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A REPORT ON
COMPREHENSIVE FIELD PRACTICE ON MANAGEMENT OF DISTRICT PUBLIC
HEALTH SERVICES Dhankuta
Submitted By Group-A
BPH Third Year (First Batch) Valley College of Technical Sciences
2011
Submitted to Department of Public Health
Valley College of Technical Sciences Mid-Baneshwor, Kathmandu
2011
A REPORT ON
COMPREHENSIVE FIELD PRACTICE ON MANAGEMENT OF DISTRICT HEALTH
SYSTEM, DHANKUTA
Submitted to Department of Public Health
Valley College of Technical Sciences Siphal, Kathmandu
2011
Submitted by Group A
BPH Third Year (First Batch) Valley College of Technical Sciences
2011
A REPORT ON
COMPREHENSIVE FIELD PRACTICE ON MANAGEMENT OF DISTRICT HEALTH SYSTEM,
DHANKUTA
Department of Public Health Submitted to
Valley College of Technical Sciences Mid-Baneshwor, Kathmandu
Group-A Submitted By
BPH Third Year (First Batch) Valley College of Technical Sciences
July 2011
GROUP MEMBERS
1. ANIL DHUNGANA 2. ANU GOMANJU
3. DINESH RUPAKHETI 4. NARESH BHATTA
5. PRABESH GHIMIRE 6. RABINA KUMARI RAJAK
7. SHREETINA K. TULADHAR 8. UTTAM GAUTAM
Group-A Comprehensive District Health Management Team
BPH Third Year (First Batch) Valley College of Technical Sciences
Siphal, Kathmandu
July 2011
APPROVAL SHEET
Purbanchal University
Valley College of Technical Sciences
Siphal, Kathmandu
This Field Practice Report Presented
by
Group A
Entitled
“Comprehensive Field Practice on Management of District Health System,
Dhankuta”
has been accepted as partial fulfillment of
the requirement for the degree of
Bachelor in Public Health
Approved by:
Prof. Chitra Kr. Gurung
Senior Consultant
(Field Supervisor)
Mr. Suman C. Gurung Head of Department
Department of Public Health Valley College of Technical Sciences
Kathmandu
Prof. Nabin Shrestha External Evaluator
Mr. Suman C. Gurung Head of Department
Department of Public Health Valley College of Technical Sciences
Kathmandu
iv A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
ACKNOWLEDGEMENT
Behind the successful accomplishment of our one month Comprehensive Field Practice
on District Health System lie the candid abutments and sumptuous kindness of many
luminaries. This field practice report is therefore, not the exclusive product of our group.
We owe much of the credit to the support and assistance of many helping hands.
We express a deep gratitude to the staffs of District Health Office for their invaluable co-
operation and magnanimous hospitality. A special thank goes to Mr. Jhalak Sharma
Poudel, District Health Officer, Dhankuta, who helped us immensely by letting pilfer
times to us out of his busy schedules by providing valuable guidance and supervision
during our stay at Dhankuta. Our sincere thanks go to Mr. Ram Narayan Shrestha
(Section Officer, DHO) who helped us establish effective co-ordination with other
sections and peripheral institutions & Mr. Purna Shekhar Shrestha (Statistician) who
supported us during data review and worked as the resource person during mini-action
project. We are very much grateful to Akshay Lal Yadav (CB-IMCI Supervisor), Toya
Ghimire (Family Plannning Supervisor), Balkumari Gurung (Public Health Nurse) and
the whole DHO family for their valuable support during critical review, epidemiological
study and five year planning.
We cordially gratify all stakeholders of Dhankuta for their colossal suppo rt. FPAN,
SOLVE & NRCS also deserve special thanks for their help and support during our
institutional visits. Danda Bazaar PHC, Pakhribas HP, Parewadin SHP are also pertinent
for heartfelt acknowledgements that supported us during our observation visits to these
institutions.
Further, we would like to extend our special thanks to Dhankuta Multiple Campus for
providing us a residence in its guest house and making our stay a magnificent.
We thank the director of Valley College of Technical Sciences Dr. Yubin Pokhrel for
providing financial allowance, logistics support and transportation services Prof. Hari
Bhakta Pradhan and Mr Suman C. Gurung (HOD) for their constructive feedback and
continuous support, Mr. Bishnu Choulagai (field co-ordinator) for his valuable
v A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
orientations, Prof. Chitra Kr. Gurung (field supervisor) and all the staffs of Valley
College of Technical Sciences.
We also would like extend our warmest appreciation to our colleagues for their cheerful
encouragement, amiable affection and ongoing support.
Last but not the least we would like to gratify all those who helped us directly or
indirectly to make our field practice a successful.
