

Objectives:
 Increase case notification through improved health facility-based diagnosis.
 Maintain the treatment success rate at 90% of patients (for all forms of TB) through to 2021.
 Provide drug resistance diagnostic services for 50% of persons with presumptive drug resistant
TB by 2018 and 100% by 2021 and successfully treat at least 75% of diagnosed drug resistant
patients.
 Further expand case finding by engaging the private sector.
 Strengthen community systems for the management, advocacy, support and rights of TB
patients in order to create an enabling environment to detect and manage TB cases in 60% of all
districts by 2018 and 100% of districts by 2021.

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Disease Control
 Contribute to health system strengthening through TB human resource management, capacity
development, financial management, infrastructure, procurement and supply management.
 Develop a comprehensive TB surveillance, monitoring and evaluation system
 Develop a plan to continue NTP services in the aftermath of natural disastersand public health
emergencies.

SDG31 global targets:


 By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and
combat hepatitis, water-borne diseases and other communicable diseases.

SDG and End TB Strategy(see Box 4.7.2)-related targets:


 Detect 100% of new sputum smear-positive TB cases and cure at least 85% of these cases.
 By 2050, eliminate TB as a public health problem (threshold of <1 case per million population).

Box 4.7.2: The End TB Strategy


The End TB Strategy was unanimously endorsed by the World Health Assembly in 2014. Its three
overarching indicators are i) the number of TB deaths per year, ii) TB incidence rate per year, and iii)
the percentage of TB-affected households that experience catastrophic costs as a result of TB. These
indicators have related targets for 2030and 2035.

The main principles for implementing the strategy are:


 government stewardship and accountability, with monitoring and evaluation;
 strong coalitions with civil society organizations and communities;
 the protection and promotion of human rights, ethics and equity; and
 the adaptation of the strategy and targets at country levels, with global collaboration.

The strategy’s components (three pillars) and related strategies are as follows:
1. Integrated, patient- entered care and prevention:
 Early diagnosis of TB including universal drug-susceptibility testing, and systematic
screening of contacts and high-risk groups.
 Treatment of all people with TB including drug-resistant TB.
 Collaborative TB/HIV activities and the management of co-morbidities.
 The preventive treatment of persons at high risk, and vaccination against TB.
2. Bold policies and supportive systems:
 Political commitment with adequate resources for TB care and prevention.
 The engagement of communities, civil society organizations, and public and private care
providers.
 Universal health coverage policy and regulatory frameworks for case notification,vital
registration, quality and rational use of medicines, and infection control.
 Social protection, poverty alleviation and actions on other determinants of TB.
3. Intensified research and innovation:
 The discovery, development and rapid uptake of new tools, interventions and strategies.

1
SDG 3: Ensure healthy lives and promote well-being for all at all ages)
164 DoHS, Annual Report 2073/74 (2016/17)
Disease Control
 Research to optimize implementation and impact, and promote innovations.

Major activities in 2073/74


 Provided effective chemotherapy to all patients in accordance with national treatment policies.
 Promote early diagnosis of people with infectious pulmonary TB by sputum smear examination
and GeneX-pert.
 Provided continuous drugs supply to all treatment centres.
 Maintained a standard system for recording and reporting
 Monitored the result of treatment and evaluate progress of the programme
 Strengthened cooperation between NGOs, bilateral aid agencies and donors involved in the
NTP.
 Coordinate and collaborate NTP activities with and HIV /AIDS programmes.
 E-TB orientation to district staff has been completed.
 Linkage of DOTS centres to Microscopic centre through courier.
 Provided training to health personnel.
 Training to medical doctors for childhood TB diagnosis.

Progress and epidemiology of TB


Institutional coverage and estimation of TB burden

Nepal adopted the DOTS strategy in 1996 and achieved nationwide coverage in 2001. All DOTS sites
are integrated in public health services or run through NTP partner organizations in public and
private sectors. In 2073/74, 4,344 institutions were offering TB diagnosis and treatment DOTS-based
TB control services. Among them, 4,204 are government health institutions. Also, several NTP
partners provide DOTS including private nursing homes, polyclinics, I/NGO health clinics, prisons,
refugee camps, police hospitals, medical colleges and municipalities.

The burden of disease from TB can be measured in terms of incidence (defined as the number of
new and relapse cases arising in a given period), prevalence and mortality. WHO estimates the
current prevalence of all types of TB cases for Nepal at 60,000 (241/100,000) while the number of all
forms of incidence cases (newly notified cases) is estimated at 44,000 (156/100,000).
Case notification
The NTP reported 31,764 tuberculosis cases in 2073/74. TheNationalCaseNotificationRate(Allforms)
is111/100,000population.BasedontheCNR, thereare 18districtshad CNR more then 120, while
30districtshad CNR between 75-120 and remaining 22 districts had below 75 CNR.Among 18 districts,
1 2 districts are from the Terai belt and mostly concentrated in central region.
There were 97% newer cases registered (New and Relapse) among all TB cases notified. Around 71 %
of all TB cases reporting in this reporting period were pulmonary cases and out of them 77%were
bacteriologically confirmed. Among those bacteriologically confirmed, 30% were confirmed using
Xpert MTB/RIF testing.
Nearly half of all TB cases (41%) of the cases were reported only from central region, where as in
terms of eco-terrain distribution, Terai belt holds more than half of TB cases (57%) reported this
year.
DoHS, Annual Report 2073/74 (2016/17) 165
Disease Control

Figure 4.7.1: Tuberculosis case notification rate, 2073/74

Table 4.7.1: TB case notification rate by region, FY 2068/69 – 2073/74


Year EDR CDR WDR MWDR FWDR NEPAL
2068/69 95 149 105 141 119 125
2069/70 105 153 120 146 135 130
2070/71 109 155 123 146 132 136
2071/72 96 137 115 137 125 123
2072/73 92 127 107 122 105 112
2073/74 83 123 106 129 110 111

Altogether 31,764 new cases were notified during 2073/74 (Figure 4.7.2). Among them 53.28
percent were bacteriologically confirmed new and relapse pulmonary cases (PBC), 16.42 percent
were clinically diagnosed pulmonary cases (PCD), 28.94 percent were extra pulmonary cases and
1.34 percent were smear positive retreatment cases (Figure 4.7.2). Just over 28,382 of these cases
(89.35%) had a new episode of TB and 3,382(10.65%) had already been diagnosed with TB but their
treatment was changed to a retreatment regimen. Among the new cases (31,764), 71.06percent
were pulmonary cases and 28.94 percent extra pulmonary cases.

166 DoHS, Annual Report 2073/74 (2016/17)


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Figure 4.7.2: TB cases registered in 2073/74 (2016/17)

TB case registered New and


Extra- relapse
pulmonary TB pulmonary
cases (9,194) smear positive
29% TB cases
Pulmonary (16,927)
Clinically 53%
diagnosed
(5216)
17%

Smear positive
retreatment
cases (427)
1%

The case notification rate of new smear positive cases (CNR/SS+) increased from 1996 until
2001when nationwide DOTS expansion was achieved. Of the 45,000–50,000 new cases (all forms)
estimated by WHO in recent years, NTP has notified 72 percent and successfully treated 91 percent
of notifiedcases. In spite of this sustained good performance, the CNR (both SS+ and all forms) has
stagnated in recent years (Figure 4.7.3). The percentage of new SS+ notification rate among new
pulmonary cases was 75percent in 2073/74, near the recommended WHO standard of 65 percent.

Figure 4.7.3: CNR new sputum positive TB cases (2068/69-2073/74)

70
67
65
60 60
55 55
53 52 53
50
45
40
2068/69 2069/70 2070/71 2071/72 2072/73 2073/74

Distribution by age and sex — Around 5.61 percent of cases registered this year were child cases. Of
the 94.39 percent adult cases there were 1.78 male to every female case. Among the childhood
cases, most (3.86% of total) were 5–14 years old. The regional age-wise distribution varied
considerably in 2073/74 from only 4 percent in the eastern region to 13 percent in the mid-western
region conversely meaning that the adult TB population was highest in the eastern region (96%) and
lowest in the mid-Western Region (89%).

Annual trends— The national CNR has been decreasing for many years Figure 4.7.4). The number of
cases registered reduced from 32,056 in the previous year to 31,764 in 2073/74. The rate of change
in CNR is 1.

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Disease Control

Figure 4.7.4: TB case notification rate (2068/69–2073/74)

160 case notification rate (PBC New)


Case notification rate (all forms)
140 130
136
123
120 125
111
112
100

80
64 67 69
60
61 60
56
40
2068/69 2069/70 2070/71 2071/72 2072/73 2073/74

Treatment outcomes
The NTP has achieved excellent treatment success rate, with a 91 percent treatment success rate
sustained since the introduction of DOTS in 1996, exceeding the global target of 85 percent.The
success rate has been 91 percent or more for new and relapse cases in the last 6 years (Figure 4.7.5).
However, the success rate has been lower for retreatment cases (loss to follow-up and retreatment)
but stable. 2073/74 saw the highest success rates for retreatment cases (88%). And the treatment
success rate among registered TB cases is almost constant in all five development regions. Out of all
TB cases registered in 2072/73, 92 percent successfully completed their treatment in 2073/74. The
western and Mid-western region achieved the highest (92%) and the far western region the lowest
success rate (87%).