July, 2011 Group A
vi A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
ACRONYMS
ABER Annual Blood Examination Rate
ADRA Adventist Relief Development Agency
AIDS Acquired Immune Deficiency Syndrome
ANC Antenatal Care
ANM Auxiliary Nurse Midwife
ARI Acute Respiratory Infection
ASL Authorized Stock Level
B/CEOC Basic/ Comprehensive Emergency Obstetric Care
BCG Bacillus Calmette Guerin
BNMT Britain Nepal Medical Trust
BPH Bachelor of Public Health
CAC Comprehensive Abortion Care
CB-IMCI Community Based Integrated Management of Childhood Illness
CB-NCP Community Based Neonatal Care Programme
CBOs Community Based Organizations
CBR Crude Birth Rate
CDD Control of Diarrhoeal Diseases
CDMA Code Digital Multiple Access
CDO Chief District Officer
CDR Crude Death Rate
COPD Chronic Obstructive Pulmonary Disease
CPR Contraceptive Prevalence Rate
CYP Couple Years of Protection
DACC District Aids Co-ordination Committee
DDC District Development Committee
DEO District Education Office
DHMT District Health Management Team
DHO District Health Office
DHOr District Health Officer
vii A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
DHS District Health System
DoHS Department of Health Services
DOTS Directly Observed Treatment – Short Course
DPT Diphtheria, Pertusis & Tetanus
EHCS Essential Health Care Services
EOP Emergency Order Point
EPI Expanded Programme on Immunization
FCHV Female Community Health Volunteer
FEFO First Expiry First Out
FP Family Planning
FPAN Family Planning Association Nepal
FY Fiscal Year
GOs Governmental Organizations
HF Health Facility
HFMC Health Facility Management Committee
HI Health Institution
HIV Human Immuno- deficiency Virus
HMIS Health Management Information System
HP Health Post
HPI Health Post Incharge
HURSADEC Human Rights Social Awareness and Development Centre
HWs Health Workers
IEC Information Education and Communication
INGOs International Non Governmental Organizations
IPD Indoor Patient Department
IUD Intra Uterine Device
KAP Knowledge Attitude Practice
LA Lab Assistant
LDOr Local Development Officer
LMD Logistics Management Division
LMIS Logistics Management Information System
viii A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
MAP Mini Action Project
MB Multi Bacillary
MCHWs Maternal and Child Health Workers
MDGs Millennium Development Goals
MO Medical Officer
MoHP Ministry Of Health and Population
MWRA Married Women with in Reproductive Age
NA Not Available
NDHS Nepal Demographic Health Survey
NESOG Nepal Society of Obstetricians and Gynecologists
NGOs Non Governmental Organizations
NTP National TB Programme
NHEICC National Health Education Information and Communication Centre
NHP National Health Policy
NHSP-IP National Health Sector Program- Implementation Plan
NHTC National Health Training Center
NIP National Immunization Programme
NPC National Planning Commission
NRCS Nepal Red Cross Society
NSMLTP National Safe Motherhood Long Term Plan
OPD Out Patient Department
OPV Oral Polio Vaccine
ORS Oral Rehydration Solution
ORT Oral Rehydration Therapy
P1 Priority- One
PAC Post Abortion Care
PB Pauci- Bacillary
PEM Protein Energy Malnutrition
PGR Population Growth Rate
PH Public Health
PHC/ORC Primary Health Care/ Out Reach Clinic
ix A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
PHCC Primary Health Care Center
PME Planning, Monitoring and Evaluation
PNC Post Natal Care
PUO Pyrexia of Unknown Origin
RBM Roll Back Malaria
RH Reproductive Health
RHCC Reproductive Health Co-ordination Committee
RHD Regional Health Directorate
RHTC Regional Health Training Centre
RMS Regional Medical Store
RTI Respiratory Tract Infection
SHP Sub Health Post
SLTHP Second Long Term Health Plan
SM/FP Safe Motherhood/ Family Planning
SMNH Safe Motherhood and Neonatal Health
SMP Safe Motherhood Program
SOLVE Society for Local Volunteer’s Effort
SPR Slide Positivity Rate
SWOT Strength, Weakness, Opportunity and Threat
TADA Travel Allowance Daily Allowance
TB Tuberculosis
TBA Traditional Birth Attendant
TT Tetanus Toxoid
U5
URTI Upper Respiratory Tract Infection
Under Five
UTI Urinary Tract Infection
VAD Vitamin A Deficiency
VDC Village Development Committee
VHW Village Health Worker
VSC Voluntary Surgical Contraception
WHO World Health Organization
x A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
SUMMARY
This report is the outcome of comprehensive field practice on management of district
health system conducted from 21th Baisakh to 20st
Jestha 2068 B.S. in Dhankuta district.
The objective of our study was to develop knowledge and skills regarding management
of district health system. The study design was descriptive & cross sectional and was
mainly based on secondary data analysis/review and primary information was collected
to triangulate the findings.