Figure 4.7.5: TB treatment success trend (2068/69–2073/74)

100
95 91 92 91
90 90 90
90
88
85
85 84 83 86
80
75
72
70
65
60 New and Relapse

55 Retreated

50
2068/69 2069/70 2070/71 2071/72 2072/73 2073/74

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Table 4.7.2: Region wise TB treatment outcomes (2073/74)
Died Lost to Not
Region Registered Success Failed (%)
(%) follow-up evaluated
EDR 5233 91% 0.4% 2.9% 3.0% 2.5%
CDR 13389 91% 0.7% 2.4% 2.6% 3.0%
WDR 5587 92% 1.1% 3.7% 1.8% 1.6%
MWDR 4734 92% 1.2% 3.4% 1.9% 1.4%
FWDR 2965 87% 1.0% 4.6% 4.6% 3.0%
Nepal 31908 91% 0.8% 3.0% 2.6% 2.5%
Drug resistant tuberculosis
Drug-resistant TB has become a great challenge for the NTP and a major public health concern in
Nepal. Innovative approaches and more funding are urgently needed for the programmatic
management of drug resistance-TB nationally to detect and enrol more patients on multi-drug
resistant (MDR) TB treatment, and to improve outcomes.
Burden of MDR-TB — The Drug Resistance Survey (2011-12) found that levels of drug resistant TB
were increasing, with 9.3 percent of new patient resistant to at least one drug. RR/MDR-TB and
registered no. of RR/MDR-TB for treatment of FY 2073/74. Around 69.0% of estimated RR/MDR-TB
cases, 72.0% of Pre XDR-TB and only 43.0% of XDR-TB cases were enrolled for treatment. Case
finding among new cases is remarkably in increasing trend i.e; new RR/MDR-TB contribution in
registration category covering 14.6%, 15.3% and 18.8% for 3 consecutive years means NTP is
simultaneously diagnosing early RR/MDR-TB cases. Likewise the contribution of “category II failure
after first line treatment” in registration category is in decreasing trend i.e; 30.8%, 28.0% 24.0% for
consecutive year means again early case diagnosis is improving before cases reached category II
failure.
Total 343 RR/MDR-TB cases registered for treatment in FY 2073/74 among them 47 cases (13.7%)
from Eastern region, 138 cases (40.2%) from Central region, 87 cases (25.4%) from Western region,
36 cases (10.5%) from Mid-western region and 35 cases (10.2%) from Far-western region. Almost
half of the total RR/MDR-TB cases registered in Central region.

Box 4.7.3: Kinds of drug resistant TB


 Rifampicin resistant TB(RR-TB) is resistant to rifampicin (detected using rapid diagnostic tests),
with or without resistance to other anti-TB drugs and covers any resistance to rifampicin.
 Pre-extensively drug resistant TB (Pre XDRTB) is amulti-drug resistant strain of TB that is also
resistant to either one of the fluoroquinolones and all the second line injectable drugs.
 Extensively drug resistant TB (XDR-TB) is a severe form of MDR-TB that is multidrug-resistant
(MDR-TB) to all the fluoroquinolones and second line injectable drugs.

Case finding— The national policy defines six types of MDR-TB cases. Drug resistant TB is detected
early by the investigation of all new TB cases.Most MDR-TB cases are diagnosed as failure after
category 2 and retreatment.

DoHS, Annual Report 2073/74 (2016/17) 169


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Figure 4.7.6: Number of MDR-TB cases notified (2071/72–2073/74)

140
124
120 108
97
100 92
80 82
80 75
69 68
62
60 52 54

40

20 10 10 9 12 12 13

0
New Relapse TAD Cat-I Failure Cat-II Failure others

2071/72 2072/73 2073/74

CDR and WDR regions have an increasing trend of notified MDR-TB case. The central region has been
identifying the most MDR-TB cases and the Far-western region the least (Figure 4.7.7).

Figure 4.7.7: MDR-TB cases notified by regions(2071/72–2073–74)

180
153 2071/72
160
138 2072/73
140
2073/74
120 109
100 87
79
80 73
57
60 50 47 50 49
38 36 35
40 28
20
0
EDR CDR WDR MWDR FWDR

Trend of treatment success rate is decreasing by 7% in FY 2071/72 compared to the result of 76% of
FY 2068/69. The fluctuation in treatment success rate is mainly affected by the proportion of failure
and lost to follow in the cohort. Another important result that was affecting success rate is deaths of
patients which was always around 9 to 11 percentage in the last couple of years. As per the cohort
report of 2071/72, 366 DR TB cases were enrolled in MDR TB however 33 MDR cases shifted to XDR
(4) and Pre-XDR (29). At the cohort analysis 10.5% (35/333) died, 9.9% (33) were lost to follow up
and few remaining were MOTT cases.
Treatment success rate of XDR-TB is extremely low ranging from 13% to 33% for consecutive year.
Most of the XDR-TB patient died within the treatment period due to disease severity, complication
and toxicity.

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Figure 4.7.8: Treatment outcomes of MDR TB cases (2068/69–2073/74

Trend of treatment outcome of


RR/MDR-TB in %
76% 2068/69 2069/70 2070/71 2071/72
71%
67% 70%

11% 12%
9% 9% 10.5% 8% 8% 11% 7% 7%
11% 9%

Rx Success Died Failure Loss to F/U & TO

NTP’s laboratory network


The diagnosis and treatment monitoring of TB patientsrelies on sputum smear microscopy because
of its low cost and ease of administration. It is also the worldwide diagnostic tool of choice
worldwide. Nepal has 596 microscopy centres that carry out sputum microscopy examinations. Most
are in government health facilities(487) with the rest in NGOs and private instructions (Table
4.7.3).There are well established networks between the microscopy centres (MCs) at PHCCs, DHOs
and DPHO, the five regional TB quality control centres (RTQCCs) and with the National TB Centre
(NTC). The microscopy centres send examined slides to their RTQCCs via DHOs according to the Lot
Quality Assurance Sampling/System (LQAS) method.

The overall agreement rate or the concordance of sputum slide examinations between microscopy
centres and RTQCCs was more than 99 percent in 2073/74 (Table 4.7.4). The agreement rate has
improved in recent years. The external quality assurance (EQA) for sputum microscopy is carried out
by the four regional health directorates and the National TB centre in Kathmandu.

Table 4.7.3: NTP laboratory network (no. of institutions)


Region EDR CDR WDR MWDR FWDR Total
GoN 118 120 90 73 86 487
Other 13 69 13 9 3 107
Total 131 189 103 82 91 596

Table 4.7.4: Number of laboratory performing agreement rates>90% (2073/74)


Region EDR CDR WDR MWDR FWDR Nepal

Agreement rate 93 107 80 72 77 429

A lot quality assurance sampling/system (LQAS) has been implemented throughout Nepal. At each
microscopy centre, examined slides for EQA are collected and selected according to the LQAS.
DoHS, Annual Report 2073/74 (2016/17) 171
Disease Control
Previously NTP used to collect all positive and 10 percent negative slides for EQA. In LQAS, slides are
collected and selected using standard procedures to give a statistically significant sample size. LQAS
is a systematic sampling technique that helps maintain good quality sputum results between
microscopy centres and quality control centres. The two means of testing for MDR-TB are given in
Box 4.7.4.

Box 4.7.4: Means of testing for MDR-TB in use in Nepal


The GeneXpert MTB/RIF is a cartridge-based technological platform that integrates sputum
processing, DNA extraction and amplification, TB and MDR-TB diagnosis. It has a similar sensitivity
to culture, targets M. tuberculosis specifically and enables the simultaneous detection of rifampicin
resistance. The Xpert MTB/RIF test is a valuable, sensitive, and specific new tool for early TB
detection and for determining rifampicin resistance. While mono-resistance to rifampicin occurs in
approximately 5% of rifampicin resistant strains, a high proportion of rifampicin resistance is
associated with concurrent resistance to isoniazid. Thus, detecting resistance to rifampicin can be
used as a marker for MDR-TB with a high level of accuracy. The use of Xpert MTB/RIF started in
Nepal in 2011/2012 and there are 42 Xpert MTB/RIF centres in Nepal.

The culture of M. tuberculosis remains the gold standard for both diagnosis and drug susceptibility
testing, and also the method of choice to monitor drug resistant TB treatment. Conventional culture
methods using Lowenstein-Jensen (LJ) has the major disadvantage of being very slow. LJ cultures
take eight weeks for negative results and four to six weeks after initial culture for drug susceptibility
testing. National TB Reference Laboratories (NRL), NTC and GENETUP, are providing culture and
drug susceptibility test (DST) servicesand the planis to establish centres in all regions in 2073/74.

Supervision and monitoring


The supervision and monitoring of TB health care services is carried out by regular visits to all levels
of the programme (Figures 4.7.9 and 4.7.10). In addition, the quarterly reporting of activities is
carried out at trimesterlyplanning, monitoring and evaluation (PME) workshops at all levels of the
programme.

The NTP regularly monitors case finding, smear conversion, treatment outcomes and programme
management reports from all levels of the programme. Data is initially analysed by DHOs and DPHOs
at district reporting and planning workshops. DTLOs report on treatment centres and districtsat
regional planning, monitoring and evaluation workshops. Finally, regional TB and leprosy officers
report by district at national PME workshops. These workshops take place every four months at the
beginning of each new trimester.