Dhankuta district, situated in eastern development region, constitutes of 2 electoral
constituencies, 1 municipality, 11 illakas, 35 VDCs and 333 wards covering 891 sq. km.
Dhankuta has the population density of 190.19 per sq. km and total population of
166,479. The major ethnic group is Rai.
District hospital, 2 Ayurvedic Ausadhalayas, 2 PHCCs, 11 HPs, 24 SHPs. 151 EPI
Clinics, 79 PHC/ORCs, 315 FCHVs and private hospitals and clinics are major
institutions for the delivery of health services in the district.
The leadership was of democratic type. Horizontal co-ordination was with different
government line agencies and vertical co-ordination with RHD and MD under DoHS. 16
posts under DHO were vacant.
Store was poorly maintained but logistics supply was done timely. HMIS reporting from
peripheral levels were satisfactory. However, DHO still couldn’t maintain co-ordination
with private sectors regarding reporting.
Major programs in the district were NIP, Nutrition, CB-IMCI, Family Planning and Safe
Motherhood Programme, FCHV and PHC/ORC Programme, TB and Malaria Control,
Leprosy Elimination and HIV/AIDS Prevention and Control Programme.
xi A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
The vaccine coverage was around 72.26% (066/67). Depo was the widely accepted FP
device. The 4 ANC visits were 56.75%. The delivery conducted by HW and SBAs was
17.58%.
TB case finding rate was lower than national level. Four new cases of HIV/ AIDS were
reported in FY 067/68. The average no. of people served by FCHVs in FY 066/67 had
increased than that of FY 065/66. The reporting has also increased as compared to
previous years.
CAC service was available in district hospital and Marie Stopes Center. In the FY 066/67
878 people had received this service. District hospital and PHCCs were providing BEOC
services. Skin disease counts the top position on top ten diseases followed by ARI.
On the basis of three years record of IPD cases in district hospital, an epidemiological
study was done on Pneumonia.
Critical reviews were done on eight different topics which were Safe Motherhood
Programme, Recording and Reporting, Integrated Supervisions, Logistic Management,
CB-IMCI, NIP, PHC/ ORC Programme, NTP and Staffing situation.
Mini Action Project was done on Recording and Reporting. In the program, orientation
on revised version of HMIS tools was given and also problems and issues on
recording/reporting were identified and solutions were drawn.
A five year plan on Safe Motherhood was done with the goal to improve maternal health
and survival of women in Dhankuta district with the budget of NRs. 28,257,600 for five
years. The plan was prepared in LFA.
The findings were shared and discussion session was held in the DHO in presence of
staffs from DHO, District Hospital and DACC.
(500 words)
xii A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
HEALTH SERVICE COVERAGE FACT SHEET, DHANKUTA
FY 2064/65 to 2066/67
Reporting Status 2064/65 2065/66 2066/67 1 Hospital 100 100 2 PHCC 100 100 3 HP 100 100 4 SHP 100 100 5 PHC/ORC 89 82 6 FCHV 94 95 7 EPI Clinics 92 93 Expanded Programme on Immunization 1 BCG Coverage 77.9% 70.27% 75.13% 2 DPT-3 Coverage 75% 70.21% 65.27% 3 Polio-3 Coverage 74.1% 70.21% 70.11% 4 Measles Coverage 70.9% 70.60% 72.26% 5 % of Pregnant women receiving TT-2 Nutrition Programme 1 % of Pregnant women receiving Iron tablets 48% 43.32% 57.44% 2 % of Postpartum Mother receiving Vitamin A 45.5% 35.55% 43.53% Acute Respiratory Infection (ARI) 1 Reported Incidence of ARI/1,000 <5 Children New
Visits (by HF) 289 412 450.55
2 Reported Incidence of ARI/1,000 <5 Children New Visits (by Community)
616 648.56 895.25
3 Percentage of new Pneumonia 55.2% 55% 52.30% Control of Diarrhoeal Diseases (CDD) 1 Incidence of Diarrhoea/1,000 <5 Children New
Cases (by HF) 129 123.70 165.13
2 % of Severe Dehydration 0.69% 0.02% 0.11% Safe Motherhood Programme 1 Antenatal First Visits as % of Expected Pregnancies 32.80% 47.10% 62.47% 2 Delivery Conducted by SBA at Home and Health
Facility as % of expected pregnancy 7.9% 7.8% 11.4%
3 Deliveries Conducted by SBA and Health Workers at Home and Health Facility as % of Expected Pregnancies
17.44% 14.8% 17.58%
4 Deliveries Conducted at Health Facilities as % of Expected Pregnancies
32.8% 42.34% 57.86%
5 PNC First Visits as % of Expected Pregnancies 34.1% 33.88% 44.89%
xiii A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
Family Planning Programme 1 Pills 3.9% 5.4% 5.4% 2 Depo Provera 13.3% 14.7% 12% 3 IUCD 0.84% 1% 0.97% 4 Norplant 0.81% 1.32% 1.69% 5 Contraceptive Prevalence Rate 30.83% 37.52% 34% Tuberculosis Control Programme 1 Cure Rate 88% 90% 91% 2 Case Finding Rate 41.5% 27% 33% Leprosy Control Programme 1 New Case Detection Rate (NCDR) /10,000 0.16 0.21 0.05 Curative Services 1 Total OPD New Visits 20901 24889 25054 2 Total OPD New Visits as % of Total Population 11.24% 11.88% 13.25%
xiv A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
TABLE OF CONTENTS
Contents Page No.