172 DoHS, Annual Report 2073/74 (2016/17)


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Figure 4.7.9: TB supervision system Figure 4.7.10: TB monitoring system

Supervision System & Schedule International International Review Annual

Region, District, National Reporting &


Centre Treatment Centre National 4 monthly
Planning Workshop
Sub Centre

Four month
District, Regional Reporting &
Regional 4 monthly
Region Treatment Centre Planning Workshop
Sub Centre
District Reporting & Planning
Treatment Centre District 4 monthly
Workshop
District Sub Centre

monthly
Treatment Center Reporting
TreatmentCentre 4 monthly
& Planning Workshop

Logistics supply management


The NTP’s logistics management system supplies anti-TB drugs and other essentials every three
months to service delivery sites based on the number of new cases notified in the previous quarter
and the number of cases under treatment (Figure 4.7.11). Each programme level maintains four
months’ additional buffer stock to prevent stock outs. The buffer stocks kept at the regional level
were recently increased from four to six months of supplies to guard against shortages caused by
unforeseen natural and other disturbances.

Figure 4.7.11: NTP procurement demand and supply organisational chart

Procurement Demand Responsible authority &level Supply

▲ Global Drug facility - WHO HQ


▲ ▲ WHO SEARO ▼
▲ WHO Nepal

MoH and National Tuberculosis Center


▲ ▼

Regional medical (logistic)stores



▲ ▼
DHOs, DPHOs
▲ ▼
PHCCs & health posts (treatment centres)

Physical and Financial Progress status


In 2073/74, NTC made 88.91 percent physical progress at the central level and 85 percent progress
at the district level programme. Financial progress was 50.59 percent at the central level and 81
percent at the district level programme. And NTC cleared 78.2 percent of financial irregularities
(beruju) in the year.

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Disease Control
Table 4.7.5: Physical and Financial Progress status
Central Level District Level
Physical 41.o3% Physical 85%

Financial 52.30% Financial 81%

Irregularity (beruju) clearance - 78.25%

1.1.1 Problems and constraints


In 2073/74 the NTP faced considerable challenges and constraints that it seeks to address (see Box
4.7.5).

Box 4.7.5 Challenges and needed responses (NTP 2073/74)

Challenges: Actions to be taken:


1. Decreasing case notification. 1. TB basic training to newly recruited health
2. Increasing trend of MDR-TB cases and personnel.
management of Pre-XDR TB and XDR. 2. Expand drug resistance treatment service to
3. Inadequate TB management training for more health facilities.
medical doctors. 3. Operate mobile screening camps.
4. Lack of effective mechanism for ensuring 4. Strengthen the public private mix approach.
active participation of local communities in 5. Update supervision checklists and prepare
the planning, resource tapping and data based entry system for effective
allocation process of the NTP. feedback.
5. Lack of operational research on increasing 6. Expand the community-based DOTs
number of retreatment cases. programme.
6. Lack of patient-friendly TB treatment service 7. Improve sputum courier service in remote
in some places. areas.
7. Inadequate courier system for transporting 8. Plan operational research on TB
slides. 9. Pilot patient-friendly treatment centres in
8. Inadequate TB IEC materials. the country.
9. Insufficient income generation programme 10. Develop and distribute patient-centred TB
for drug resistance TB patients and their IEC materials.
families. 11. Strengthen the Community Support System
10. Difficultly of coordinating with regional and programme
zonal hospitals. 12. Develop communication mechanism among
11. Lack of effective coordination among the inpatient and outpatient department,
outpatient and inpatient departments, laboratory and x-ray unit for tracking the
laboratory and X-ray units in the hospitals suspects for diagnosis.
12. Difficulty in timely identification and 13. Train medical doctors for diagnosis of
diagnosis of TB in children childhood TB.

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4.8 HIV/AIDS and STI


1: Background
With the first case of HIV identification in 1988, Nepal started its policy response to the epidemic of
HIV through its firstNational Policy on Acquired Immunity Deficiency Syndrome (AIDS) and Sexually
Transmitted Diseases (STDs) Control, 1995 (2052 BS). Taking the dynamic nature of the epidemic of
HIV into consideration, Nepal revisited its first national policy on 1995 and endorsed the latest
version: National Policy on Human Immunodeficiency Virus (HIV) and Sexually Transmitted Infections
(STIs), 2011. A new National HIV Strategic Plan 2016-2021 is recently launched to achieve ambitious
global goals of 90-90-90.By 2020, 90% of all people living with HIV (PLHIV) will know their HIV status
by 2020, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral
therapy,andby 2020, 90% of all people receiving antiretroviral therapy will have viral suppression.

1.1.Overview of the Epidemic


Starting from a ‘low level epidemic’ over the period of time HIV infection in Nepal evolved itself to
become a ‘concentrated epidemic’ among key populations (KPs), notably with People who Inject
Drugs (PWID), female sex workers (FSW), Men who have Sex with Men (MSM) and Transgender
(TG) People in Nepal. A review of the latest epidemiological data, however, indicates that the
epidemic transmission of HIV has halted in Nepal. The trend of new infections is evidently taking a
descending trajectory, reaching its peak during 2001-2002.The epidemic that peaked in 2000 with
almost 8,000 new cases in a calendar year has declined to 942 in 2016 (reduced by 88%). This
declineis further accompanied bythedecreasing trend of estimated new HIV infections occurring
annually in Nepal as shown inError! Reference source not found. below.

Figure 1: : Trend of HIV Prevalence among 15+ years (1985-2020)


0.5

0.4
Number

0.3
0.21
0.2 0.17
0.1 0.13

Male Female Total

DoHS, Annual Report 2073/74 (2016/17) 175


Disease Control

This prevalence has dropped from 0.42% (highest level projected in 2004) to 0.17 in 2016 and is
expected to maintain a plateau at 0.2% through 2020 with thecurrent
current level of efforts.

Figure 2: Estimated HIV infections by age group, 2016 Male


15,000 13,777
Female
9,361
10,000
Number

5,085
5,000
1,790
611 585 759 767
-
0--14 years 15-24
24 years 25-49
49 years 50+ years

Figure 3: Annual HIV infections among adults (15+) by route of transmission : 1990
1990-2020
2020
8,000

6,000

4,000

2,000

0
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
External infections Needle sharing Male
Male-male sex Wife to husband Husband to wife Sex Work

Overall, the epidemic is largely driven by asexual


sexual transmission that accounts for more than 73% of
the total new HIV infections.Making
infections Making up 3.6% % of the total estimated PLHIV(32,735
32,735),, there are about
1,197children
children aged up to 14 years who are living with HIV in Nepal in 2016,, while the
the adults aged 15
years and above account for 96 6.4%. With an epidemic that has existed for more than two decades,
there are 6,875 infections estimated among thepopulation
population aged 50 years and above (21%).
( %). By sex,
males account for two-thirds
two (62
2%)
%) of the infe
infections
ctions and the remaining more than one-third
one third (38%)
( of
infections are in females, out of which around 81% % are in the reproductive age group of 15-49
15 49 years.
years

Heterosexual
eterosexual transmission is the major routine of transmission in the total pool of HIV infection in
Nepal.The contribution from all bands of KPs is similar in the period of projection
projecti 1995-2020,
2020, only
the level is varying
varying.

176 DoHS, Annual Report 2073/74


207 (201
(2016/17)
Disease Control

In 2016, 96.4% of the total infection was


Figure 4: Distribution of population with HIV infection
distributed among the population having age among 15 years and above in 2016
group 15 years and above. The estimate indicates
that among total infections are distributed
among PWIDs (4%), MSWs(6%), MSM and TG
(7%), FSWs (1%) and Client of FSWs (7%). These
apart, low-risk males including MLM account for
38%,andlow-risk females account for 37% of the
remaining infections.The estimated number of
annual AIDS deaths of all ages is estimated to be
around 1,771 for 2016.

Civil societies have also played pivotal roles in


the national response. Civil societies, through
empowerment of KPs, have been playing instrumental roles in prevention, treatment, care and
support as well as bringing about changes in legal and policy environment through advocacy.

External development partners equally support the national response to HIV in Nepal by providing a
substantial amount of resources required for combating HIV.The Global Fund, bilateral agencies,
namely Global Fund for AIDS, TB and Malaria (GFATM), United States Agency for International
Development (USAID), United Nations Children’s Fund (UNICEF),AIDS Health Care Foundation (AHF)
are the external sources that are contributing to the national HIV response.

2: Policy Environment and Progress in National HIV Response

2.1 Introduction
More than two decades of the HIV epidemic has stimulatedNepal to respond with a number ofpolicy
initiatives. These policy responses have come cross cuttingly from the health sector as well as other
development sectors aiming at creating an enabling policy environment for the containment of HIV
as well as mitigation of the epidemic. Notable policy developments taken for guiding the national
response to HIV are spelt out here.

The National Health Sector Strategy Implementation Plan (NHSS-IP 2016-2021)


Nepal’s HIV and STI response, recognized as a priority 1 programme by Government of Nepal, is
guided by the ‘National HIV Strategic Plan 2016-20121’, the Sustainable Development Goals, and the
National Health Sector Strategy (2015-2020). National Health Sector Strategy Implementation Plan
(NHSS-IP) operationalizes objectives of Fast-Tracking HIV response to achieve ambitious 90-90-90
targets by 2020 and ending the AIDS epidemic as a public health threat by 2030.

National HIV Strategic Plan 2016-2021


The National HIV Strategic Plan 2016-2021, the fifth national strategywith the aim of meeting the
global goal of 90-90-90 by 2020. By 2020, 90% of all people living with HIV will know their HIV status
by 2020, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral
therapy,andby 2020, 90% of all people receiving antiretroviral therapy will have viral
suppression.The National HIV Strategic Plan for the period 2016–2021 is a set of evidence-informed
strategies focused on building one consolidated, unified, rights-based and decentralized HIV
DoHS, Annual Report 2073/74 (2016/17) 177
Disease Control

programme with services that are integratedinto the general health services of the country. It builds
on lessons learned from implementation of the National AIDS Strategy 2011–2016, its mid-term
review and the Nepal HIV Investment Plan 2014–2016, and it applies recommendations from the
AIDS Epidemic Model exercise and other strategic information from studies, surveys and
assessments.

National Health Sector Strategy(2015-2020)


The Ministry of Health, National Centre for AIDS and STD Control is accountable for the
implementation of the National HIV Strategic Plan, through the public health service infrastructure
at national, regional, district and village level. Its implementation takes place in coordination with
other public entities and the private sector, including services that are provided by civil society and
other non-government networks and organizations. Because financing the HIV response in Nepal
relies heavily on external funding that is rapidly declining, it is imperative that relevant and mutually
beneficial public-private partnerships be established and maintained, and that wise, evidence-
informed investment choices are made.
The commitment by Nepal of both the global “UNAIDS Strategy 2016-2021,” and the “Sustainable
Development Goals” adopted by the UN General Assembly, include commitments to Fast-Tracking
the HIV response to achieve ambitious 90-90-90 targets by 2020 and ending the AIDS epidemic as a
public health threat by 2030.

2.2 Policy related activities/highlights from FY073/074


With the aim of effective implementation of the national response to achieve thenational goal of 90-
90-90, a number ofnational guidelines also have been put into operation. These include "National
HIV Testing and Treatment Guidelines, 2017", National Consolidated Guidelines on Strategic
Information of HIV Response, 2017, PMTCT Training Manual, 2017, HIV Treatment Literacy Training
Manual 2017, Pediatrics Disclosure Guidelines 2017 and National Guidelines on Community Led HIV
Testing in Nepal 2017.

National Consolidated Guidelines on Strategic Information of HIV Response in Nepal


Strategic Information is very critical for evidence-based planning and informed policy and
programme decisions. For the effective response to HIV, the country requires strategic information
systematically collected, collated, analyzed, disseminated and applied. The consolidated guideline is
essential to generate strategic information for informed policy and programme decisions. The
consolidated SI guideline consolidates M&E guideline, Surveillance guideline and National HIV
research agenda to generate indicators at various levels. The consolidated SI guideline is in the
process of development and soon will be published.

3: HIV Testing Services and STI Management


3.1Introduction
Pursuant to its goal of achieving universal access to prevention, treatment care and support, HIV
Testing Services (HTS) has been a strategic focus in the national response to HIV ever since Nepal
started its response to HIV. The first ever HTC began in 1995 with the approach of voluntary Client-

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Initiated Testing and Counseling (CITC). Moving further from its previous approach of voluntary CITC,
the national HIV testing and counselling program has been later widened to include Provider-
Initiated Testing and Counseling (PITC), as well as CITC as crucial components of the nation’s fight
against HIV. With the expansion of HTC sites across the country, there has been parallel
development. National Guidelines on HTC was formulated in 2003 and updated in 2007, 2009 and
2011 and later the separate guidelinesis merged as acomprehensive guideline on treating and
preventing HIV in 2014. The community based testing approach has also been initiated in key
population,and as suggested by National HIV Testing and Treatment Guidelines, 2017 Nepal is also
moving forward to implement community-led testing approachin order tomaximize HIV testing. For
this approach,National Guideline on Community Led HIV Testing in Nepal 2017’is also endorsed.
Human resources for HTC have been trained for public health facilities as well as NGOs-run HTS sites.
Along with HTS, detection and management of Sexually Transmitted Infections (STIs) havealso been
a strategic focus and integral part of the national response to HIV ever since Nepal started its
response to HIV. Over the years, STI clinics have been operating across the country maintaining their
linkage to KPson the basis of the National STI Case Management guideline which was developed in
1995 and also revised in 2009 and 2014.

3.2 Key strategies and activities


HIV Testing Services
The National HIV Strategic Plan 2016-2021 envisions rapid scaling up of testing services by
community-led/based testing in a non-duplicated manner in targeted locations in a cost-effective
way to ensure maximum utilization with strong referral linkage to ahigher level of treatment, care
and support. The National Strategy further foresees that the public health system will gradually take
up HIV testing services as an integral part of the government health care service by 2015.

The Government of Nepal is promoting the uptake of HIV testing among KPs through targeted
communications and linkages between community outreach and HTS. Likewise, Provider-Initiated
Testing and Counseling (PITC) havebeen taken to STI clinics, Antenatal Clinic (ANC), childbirth,
malnourished clinic, postpartum, Family Planning, and TB services. Thus in this context, the national
response, over the years, has seen an expanding coverage of HTS as an entry point to:

 Early access to effective medical care (including ARV therapy, treatment of opportunistic
infections(OIs), preventive therapy for tuberculosis and other OI and STIs;
 Reduction of HIVin all including mother-to-child transmission;
 Emotional care (individual, couple and family);
 Referral to social support and peer support;
 Improved coping and planning for the future;
 Normalization of HIV in society (reduction of stigma and discrimination);
 Family planning and contraceptive services; and
 Managing TB/HIV co-infection.

Detection and Management of STI


In the context of detection and management of STI, the standardization of quality STI diagnosis and
treatment up to health post and sub-health post level as a part of primary health care services has
been a key strategy in the national response to HIV. This strategy further foresees standardization of

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syndromic approach with the referral for etiological treatment when needed.

Strengthening documented linkages (referral of follow-up mechanisms) between behavioral change


communication (BCC) services and HIV testingandcounseling, including thestrengthening of linkage
between HTC and STI services has been one of thekey actions in the context of the concentrated
epidemic of Nepal.

3.3Progress and Achievement


HIV Testing Services
There are 175HIV Testing and Counseling sitesin Nepalthat include39non-government sites and 136
government sites operating in the country also maintaining their linkages with KPs as well as with
ART sites as well as PMTCT sites.The trend of programmatic data of people who were tested and
counseled over the last three yearsis showed in Table 1.

Table 1: Service Statistics HIV Testing and Counseling for the period of BS 2071/72-2073/74
Indicators 2071/72 2072/73 2073/74
Total tested for HIV 2,64,081 122,888 176,228
Total Positive reported 1,480 2,163 1,781
Cumulative HIV reported cases 26,702 28,865 30,646
Source: NCASC
The HIV testing is higher in Province 7 (40,388) and Province 3 (39,043) whereas the percentage of
positivity yield is higher in Province 2 and Province 3. The province wise detail is also shown in Table
2.

Table 2: Province wise Service Statistics HIV Testing and Counseling in 2073/74
Provinces Tested for HIV Positive reported % of positivity yield
Province 1 31,780 207 0.7%
Province 2 14,245 273 1.9%
Province 3 39,043 630 1.6%
Province 4 4,530 108 2.4%
Province 5 45,104 134 0.3%
Province 6 682 9 1.3%
Province 7 40,844 208 0.5%
176,228 1781 1.0%
Source: NCASC

3.4 Key challenges/Issues and recommendations


Issues Recommendations
Huge data gap is found in HIV program Coordination between DPHO and service sites
especially the report from many should be strengthened.
sites(Hospitals,and NGOs) are yet to be covered
in the electronic HMIS system.
The community-based HIV testing service Coordination between DPHO or HMIS and NGO
among key population is mainly run through should be strengthened. All the working NGO must
NGOs,andHMIS database system does not fully be enlisted in the system. So that, the total testing
cover NGO setting. The reporting from the numbers could be incorporated.

180 DoHS, Annual Report 2073/74 (2016/17)


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working NGO yet to be covered in the electronic


HMIS system.
Low HIV testing coverage among KPs has been Effective roll out of Community-led HIV Testing
and Treatment Competence (CTTC) approach with
along-standing challenge in response to HIV. The
problem of low coverage is most prominent for active monitoring should be in place.Provide
the returning labor migrants among all KPs. testing facilities at transit points as well as
destinations of migrant population.
The service gap among the key population that The service need to be revivedto increase the
was supportedunder pool fund. testing coverage among the key population.

Expansion of HIV testing sites. The establishment of testing sites in government


institutions should be scaled up to increase the
accessibility of the service including the
community based/led testing service through
NGOs.

4: Prevention of Mother to Child Transmission for eVT

4.1 Introduction
Nepal started its Prevention of Mother to Child Transmission (PMTCT) program in 2005 with setting
up three sites at: 1) B. P. Koirala Institute of Health Science (BPKIHS), Dharan; 2) Maternity Hospital,
Kathmandu and; 3) Bheri Zonal Hospital, Nepalgunj. Moving further in this direction, apart from the
free provision of maternal ART and prophylaxis for infants, the National Guidelines on PMTCT have
been developed and integrated intoNational HIV Testing and Treatment Guidelines in Nepal, 2017.
Humanresources, especially from maternal and child health care, have been trained in alignment
with PMTCT services. Along with that the preparation and updating of training manuals have taken
place. Apartof it,HIV testinghas been incorporated into maternal and child health care in the form of
PITC. Tailoring to the needs of HIV-infected infants as well as HIV exposed babies; counselling and
information on infant feeding have been adjusted accordingly.