GROUP MEMBERS ii
APPROVAL SHEET iii
ACKNOWLEDGEMENT iv
ABBREVIATIONS vi
SUMMARY x
HEALTH SERVICE COVERAGE FACT SHEET xii
TABLE OF CONTENTS xiv
LIST OF TABLES xviii
LIST OF FIGURES xxi
CHAPTER I: INTRODUCTION 1-10
1.1 Background 1
1.2 Objectives 3
1.3 Methodology 4
1.4 Validity and Reliability 7
1.5 Logistics 9
1.6 Plan of Action 10
CHAPTER II: DISTRICT PROFILE 11-20
2.1 Introduction 11
2.2 Political and Administrative Division 11
2.3 Geographical Features 12
2.4 Socio-economic Status 12
2.5 Climate 14
2.6 Major Rivers 15
2.7 Tourist Places 15
2.8 Cultural and Religious Heritages 15
xv A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
2.9 I/NGOs 16
2.10 Government Organizations 16
2.11 Development Resources 16
2.12 Transportation 17
2.13 Communication 17
2.14 Water Supply and Sanitation 18
2.15 Crime Incidents 18
2.16 Demographic Characteristics 19
2.17 Map of Dhankuta 20
CHAPTER III: DISTRICT HEALTH SYSTEM 21-61
3.1 Introduction 21
3.2 District Health Management in System Model 24
3.2.1 Service Inputs 25
3.2.2 Process 29
3.2.3 Output 40
3.2.3.1 Child Health Programme 40
3.2.3.2 Reproductive Health Programme 47
3.2.3.3 Disease Control Programme 52
3.2.3.4 FCHV Programme 54
3.2.3.5 PHC-ORC Programme 55
3.2.3.6 Curative Services 56
3.3 Top Ten Diseases in Dhankuta 59
3.4 SWOT Analysis of District Health System 59
3.5 Recommendations 61
CHAPTER IV: VISITED ORGANIZATIONS 62-81
4.1 Peripheral Health Institutions 62
4.2 Supporting Organizations 74
xvi A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
CHAPTER V: EPIDEMIOLOGICAL STUDY 82-86
5.1 Introduction 82
5.2 Objectives 82
5.3 Rationale 82
5.4 Methodology 83
5.5 Study Variables 83
5.6 Epidemiological Characteristics 83
5.7 Findings and Discussions 84
5.8 Conclusions 86
5.9 Recommendations 86
CHAPTER VI: CRITICAL REVIEW 87-121
6.1 Logistics Management 87
6.2 Integrated Management of Childhood Illness 93
6.3 National Immunization Programme (NIP) 97
6.4 Recording and Reporting 101
6.5 Staffing Situation 106
6.6 Case finding in National TB Programme 109
6.7 Primary Health Care outreach Clinics Programme 114
6.8 Integrated Supervision 117
CHAPTER VII: MINI-ACTION PROJECT 122-126
7.1 Introduction 122
7.2 Rationale 122
7.3 Objectives 122
7.4 Date, Venue and Time 123
7.5 Methodology 123
7.6 Plan of Action 124
7.7 Activities 125
7.8 Results 125
xvii A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
7.9 Evaluation of MAP 125
7.10 Sustainability of MAP 126
CHAPTER VIII: FIVE YEAR PLAN 127-146
8.1 Introduction 127
8.2 Rationale 127
8.3 Process of Developing the Plan 128
8.4 Plan Format 129
8.5 Goal and Objectives 129
8.6 Targets 130
8.7 Safe Motherhood Plan in LFA 131
8.7 Major Activities 137
8.8 Targets for Safe Motherhood Programme 142
8.9 Budget Plan 144
CHAPTER IX: OTHER ACTIVITIES 147-151
9.1 District Presentation 147
9.2 Participated Programmes 150
CHAPTER X: CONCLUSIONS AND RECOMMENDATIONS 152-154
10.1 Conclusions 152
10.2 Recommendations 154
BIBLIOGRAPHY 155-156
ANNEX 157
xviii A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
LIST OF TABLES
Table no. Table Title Page No.
1 Work Plan of Comprehensive Field Practice 10
2 Level & Sex-wise Distribution of Students 12
3 Institution-wise Distribution of Education 13
4 Distribution of Ethnicity in Dhankuta 13
5 Language Distribution in Dhankuta 14
6 Distribution of Land in Dhankuta 16
7 Transportation Facility in Dhankuta 17
8 Crime Incidents in Dhankuta 18
9 Demographic Characteristics of Dhankuta 19
10 Staffing Pattern of DHO 25
11 Distribution of Health Institutions in Dhankuta 26
12 Health Logistics in DHO 27
13 LMIS Reporting Schedule in Dhankuta 39
14 Immunization Coverage 40
15 Vaccine Wastage 41
16 Immunization Drop-out Rate 41
17 Problems and Constraints in Immunization Programme 42
18 Growth Monitoring Status of Under-5 Children 43
19 Achievements of Child Nutrition Programme 44
20 Achievements of Nutrition Programme for Mothers 44
21 Problems and Constraints in Nutrition Programme 45
22 Service Statistics of ARI Control 46
23 Problems and Constraints in ARI Control Programme 46
24 Service Statistics of CDD 47
xix A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
25 Service Statistics of Family Planning 48
26 Acceptors of Family Planning Devices 48
27 Problems and Constraints in FP Programme 49
28 Trends of ANC Visits 49
29 Delivery Services Statistics in Dhankuta 50
30 Trends of PNC Visits 50
31 Problems and Constraints of SM Programme 51
32 Service Statistics of Malaria Control Programme 52
33 Achievements of Malaria Control Programme 53
34 Service Statistics of Leprosy Control Program 53
35 Service Statistics of FCHV Programme 54
36 Problems and Constraints of FCHV Programme 55
37 Service Statistics of PHC-ORC Programme 55
38 Problems and Constraints of PHC-ORC Programme 56
39 Service Statistics of District Hospital 57
40 Other Service Statistics in District Hospital 57
41 Top-Ten Disease in Dhankuta 59
42 SWOT Analysis of District Health System 60
43 Staffing Pattern of Dandabazar PHCC 63
44 Service Indicators of Dandabazar PHCC 65
45 Staffing Pattern of Pakhribas Health Post 68
46 Service Indicators of Pakhribas Health Post 69
47 Data trends on ARI Incidence 94
48 Four Years Trend Analysis on Immunization 98
49 Immunization Drop-out Rate 99
50 HMIS Reporting from Different Institutions 102
51 HMIS Reporting Status of Different Organizations 103
52 Post wise Staffing Situation 107
53 DOTS Treatment Centre wise case Detection Ratio 112
xx A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
54 Trends in PHC/ ORC Conducted in Dhankuta District 115
55 Routine Supervision Strategy in District Level 118
56 Supervision Status of the District 119
57 Plan of Action of MAP 124
58 Safe Motherhood Plan in Log-Frame Approach 131
59 Major Activities in Safe Motherhood Plan 137
60 Targets for Safe Motherhood Programme 142
61 Budget Plan for Safe Motherhood Programme 144
xxi A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
LIST OF FIGURES
Table no. Figure Title Page No.
1 Map of Dhankuta District 20
2 District Health System in Dhankuta 22
3 Central Role of DHO Within the DHS 23
4 System Model of District Health System 24
5 PME Cycle of DHO 29
6 Planning Cycle of District Health Services 30
7 Micro-planning in Dhankuta 31
8 Organizational Structure of HIs in Dhankuta 33
9 Organogram of DHO 34
10 HMIS Process in DHO, Dhankuta 37
11 LMIS Process in DHO, Dhankuta 38
12 Health Budgeting Process in Dhankuta 39
13 Time Distribution of Pneumonia 85
14 Sex Distribution of Pneumonia 85
15 Age Distribution of Pneumonia 86
16 Logistics Flow System 89
17 Logistics Management Information System 90
18 Trends of Diarrhoeal Incidence 95
19 New Growth Monitoring Coverage in Dhankuta 95
20 Year wise TB Case Detection Ratio 111
21 Phases of MAP 124
CHAPTER I
INTRODUCTION
1 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta, 2011
CHAPTER I
INTRODUCTION
1.1 Background
The district is the most peripheral unit of local government and administration that has
comprehensive powers and responsibilities. It differs greatly from country to country in
size and degree of autonomy, and population may vary from less than 50,000 to over
300,000. It comprises first and foremost “a well-defined population living within a
clearly delineated administrative and geographical area”. The district is the level where
health policies and health sector reforms are interpreted and implemented.
The district headquarter is usually in the main town where there are the offices of all the
principal ministries that are concerned with district and local affairs, such as health,
agriculture, education, social welfare and community development. The district is the
natural meeting point for “bottom-up” community planning and organization, and for
“top-down” central government planning and development. It is, therefore, a natural
place for the local community needs to be reconciled with national priorities.