4.2 Key strategies and activities


Taking Mother-to-Child Transmission (MTCT) is a potentially large source of HIV infections in children
in Nepal into consideration; National Strategyaims toeliminate new HIV transmission by 2021. In the
cognizance of a very low coverage of PMTCT, the current National Strategy envisages the PMTCT
programme to be integrated and delivered through Reproductive Health (RH) and Child Health
Services. The National Strategy also foresees the integration of PMTCT into RH Programme placing it
under the aegis of Family Health Division (FHD). The National Strategy has structured the PMTCT
programme around the following comprehensive and integrated four-prong approach:

i. Primary prevention of HIV transmission


ii. Prevention of unintended pregnancies among women living with HIV
iii. Prevention of HIV transmission from women living with HIV to their Children, and
iv. Provision of Treatment, Care and Support for women living with HIV and their children and
families.
Pursuant to the last two elements of the four prong approach, a package with the entailment of the
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following services isbeing provided to pregnant women:

 HIV testing and counseling during ANC, labour and delivery and postpartum
 ARV drugs to mothers infected with HIV infection
 Safer delivery practices
 Infant feeding information, counseling and support,
 Early Infant Diagnosis (EID) of all HIV exposed children at 6 weeks and
 Referrals to comprehensive treatment, care and social support for mothers and families with
HIV infection.
With the collaboration of community-basedorganization, the government of Nepal launched
Community-Based Prevention of Mother to Children Transmission (CB-PMTCT) program in 2009
taking PMTCT services beyond hospitals and making the services accessible to pregnant women
living in remote areas. The CB-PMTCT program, drawing the leverage of community support, has
found to have increased ANC coverage as well as HTC uptake among pregnant women (UNICEF
2012). CB-PMTCT programme hasbeen expandedthroughout the country.
Apart from CB-PMTCT program, adhering to the key actions envisaged by the National Strategy, the
country is scaling up PMTCT service synchronizing with planned ART, HTC /STI, OI services for
ensuring access to acontinuum of care and ART to pregnant women with HIV. Furthermore, linkages
have been established between PMTCT sites and KAP targeted intervention, Family Planning, SRH
and counseling services.

4.3Progress and Achievement


Pursuant to its commitment toeliminate vertical transmission of HIV among children by 2021, Nepal
has scaled up it PMTCT services in recent years. As a result of this scale up of PMTCT sites,the
number of women attending ANC and labour who were tested and received results has increased
over the years. Despite this relative increase in uptake, the coverage for PMTCT is still low (63.7%).
The three-year trend of service statistics is showed in Table3.

Table 3:Service Statistics on PMTCT in Nepal for the period of BS 2071/72 -2073/74

Indicators 2071/72 2072/73 2073/74


Tested for HIV (ANC &Labour) 135,904 276,593 382,887
HIV Positive Pregnant women 108 145 128
Total Deliveries by HIV +ve mothers 88 128 126
Mothers received prophylaxis and ART 74 163 175
Babies received prophylaxis 73 119 112
Source: NCASC

The HIV testing among pregnant women is higher in Province 3 (100,340),and Province 5 (74,829)
whereas the percentage of positivity yield among pregnant women is higher in Province 1, 2, 3 and 4
than national. The province-wise detailis also shown in Table 4.

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Table 4: Province wise Service Statistics on PMTCT in Nepal 2073/74

Provinces Pregnant women Positive pregnant


Positivity Yield
tested for HIV women identified
Province 1 53,646 27 0.05%
Province 2 32,724 17 0.05%
Province 3 100,340 45 0.04%
Province 4 45,189 20 0.04%
Province 5 81,521 13 0.02%
Province 6 16,899 0 0.00%
Province 7 52,568 6 0.01%
Total 382,887 128 0.03%
Source: NCASC

Aiming at the elimination of mother to child transmission, Nepal takinga major transformative
measure this fiscal year, adheres to Option B+ and embarks for providing lifelong ART for all
identified pregnant women and breastfeeding mothers with HIV, regardless of CD4 along with
prophylaxis treatment for their infants as well. The rollout of the lifelong treatment adds the
benefits of thetriple reinforcing effectivenessof the HIV response: (a) help improve maternal health
(b) prevent vertical transmission, and (c) reduce sexual transmission of HIV to sexual partners.

Early Infant Diagnosis (EID)


Initiatives for Early Infant Diagnosis (EID) of HIV in infants and children below 18 months of age have
been takenwith the goals a) of identifying infants early in order to provide them lifesaving ART; and
b) of facilitating early access to care and treatment in order to reduce morbidity. In this context, a
Deoxyribonucleic Acid (DNA) Polymerase Chain Reaction (PCR) testing facility has been set up at
National Public Health Laboratory in Kathmandu.With this, as of end FY 2073/74, there were 25sites
where DBS sample are collected with thesupport of NPHL. Likewise,5sitesare supported by USAID-
funded SSP providing for DBS sample collection. Thiswas complemented by the development of a
training package on thepreparation of Dried Blood Sample (DBS).

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Figure 5: CB PMTCT districts and EID Sites

4.4
.4 Key challenges/Issues and recommendations
Issues Recommendations
Availability of HIV test kits with limited expiry date
date. Ensure timely procurement and supply of test
kits to service sites.
Tracking of HIV-positive
positive mothers and exposed baby for The robust tracking system to track the HIV-
HIV
EID positive women should be developed,
developed and
home-based
based blood sample for EID test of
exposed baby can be recommended.
recommended
Mainstream
Mainstreaming
ing the private hospital in the national District should strengthen coorrdination with
reporting system for PMTCT test private hospitals to regularize the reporting
to district.
district
Supportive monitoring visit at service delivery points Frequent monitoring visit should be
from the district and centre performed to intensify the service at
abirthing
birthingcentre
centre and beyond birthing centre.

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207 (201
(2016/17)
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5: HIV Treatment, Care and Support Services

5.1Introduction
With a primary aim to reduce mortality among HIV-infected patients, the government, in 2004,
started giving free ARV drugs in a public hospital and that was followed by the development of first
ever national guidelines on ARV treatment. Since then, a wide array of activities has been carried out
with the aim of providingTreatment, Care and Support services to People Living with HIV (PLHIV).
Based on National HIV Testing and Treatment Guidelines 2017 county implemented ‘test and treat’
strategy form February 2017. Necessary diagnostic and treatment-related infrastructures such as
CD4 machines and viral load machines have been set up in different parts of the country for
supplementing ART management program. Human resources have been trained for Treatment, Care
and Support in parallel with the preparation and updating of training guidelines. People Living with
HIV have been empowered aiming at enhancing their supplementary roles in Treatment, Care and
Support.

5.2 Progress and Achievement


By the end of2016, out of
Figure 6: Treatment Cascade as of the end of 2016
13,069 of those who were on 32,735
35000
ART, there were11,318 30000
retained in the treatment for 25000
18,130
20000
12 months and among the 13,069
15000 11,318
total tested (7,042) almost 10000 7,042 6,209
90%(6,209) ofPLHIV were 5000
0
with their viral load
Estimated # of alive PLHIV Retension on Viral Load Viral Load
suppressed (Figure6). The Number of PLHIV and receiving ART ART (12 Test Suppression
PLHIV Know their Months)
total cumulative number of status
PLHIV receiving ART by the
end of fiscal year
2073/2074has reached the figure of 14,544. Over the years, there have been gradual increases in the
number of people enrolling themselves on ART as well as receiving ARVs (Table5).

Out of those who are currently on ART, 91.7% are adults and remaining 8.3% are children, while
male population makes 51.0%, female population 48.6%, and remaining 0.4% are of thethird gender.

Table 5: ART Profile of the period of FY 2070/71-FY 2073/74

Indicators 2071/72 2072/73 2073/74


People living with HIV ever enrolled on ART (cumulative) 14,745 16,499 19,388
People with advanced HIV infection receiving ARVs (cumulative) 11,089 12,446 14,544
People lost to follow up (cumulative) 1,216 1,612 2,049
People stopped treatment 30 31 25
Total deaths (cumulative) 1,834 2,410 2,770
Source: NCASC

The number of people on ART is higher in Province 3 (4,082) and Province 7 (2,824). The province
wise detailis also shown in Table 6.
DoHS, Annual Report 2073/74 (2016/17) 185
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Table 6: Province wise people on ART FY 2073/74

Province People on ART


Province 1 1,197
Province 2 1,428
Province 3 4,082
Province 4 1,807
Province 5 2,772
Province 6 434
Province 7 2,824
Total 14,544
Source: NCASC
There are total68ART sites across 59 districts till the
Figure 7: Outcomes of ART Programme in Nepal
end of the fiscal year 2073/74and it shows that 14%
of those ever registered on ART died and 11% have 0% 11%
been lost to follow-up, while 75% are alive on 0%
treatment.
14%
The Program data (FY073/74) showed that of all the
patients registered on ART during the period, 88%
were still actively on ART after 12 months while
75%
83% were still actively on ART after 24 months of
treatment. With the aim of supplementing the ART
management program, CD4 countstesting service
are available on30 different sites. Some of the Currently on ART Death
Missing Stopped treatment
portable CD4 counting machineshave been placed Lost to follow up

in thehilly districts of western, mid-western and far


western districts of Nepal to provide timely CD4 count service to monitor ARV effectiveness that
leads to support PLHIV to sustain quality and comfortable life. To monitor ART response and
diagnosing treatment failure, viral load testing is recommended for people receiving ART. National
Public Health Laboratory (NPHL), Bir hospital and Seti Zonal Hospital offer viral load test service to
the people on ART treatment.