(Manual of Epidemiology for District Health Management: WHO; 1989)
The term district is widely accepted as a generic term for the level of health systems
management where plans and budgets are prepared and implementation is co-ordinated
with local government and with other sectors.
(Strengthening Health Management in Districts and Provinces, WHO; 1995)
A district health system includes the interrelated elements in the district that contribute to
health in homes, educational institutions, workplaces, public places and communities, as
well as in the physical and psychosocial environment. It includes self-care and all health
care personnel and facilities, whether governmental or non-governmental, up to and
including the hospital at the first referral level and the appropriate support services
(laboratory, diagnostic and logistic support).
(Health Sector Reform and District Health Systems: WHO; 2004)
2 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta, 2011
The following are some of the components of a district health system:
• district health office;
• district hospital or hospitals;
• health centers;
• community, neighborhoods and households;
• Private health sector, NGOs and mission health services.
The sound health of the district inevitably requires the effective and efficient
management of district health system.
Management of district health services is a process whereby action is taken related to
resources, such as people, finances, equipment and facilities, to achieve identified goals.
The District Health Office is responsible to ensure the equitable delivery of high quality,
cost-effective district health services. DHO is also concerned with the day-to-day
management of the district health system. Common DHO functions include planning,
supervision, budgeting and finance control as well as problem-solving and crisis
management.
Bachelor of Public Health is an undergraduate degree which aims to prepare professional
public health specialist who are technically and managerially competent and significantly
responsible in the planning, implementation, monitoring and evaluation of overall district
level public health services as well as in the administration and management of district
public health system.
The comprehensive field practice on management of district health system is one
of the important practice oriented field based program, designed by Purbanchal
University for the students of BPH 3rd year to provide an opportunity to learn the needed
managerial skills and other technical skills in terms of district health management. This
field practice aims to develop the basic skills in the students to assess resources
potentiality and constraints, prioritize the health problems and set strategies for solving
them, assist in developing suitable options and action plan for addressing the priority
health problems in the districts. So, the BPH product should be able to carry out the
3 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta, 2011
responsibilities designed for the district (public) health officer, which is not only possible
through theoretical classes in the campus but it also requires practical exposures in the
real field. Holistic practical learning is not justifiable without such type of field program.
1.2 Objectives
1.2.1 General Objective
• To develop knowledge and skills regarding management of district public
health services by exploring the health system of Dhankuta district.
1.2.2 Specific Objectives
• To analyze the demographic and health profile of Dhankuta District.
• To explore the epidemiological factors regarding specific diseases
phenomenon.
• To critically appraise the different health and/or management aspects of
District Health System.
• To develop a Comprehensive Five Year Plan on a prioritized health or
management issue.
• To plan, implement and evaluate a Mini Action Project (MAP).
4 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta, 2011
1.3 Methodology
1.3.1 Study type
The study design was cross sectional descriptive type as the data were
collected and reviewed at a particular point of time and findings were
presented in descriptive forms through texts, tables and figures.
1.3.2 Study area
Dhankuta district was conveniently selected as the area of study for our
comprehensive field practice. It was finalized as the study area after
communication with the DHOr.
1.3.3 Study duration
The time duration for our study was of 30 days beginning from 21st Baisakh to
20th
Jestha.
1.3.4 Techniques and tools of data/information collection
• Secondary data review
Data review was done from monthly monitoring and annual performance
review worksheets of four fiscal years from FY 2064/65 to FY 2067/68,
that were available at the statistical section of DHO. Service statistics of
district hospital were also reviewed from hospital records. Discharge
registers were used to review the cases of pneumonia among IPD cases.
Various secondary data review formats were prepared and used for data
review.
• Interview (Key informant, In-depth)
Interview was done with DHOr to understand the overall management
issues of DHO and to identify the health status of Dhankuta. The interview
was done using interview guidelines. Section officer and various
programme officers (FP supervisor, Public Health Nurse, IMCI
5 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta, 2011
supervisor) were also interviewed for critical review on various health
programmes and management issues. Statistician was interviewed to
analyze the recording and reporting status of the district and store keeper
was also interviewed to critically analyze the logistics management system
operating within the district
The in-charges of Dandabazar PHCC, Pakhribas HP and Parewadin SHP
were interviewed using interview guidelines to identify the management
issues within their institutions.
Further, interview was done with the head of various supporting
organizations viz. FPAN, NRCS, BNMT and SOLVE.
• Meeting (formal and informal)
At the very beginning, formal meeting was conducted with the whole
DHO family for sharing our objectives of field visit and appeal for co-
ordination. Numerous informal meetings were conducted to facilitate our
study process. Meeting was done with public health nurse for preparing
five- year plan, with statistician to discuss on issues regarding MAP, and
with DHOr during supervisory visits from the college.
• Observation
District medical store and cold chain centre in the district health office
were observed to explore the logistics management system of the district.
The observation was done using observation checklist.
The peripheral institutions (Dandabazar PHCC, Pakhribas HP and
Parewadin SHP) were also observed to analyze the managerial system of
these institutions regarding waste management, store management,
infrastructures and logistics.
6 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta, 2011
1.3.5 Data Sources
In order to prepare the socio-demographic and health profile of the district, the
information was collected from various agencies and institutions. Health
System being the concern of our study, District Health Office was the chief
source for information collection. Necessary information regarding district
profile was available from District Development Committee. Other related
data were collected from several other line agencies such as District Education
Office (Education related data), District Police Office (data on crime
incidents), District Agriculture Development Office, District Traffic Police
Office (data on RTAs), and District Livestock Development Office.
Information were also collected from FPAN, NRCS, SOLVE and BNMT
regarding supportive health programmes conducted in the district.
1.3.6 Analysis
Data analysis involved series of processes. The collected data from the manual
monthly monitoring sheets were first verified from the electronic version of
monitoring sheets. The data were then classified according the objectives and
three years data trend were analyzed by preparing tables and charts.
1.3.7 Data/ Information Presentation
All the collected information was presented through various graphs, tables and
necessary figures. Figures included organograms, flow charts of various
management systems (Logistics management and information systems),
managerial processes (planning cycle, co-ordination, budgeting) and other
necessary frameworks to generate the clear concepts on various processes
within district health system. Three years data trend were presented through
tabular forms. Texts were used to describe the findings more clearly and
precisely.
7 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta, 2011
1.3.8 Dissemination
The dissemination of findings regarding the collected information was done
through two different approaches. Two presentation sessions were organized
at the seminar hall of DHO to present the major findings of our study. After
the completion of our field practice, the presentation was also organized at the
college.
Finally, the overall information was disseminated through the comprehensive
report.
1.3.9 Ethical consideration
The official letter was submitted from campus to the DHO.
Objectives of the study were clarified to the stakeholders of the
district.
Verbal consent was taken prior to interview.
Assurance of the confidentiality on sensitive issues was done.
1.4 Validity and Reliability
1.4.1 Validity
• External Validity
The information that was collected from DHO included comprehensive data
from each and every VDCs of the district. Hence, findings can be generalized
to the entire population within the district.
• Construct Validity
Pre-testing of interview guidelines for health post incharge was done by
interviewing HP in-charge of Dharmasthali VDC and necessary
modifications were made in the tool. However due to constraint of time we
were unable to test all the tools that were prepared for the study in Dhankuta.
8 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta, 2011
• Content Validity
Before going to assigned district, we were given four days’ orientation
classes on various subjects to be considered during the course of our study.
Numbers of reports from senior batches of different colleges were reviewed
to design the various tools (interview guidelines and secondary data review
formats) as well as to identify core aspects to be studied during the field stay.
The tools were later revised during the orientation classes in presence of field
co-ordinator.
• Face Validity
Findings and conclusions were accepted and valued by DHOr as well as
other staffs of DHO during the presentation session.
1.4.2 Reliability
• Information Collection
All the records were maintained in the form of detailed notes. Information
that was collected during the interview was presented exactly as what had
been told by the interviewee (DHOr, programme officers, section officer,
statistician and store keeper).
• Data Verification
Each data collected from monthly monitoring sheets were cross-checked so
that any mis/under responding could be corrected.
• Tabulation of data
Cross checking of tables was done among the subgroups to maintain
consistency as far as possible.
9 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta, 2011
• Comparisons
Our findings showed similar results when compared against the report of the
previous comprehensive field study done at Dhankuta by senior batch from
Tribhuwan University.
• Supervision
Intermittent supervision was done by field coordinators Prof. Chitra Kr.
Gurung and Bishnu Choulagai and DHOr Jhalak Sharma Poudel was
assigned as the local supervisor.
1.5 Logistics
• Lodging and Fooding:
We stayed at the guest house of Dhankuta Multiple Campus for which we had to
pay Rs 12000. We had arranged our fooding at the canteen of the same campus at
Rs 60 per meal.
• Stationeries:
The necessary stationeries were provided by the college.
• Financial support:
A daily allowance of Rs. 300 was provided by the college.
• Camera and films:
We had three digital cameras to take the photos of important events during our
study period.
• Computing materials:
We had 1 lap-top & 3 calculator for data entry and computation.
• Transportation:
The two way transportation facility was provided by the college.