With the purpose of early diagnosing HIV infection among children born to HIV infected mother
earlyDeoxyribonucleic Acid (DNA) Polymerase Chain Reaction (PCR) test is done at the National
Public Health Laboratory in Kathmandu. The DNA PCR test is done at birth and 6 weeks. This test is
recommended for diagnosing HIV status of children below 18 months and for those whose test
result is inconclusive by rapid test.
As of 2073/74,total 8,669has received CHBC services from 43 covering districts (Table 7). In the same
context, 42 districts have CCCs areacross the country which have been delivering their services to
PLHIV (Table 8).

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Table 7: Service Statistics on CHBC Services in Nepal, as of the end of FY 2073/74

Indicators Numbers
Number of PLHIV received CHBC services 8,669
Number of PLHIV referred for ART management 4,210
Number of PLHIV referred for management of opportunity infections 730

Table 8:Service Statistics on CCC Services in Nepal as of the end of FY 2073/74

Indicators Numbers
Number of CCC sites in Nepal 44
Number of PLHIV received psycho-social counseling support 6,500
Number of PLHIV received nutritional support 6,410
Number of PLHIV referred for management of opportunity infections 1,932

5.3 Key challenges/Issues and recommendations

Issues Recommendation
Low access to CD4 Count Placement of point of care CD4 machine and implementing viral load
and Viral Loadmachines testing by GenXpert and using DBS is recommended.
Client duplication in the The robust, unique identifier system should be developed to track
service the individual client within and across the service sites.
Start an electronic record keeping system with backup capability. In
Lost or deteriorating medical
addition, creating a client coding system would facilitate improved
records(Recording and
record keeping and continuity when clients are transferredin or
Reporting)
transferredout.
Poorsupply of OIs medicines Provide aconsistent supply of OIs medicines that are supposed to be
as per demand provided according to the program.
The PLHIVs face financial problems, but there is not sufficient
Inadequate financial support government support to pay for medical care and treatment. So
for the clients thegovernment should establish a mechanism to share the financial
burden facing by PLHIV.
Poor Monitoring and Regular and frequent monitoring and supervision to all ART Centers
Supervision of the ART for the effectiveness and efficient running of the program(Site by
Programs site visit)
CHBC services coverage is Government should invest in such an essentialservice in
declining over time due to coordination with NGOs.
limited support from donors.

6: Province level HIV related Services and Indicators


In the early 1990s, a national HIV surveillance systemwas established in Nepal to monitor the HIV
epidemic and to inform evidence-based HIV prevention efforts.Since then, integrated biological and
behavioral surveillance (IBBS) survey surveys have been conducted every two/three years among

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key populations at higher risk of HIV (PWID, MSM and TG, FSW and migrants) in identified three
epidemic zones (figure 7) to collect information on socio-demographics and biological markers to
assess the prevalence of HIV and other sexually transmitted infections (STI), behavioural information
(condom use, number of sex partners, needle sharing behaviours).The epidemic zones are based on
different distributions of key populations at risk, mobility links and HIV risk behaviour (figure 7).

6.1 Province Number 1


Province number one lies in theeastern part of Nepal and stretches from the Terai in the south to
the Himalayas in the north. It constitutes of one metropolitan, 46 municipalities and 90 rural
municipalities in new federal context. Fourteen districts from previous administrative division
(Eastern Development region) constitute of Province one. These districts are as follows: Bhojpur;
Dhankuta; Ilam; Jhapa; Khotang; Morang; Okhaldhunga; Panchthar; Sankhuwasabha; Solukhumbu;
Sunsari;Taplejung, Terhathum; Udaypur

Female sex workers and their clients, and MSM & TG, male labour migrants are amajor key
population at risk for HIV in this province. These key populations mainly reside in highway districts
(Sunsari, Morang and Jhapa). NCASC, as per its national surveillance plan has been conducting IBBS
surveys among key populations such as FSW, MSM & TG, and PWID in adifferent cluster. HIV
prevalence among PWID in Eastern Terai is 8.3% (IBBS, 2015) and 6.3% among MSM & TG in Eastern
Terai (IBBS, 2015). Currently, 24 HTS sites are providing HIV testing and counselling services in
Province one whereas 9 ART sites are providing treatment and care support to PLHIV. Similarly, 2
OST sites are providing OST service to PWID.

OST sites in Province one

i) Koshi Zonal Hospital, Morang


ii) Mechi Zonal Hospital, Jhapa

ART Sites in Province One

I. District Hospital, Dhankuta VI. Inaruwa Hospital, Sunsari


II. District Hospital, Ilam VII. BP Koirala Institute of Health Sciences
III. Mechi Zonal Hospital, Jhapa (BPKIHS), Sunsari
IV. Koshi Zonal Hospital, Morang VIII. District Hospital, Okhaldhunga
V. District Hospital, Udaipur IX. District Hospital, Sankhuwasava
6.2 Province Number 2
Province number 2 lies in the southeastern planes of Nepal. It consists of 8 districts from Saptrai in
the east to Parsa in the west. The province compromises of following districts:Bara; Dhanusha;
Mahottari; Parsa; Rautahat; Saptari; Siraha and Sarlahi. There are one Metropolitan city, three sub-
metropolitan cities, 43 Municipalities and 80 rural municipalities in province two. emale sex workers
and their clients, PWID, and MSM & TG are main epidemic drivers for HIV in these districts. IBBS
surveys are regularly conducted among the key population (FSW, PWIDs, and MSM/TG). In this
province, HIV responses are targeted to these groups. Currently, 15 HTS sites are providing HIV
testing and counseling services in Province two whereas 8 ART sites are providing treatment and
care support to PLHIV. NarayaniSub-regional Hospital is the only site providing OST service to PWID
in this province.

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ART Sites in Province Two

I. District Hospital, Bara VI


VI. Narayani Sub regional Hospital,
II. District Hospital, Rautahat Birgunj
III. District Hospital, Sarlahi VII
VII. Sagarmatha Zonal Hospital, Saptari
IV. District
rict Hospital, Jaleshwor, Mahottari VIII.
VIII Ram Kumar Uma Shankar Charity
V. Janakpur Zonal Hospital Hospital Siraha
Hospital,

Figure 7
7:: HIV epidemic zones in Nepal

6.3. Province Number 3


Province number 3 lies in the central part of Nepal. Most of the area of this province is hilly and
mountainous
mountainous.. The national capital (Kathmandu) also lies in this province. It consists of 3
metropolitan
metropolitans, 1sub
sub-metropolitan
metropolitan city, 44 Municipalities and 74 rural muni
municipalities
cipalities as per the new
federal structure. Province number 3 consist of 13 districts as per old structure namely:Bhaktapur;
namely: Bhaktapur;
Chitwan; Dhadhing; Dolakha; Kathmandu; Kavre; Lalitpur; Makwanpur, Nuwakot; Ramechhap;
Rasuwa; Sindhuli; Sindupalchowk. As per epi
epidemic
demic zones, this province consists of highway districts
and the Kathmandu Valley, and its epidemic is mainly driven by PWID (Male and females), FSWs,
clients of sex workers and MSM/TG.
MSM/TG. Some districts in this province are categorized as low HIV
prevalence zone where no such risk groups are drivers of HIV epidemic.

IBBS surveys are conducted among FSW, PWID and MSM/TG in the Kathmandu Valley. HIV
prevalence among FSW in the Kathmandu Valley is 2% (IBBS, 2015) whereas HIV prevalence among
PWID and MSM/TG is 6.4%6.4% and 2.4% respectively. HIV prevention services are being targeted to
these groups, and are being provided by the implementation partners whereas treatment, care and
support services are provided through government and community organizations.
organizations. There are 36 HTS
sites, 14 ART sites and 6 OST sites providing HIV prevention, treatment and care services in this
province.

List of ART sites in Province 3

I. Bhaktapur Hospital, Bhaktapur II. Bharatpur Hospital, Chitwan

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III. District Hospital, Dhading IX. Maternity Hospital, Kathmandu


IV. Sukraraj Tropical & Infectious Disease X. Dhulikhel Hospital, Kavre
Control Hospital, Kathmandu XI. Sparsha Nepal, Lalitpur
V. Kanti Children’s Hospital, Kathmandu XII. District Hospital, Makwanpur
VI. Maiti Nepal, Kathmandu XIII. Trishuli Hospital, Nuwakot
VII. Bir Hospital, Kathmandu XIV. District Hospital, Sindhuli
VIII. Tribhuvan University Teaching XV. District Hospital, Sindhupalchowk
Hospital (TUTH), Kathmandu
List of OST sites in Province 3

I. Tribhuvan University Teaching IV. AavashSamuha, Bhaktapur


Hospital (TUTH), Kathmandu V. SPARSHA, Lalitpur
II. Patan Hospital, Lalitpur VI. Saarathi Nepal, Kathmandu
III. Richmond Fellowship Nepal (RFN), VII. Youth Vision, Kathmandu
Kathmandu VIII. Youth Vision,Lalitpur

6.4 Province Number 4


Province number 4 lies in the western part of Nepal and mostly consists of hills and mountain region.
It constitutes of 1 metropolitan, 29 municipalities and 55 rural municipalities (85 local bodies in
total). It consists of 11 districts: Baglung; Gorkha; Kaski; Lamjung; Manang; Mustang; Myagdi;
Nawalpur; Parbat; Syangja and Tanahun.

This province consists of highway districts and the Pokhara Valley. FSW and their clients, MSM/TG,
PWIDs and migrant workers are key populations in the Pokhara Valley whereas rest of the districts
are considered as low HIV prevalence zones. IBBS surveys are conducted in the Pokhara valley in
regular intervals among key populations. HIV prevalence among FSW, PWIDs is 0.3%,
2.8%.respectively. There are 24 HTS sites, 1 OST site (Western Regional Hospital) and 9 ART centres
in this province which are providing HIV prevention, treatment and care services.

List of ART sites in Province 4

I. Dhaulagiri Zonal Hospital


II. District Hospital, Gorkha
III. Western Regional Hospital, Pokhara
IV. Lamjung Community Hospital
V. District Hospital, Myagdi
VI. District Hospital, Syangja
VII. District Hospital, Tanahun
VIII. District Hospital, Parbat
IX. Walling PHC, Syanja

6.5 Province Number 5:

Province number 5 lies in the mid-western Terai and hilly region of Nepal. It consists of 12 districts
namely:Arghakhanchi; Banke; Bardiya; Dang; Gulmi; Kapilvastu; Nawalparasi west; Palpa; Pyunthan; Rolpa;
Rukum and Rupandehi. This province consists of Terai highway districts and Hilly regions from where
people migrate to India and other countries. Female sex workers and their clients, PWIDs MSM/TG, are key
risk populations in Terai districts whereas migrants are the key risk populations in the hilly districts. NCASC

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conducts IBBS surveys among key population (PWID in Western to Far-western Terai highway districts,
MSM/TG in Terai districts, and migrants in western hilly regions). There are 26 HTS sites, 3 OST sites, and
12 ART sites in this province which are providing HIV prevention, treatment and care services.

List of ART sites in province 5

I. Bheri Zonal Hospital, Banke VIII. Prithivi Chandra Hospital, Nawalparasi


II. Rapti Sub Regional Hospital, Dang IX. United Mission Hospital, Palpa
III. District Hospital, Bardiya X. Lumbini Zonal hospital, Rupandehi
IV. District Hospital, Rolpa XI. District Hospital, Rukum
V. District Hospital, Pyuthan XII. Bhim Hospital, Rupandeh
VI. District Hospital, Gulmi XIII. District Hospital, Argakhachi
VII. District Hospital, Kapilvastu

List of OST sites

I. Bheri Zonal Hospital, Banke


II. Lumbini Zonal hospital, Rupandehi
III. Youth Vision, Rupandehi

6.6 Province Number 6


Province number 6 lies in Midwestern hills and Mountain region of Nepal. It consists of 10 districts which
are categorized as low HIV prevalence zones in Nepal (Dailekh; Dolpa; Humla; Mugu; Jajarkot; Rukum
west;Salyan; Kalikot;Jumla and Surkhet).

There are only 14 HTS sites and 2 ART sites in this province. Only migrants who migrate to high-risk areas
such as in Indian cities where HIV prevalence is high can be key population in this province.

List of ART sites

I. District Hospital, Dailekh III. Kalikot District Hospital, Kalikot


II. Mid-Western Regional Hospital, IV. Salyan District Hospital, Salyan
Surkhet

6.7 Province Number 7


Province number7 lies in the far-western region of Nepal and consists of 9 districts. It is similar to previous
Far-Western Development Region which consisted of 9 far-western districts as mentioned below (Achham;
Baitadi; Bajhang; Bajura; Dadeldhura; Darchula; Doti; Kailali and Kanchanpur).

This province comprises of 2 Terai highway districts and 7 districts in hilly and mountains regions. FSW,
PWIDs and MSM/TG are key drivers of HIV in Terai region whereas male labor migrants are key
populations in the 7 hilly districts. IBBS surveys are regularly conducted among these groups in this
province. There are 21 HTC and 11 ART sites in this province that provide HIV prevention and treatment
and care services to key population.

List of ART sites in Province 7

I. District Hospital, Achham VII. Dadeldhura Sub-regional Hospital,


II. Bayalpata Hospital, Achham Dadeldhura
III. Kamalbazar PHC, Achham VIII. District Hospital, Darchula
IV. District Hospital, Bajhang IX. District Hospital, Doti
V. District Hospital, Bajura X. Seti Zonal Hospital, Kailali
VI. District Hospital, Baitadi XI. Tikapur Hospital, Kailali
XII. Mahakali Zonal Hospital, Mahakali

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6.8 List of Possible Indicators for Province One, Two, Three, Four, Five and Seven
The following indicators might be useful to track HIV response in a particular province considering the
drivers of HIV epidemic in that province and HIV services being provided. However, the province can select
indicators that are deemed necessary to track HIV response. NCASC will provide any required support to
the provinces as and when needed.

Impact level Indicators

a) HIV prevalence among key population


b) HCV and HBV prevalence among people who inject drugs

Outcome level indicators

c) Percentage of sex workers reporting condom use with most recent client
d) Percentage of people who inject drugs reporting having used a condom the last time they had a
sexual intercourse
e) Percentage of men reporting the use of condom the last time they had anal sex with a male
partner
f) Percentage of migrants aged 15-49 reporting the use of condom the last time they had sex with
non-regular sexual partner

Output level indicators


g) Needle and syringe distributed per person who inject drugs
h) Percentage of individuals receiving Opioid Substitution Therapy who received treatment for at
least six months
i) Number and percentage of key population who had an HIV test in the past 12 months and know
their results
j) Percentage of key population reached by HIV prevention programmes - (BCC intervention, condom
and lube distribution)
k) Number of key population screened for HIV by trained layperson
l) Percentage of pregnant women with known HIV status
m) Percentage of pregnant women living with HIV who received antiretroviral therapy to eliminate
vertical HIV transmission
n) Percentage of reported congenital syphilis cases (live births and stillbirths)
o) Number and percentage of people living with HIV who are receiving HIV care (Including ART)
p) Percentage and number of adults and children on antiretroviral therapy among all adults and
children living with HIV at the end of the reporting period
q) Percentage of people living with HIV who are on retained on ART after 12, 24 and 36 months after
initiation of antiretroviral therapy
r) Percentage of health facilities dispensing antiretroviral therapy that experienced a stock-out of at
least one required antiretroviral drug in the last 12 months
s) Number (and percentage) of adults and children living with HIV currently receiving care and
support services from outside facilities
t) Percentage of HIV-positive patients who were screened for TB in HIV care or treatment settings
u) Percentage of TB patients who had an HIV test result recorded in the TB register

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4.9 EYE CARE


Comparing with the past, a considerable progress has been made in the field of eye health. This
can be taken as a good model for public-private partnership (PPP). Studying from the criteria of
World Health Organisation (WHO) Nepal’s status of blindness has declined from 0.81% in 1981
to 0.35 % in 2011.1 Though the situation of blindness has decreased more than half, there has
been no significant decline in the number of the blind as the population of the country has
doubled in comparison with that of 1981.

Though considerable progress was achieved in mitigating blindness in the past decades, there is
a need to implement more effective programmes to meet the goal of Vision 2020 and WHO
Global Action Plan and a lot of effort should be made to realise the vision of sight for all. In this
period, considerable development has been achieved in the sector of infrastructure
development also. At present the services at primary eye care centres/eye hospitals are
available in all the districts of the country. The technology applied in eye care has been
regularly updated to the global standard.

A considerable progress has also been made in the field of producing human resource in the
area of eye care. In 1981 there were total seven ophthalmologists in the country. This number
has now reached 205.At present there is one ophthalmologist for an estimated population of
150,000. In 1981 there was not even one optometrist in Nepal. Now there are 160 optometrists
in the country. The number of ophthalmic assistants has also reached 425 from zero. The
number of other directly involved health workers and nurses has also reached 450 and the
number of eye care managers and equipment maintenance personnel is also increasing
gradually. The number of necessary human resource necessary for effective management of
eye care service in proportion to the pressure of the patients and the population is still a
challenge.

One of the important decisions of Nepal Government in the field of eye care is to include eye
care service in the package of basic health service in Nepal Health Sector Strategy (NHSS) III. It
may increase the government ownership in and expansion of eye care sector in the future.

Though it is positive to score significant achievement in the field of eye care services, new
problems and challenges are coming up in the field of eye care service.

1
Epidemiology of Blindness in Nepal:2012 Nepal Netra Jyoti Sangh
DoHS, Annual Report 2073/74 (2016/17) 193
Disease Control

Goal and Objectives:

To reduce the overall blindness below 0.2% among the visual acuity <3/60 and <0.4% among the visual
acuity 6/60 by the year 2020.

Outputs for (2016)

With all this opportunities and challenges the service output of the of the eye care services for the fiscal
year 2016 are as given below table:

Hospital Base Hospital Base


OPD
(Screening Nepali Foreign Surgery Nepali Foreign
+ECC+Outr Patient Patient Total (Outrea Patient Patient Total
S.No. Eye Hospital Name each) OPD (OPD) (OPD) ch) Surgery Surgery Surgery
Birat Eye Hospital
5787 16912 67644 90343 442 4200 12110 16752
1 Biratnagar, Morang
Chitwan Eye
15931 10632 151 26714 0 131 6 137
2 Hospital,Bharatpur
Kakarvitta Eye Hospital,
10556 12241 15874 38671 596 957 1858 3411
3 Birtamod, Jhapa
Lions Eye Hospital ,
0 37330 23 37353 0 0 0 0
4 Kathmandu
Mechi (Distri Eye
451 22118 16945 39514 39 2166 2159 4364
5 Hospital), Jhapa
Mechi Eye Hospital ,
41830 63032 95222 200084 1923 4047 17862 23832
6 Birtamod ,Jhapa
Mechi Netralaya &
Ophthalmic Research 2183 10248 36919 49350 82 1124 2306 3512
7 Centre P. Ltd. , Kakarvitta
Nepal Eye Hospital,
Tripureshwor , 16350 100317 14426 131093 473 3145 869 4487
8 Kathmandu
Nepal Netra Jyoti Sangh-
131438 90314 2275 224027 4862 1805 61 6728
9 Bharatpur Eye Hospital
Nepal Netra Jyoti Sangh-
58885 40314 217899 317098 248 7691 53170 61109
10 Biratnagar Eye Hospital
Nepal Netra Jyoti Sangh-
31744 56005 238 87987 0 1674 20 1694
11 Butwal Lions Eye Hospital
Nepal Netra Jyoti Sangh-
Chhanda(K) Narayani Eye 0 21619 47186 68805 0 1367 7271 8638
12 Hospital
Nepal Netra Jyoti Sangh-
Dr. Binod (N) Kadel Eye 9683 31731 11053 52467 917 374 313 1604
13 Hospital
Nepal Netra Jyoti Sangh-
Dr.Ram Prasad Pokharel 8009 0 0 8009 0 134 0 134
14 Eye Hospital
Nepal Netra Jyoti Sangh-
19718 57709 44878 122305 851 4237 5902 10990
15 Fateh Bal Eye Hospital
Nepal Netra Jyoti Sangh-
22542 35869 49995 108406 306 5309 7213 12828
16 Gaur Eye Hospital
Nepal Netra Jyoti Sangh-
218563 55968 45748 320279 3098 4695 21386 29179
17 Geta Eye Hospital
Nepal Netra Jyoti Sangh-
91767 109452 0 201219 2322 5552 0 7874
18 Himalaya Eye Hospital
Nepal Netra Jyoti Sangh-
36675 80549 0 117224 2662 4158 8997 15817
19 R.M.Kedia Eye Hospital
20 Nepal Netra Jyoti Sangh- 0 31764 19 31783 0 1394 8 1402

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Hospital Base Hospital Base


OPD
(Screening Nepali Foreign Surgery Nepali Foreign
+ECC+Outr Patient Patient Total (Outrea Patient Patient Total
S.No. Eye Hospital Name each) OPD (OPD) (OPD) ch) Surgery Surgery Surgery
Lamahi Eye Hospital
Nepal Netra Jyoti Sangh-
216170 0 0 216170 0 0 0 0
21 Lumbini Eye Institute
Nepal Netra Jyoti Sangh-
Mahendra Nagar Eye 21167 0 0 21167 0 0 0 0
22 Hospital
Nepal Netra Jyoti Sangh-
Palpa Lions Lacoul Eye 27471 18845 0 46316 0 1173 0 1173
23 Hospital
Nepal Netra Jyoti Sangh-
65494 73828 0 139322 1257 2674 0 3931
24 Rapti Eye Hospital
Nepal Netra Jyoti Sangh-
Sagarmatha Chaudhary 0 169644 168901 338545 3332 13088 38026 54446
25 Eye Hospital
Nepal Red Cross Society ,
51947 51947 0 103894 648 648 30 1326
26 Surkhet
Netradham Eye Care
6500 6500 0 13000 0 860 0 860
27 Center, Kathmandu
NRCS shree Janaki Eye
43794 73947 31536 149277 0 3575 0 3575
28 hospital Janakpur
Padma Nursing Home ,
0 2560 0 2560 0 46 0 46
29 Pokhara
Ramlal Golchha Eye
Hospital , Biratnagar, 9975 38432 29009 77416 1163 1495 3539 6197
30 Morang
Shree krishna netralya
0 4631 5485 10116 0 78 695 773
31 eye clinic , Bhairahawa
Tilganga Inst. Of
102997 351659 28170 482826 7490 22938 654 31082
32 Ophthalmology
Grand Total 1267627 1676117 929596 3873340 32711 100735 184455 317901

DoHS, Annual Report 2073/74 (2016/17) 195


Disease Control

4. 10 Entomology

Background
The Entomology Section and its laboratory is an integral part of the Epidemiology and Disease
Control Division. The section was established in 2012/13. The section plans, implement, monitors
and supervises entomological activities including surveillance, risk assessmentsandthe operational
research of vector and carrier borne diseases including malaria, kala-azar, filariasis, dengue,
chikungunya, zika, Japanese encephalitis, chandipura encephalitis, scrub typhus, leptospirosis,
plague, gastroenteritis and emerging and re-emerging diseases with the potential of epidemic
outbreaks. It is also responsible for assuring the quality of tests to diagnose vector borne diseases.
There is the provision for entomology sections in all regional health directorates and EDCD. The
objectives of the section are listed in Box 4.10.1.

Box 4.10.1: Objectives of the Entomology Section


 To make available an accessible, affordable, acceptable and sustainable level of vector control
methods through community participation for scientific protection from vector borne diseases.
 To enhance vector control activities for eliminating targeted vector borne diseases.
 To provide rapid test kits, chemicals, lab equipment and accessories to diagnose vector-borne
diseases.
 To develop the capacity of laboratory personnel on malaria microscopy to help achieve a malaria
free Nepal by 2025.
 To develop the capacity for laboratory quality control and assurance and research on vector
borne diseases and epidemic prone diseases.
 To investigate the source of infection during outbreak situations.

Activities in 2073/74
The following investigations were carried out in 2073/74

Investigations and an entomological survey in all five regions in 12 districts of Nepal. In that survey
Anopheles mosquitoes were collected. These are the common species of anopheles
mosquito which were found in that survey.An. Culicifacies, An. vagus, An. annularis, An.
fluviatilis, An. splendidus,An. peditaeniatus

Problems, challenges and action plan


The main problems facing the Entomology Section and the recommended actions for overcoming
them are presented in Table 4.10.1.

196 DoHS, Annual Report 2073/74 (2016/17)


Disease Control
Table 4.10.1: problems, challenges and action plan
Problems and challenges Action plan
 No regular sending of malaria slides by peripheral  Develop and appoint human resources.
health facilities for quality control at the centre.  Establish well-equipped entomological
 Inadequate trained personnel including public health laboratories at different levels.
entomologists, administrators, scientists and  Form technical working groups at central,
researchers. state and regional levels.
 Inadequate laboratory activities for investigating  Establish insectariums.
outbreaks.
 Regular central level monitoring and
 Vacant EDCD laboratory positions on research and supervision of peripheral facilities on vector
investigation. borne disease issues.
 Lack of a research laboratory in EDCD.  Prepare and develop a malaria slide bank for
 No progress report received by EDCD from VBDRTC basic and refresher training.
 Lack of coordination between the entomology lab  Involve laboratories in water quality
and Save the Children’s Global Fund-supported surveillance.
malaria programme.  The regular quality control of malaria slides.
 No proper distribution of basic and refresher malaria
microscopy training for other districts and private
sector medical college and hospitals.

DoHS, Annual Report 2073/74 (2016/17) 197


Disease Control
4.11 Epidemiology and Outbreak Management

The objectives and strategies of the Epidemiology and Outbreak Management Section are given in
Box 4.11.1.

Box 4.11.1: Objectives and strategies of the Epidemiology and Outbreak Management Section

Objective — To reduce the burden of communicable diseases and unwanted health events through
preparedness and responses during outbreak and epidemic situations by using the existing health care
system.

Strategies:
 The development and execution of preparedness planning to respond to outbreaks, epidemics and the
control of unwanted health events.
 The formation and mobilization of rapid response teams.
 The regular monitoring of outbreaks and epidemics through surveillance activities.

Regular activities
Preparedness planning for outbreaks, epidemics and unwanted health events:
 The identification of outbreak and epidemic prone districts and communities based on the
review of previous data.
 The identification of outbreak and epidemic potential diseases and health problems by analysing
disease seasonality.
 The preparation and annual updating of preparedness plans at regional and district levels.
 The preparation of lists of drugs and health logistics for use in outbreaks and epidemics.
 The stock-pilling of drugs and health logistics at strategic locations.
 The preparation of Infectious Disease Control Guidelines and orientation on them at the regional
level.

Rapid response teams for investigating and responding to outbreaks and epidemics:
 The formation of rapid response teams at central, regional, district and community levels and
their mobilization during outbreaks and epidemics.
 Investigating outbreaks.
 Responding to outbreaks through awareness activities and IEC activities, case management,
community mobilization and the coordination of stakeholders.

 The regular monitoring of outbreaks and epidemics


 The monitoring of outbreak potential diseases (malaria, kala-azar, dengue, acute gastroenteritis,
cholera and severe acute respiratory infections)at sentinel sites.
 The active surveillance of outbreak potential diseases in outbreak situations.
 Media monitoring and countering rumours.

Major outbreaks in 2073/74


Forty-one communicable disease outbreaks were recorded in Nepal in 2073/74, which affected
3,565 people and resulted in 29 deaths (Table 4.11.1). However, not all outbreak events are
198