10 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
1.6 Plan of Action
Table 1: Work plan of comprehensive field practice
Activities 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Departure to Dhankuta
Arrangements
Rapport Building
NGOs/ INGOs Visit
Data Collection
Data Analysis
Critical Review
PHCC/HP/SHP Visits
Epidemiological Study
Mini-Action Project
First Presentation
Five Year Planning
Final Presentation
Departure to Campus
CHAPTER II
DISTRICT PROFILE
11 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
CHAPTER II
DISTRICT PROFILE
2.1 Introduction
Dhankuta District, a part of Koshi Zone, is one of the seventy-five districts of Nepal. The
district covers an area of 891 km² and has a population (2001) of 166,479. Dhankuta is
the district headquarter and a major administrative region in the Eastern region. Dhankuta
Bazaar, on the North-South Koshi Highway, is the administrative headquarters for the
Eastern Development Region, and is home to a number of NGOs/ INGOs and various
other aid agencies. The large bazaar of Hile further up the road is an important trading
centre and major road head, serving the remote hinterlands of the Arun valley and
Bhojpur.
2.2 Political/Administrative Division
• Development Region: Eastern
• Zone: Koshi
• District headquarter: Dhankuta municipality
• Electoral constituency: 2
• Municipality 1
• Illaka: 11
• VDCs: 35
• Ward: 333
The districts are uniquely placed at a level where they are in a position to maintain a vertical relationship with higher management levels, horizontal relationship with other local departments and an external relationship with the communities and organizations they serve.
(District Health Planning Manual)
12 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
2.3 Geographical features
2.3.1 Topography
• Area: 891 sq Km
• Latitude: 26º35’ to 27º11’ North
• Longitude: 87º19’ to 87o
• Altitude: 120 meter(Ahale VDC) to 2702 meter (Murtidhunga VDC)
33’ East
2.3.2 Boundaries
• East: Teharathum and Panchthar
• West: Bhojpur and Udayapur
• North: Sankhuasabha
• South: Morang and Sunsari
2.4 Socio- economic status
2.4.1 Education
2.4.1.1 Level and sex wise distribution of students
Table 2: Level and sex wise distribution of students
Level Females Males Total
Primary schools 16775 17131 33906
Lower secondary 7218 6984 14202
Secondary schools 3520 3218 6738
Source: District Education Office, Dhankuta
13 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
2.4.1.2 Distribution of Educational (institutions level wise)
Table 3: Institution wise distribution of education
Level Government Private Total
Primary 215 23 238
Lower Secondary 36 1 37
Secondary 45 7 52
Higher Secondary 16 2 18
Higher Level 3 - 3
Total 315 33 348
Source: District Education Office, Dhankuta
2.4.2 Ethnicity
Table 4: Distribution of Ethnicity in Dhankuta
Ethnic Grouops Percentage
Rai 24.51%
Magar 10.34%
Limbu 14.20%
Chhetri 19.85%
Brahmin 5.49%
Tamang 6.28%
Others 19.33%
Source: ‘Jilla Parswochitra’; DDC (065/66)
14 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
2.4.3 Languages
Table 5: Language distribution in Dhankuta
Language Percentage
Nepali 44.87%
Bantawa 19.72%
Magar 8.87%
Limbu 13.75%
Tamang 5.21%
Yakhha 2.94%
Others 4.83%
Source: Annual Report; DHO (066/67)
2.4.4 Religions
• Buddhist
• Hindu
• Kirat
• Islam
• Christian
2.5 Climate
• Sub tropical: <1200 Meter
• Temperate: 1200-2100 meter (mid hilly region)
• Cold temperate: 2100-3300 meter (high hills)
• Average rainfall: 14.95*
• Minimum rainfall yearly: 7.1
mm *
• Maximum temperature: 28.6º c
mm
• Minimum temperature: 7.1º c
*
Source: Annual Report; DHO (066/67)
*
15 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
2.6 Major Rivers
• Tamor khola
• Muga khola
• Patale khola
• Arun khola
2.7 Touristic places
• Bhedetar
• Dhawanje Danda
• Thulo Rukh
• Hile
• Pahkribas
• Panchakanya shahid smirti
• Raja-rani
2.8 Cultural/religious heritages
• Jalapadevi/Chintanj Devi Temple
• Nishan Bhagwati
• Siva Panchanya/Bishranti Temple
• Pathibhara Devi Temple
• Madhu Ganga mahadevsthan
• Nageshor Mahadev Temple
• Margasthan Temple
• Chaturbahu Temple
• Bisranti Temple
16 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
2.9 I/NGOs
• HUSADEC
• PARDEP
• SOLVE
• BNMT
• Marie Stopes
• FPAN
2.10 Governmental Organizations
• District Administration Office
• District Development Committee
• District Forest Office
• District Police Office
• Drinking Water Development Office
• District Veterinary Office
• District Livestock Service Office
2.11 Development Resources
• Land
Table 6: Distribution of land in Dhankuta
Features Area (hectares) Percent occupied
Cultivable Land 40723 49.55
Forests 36383 44.11
Pasture Land 220 0.04
Others 5203 6.40
17 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
• Irrigation
Evergreen Irrigation: 1255 hectare (6.44%) of total cultivated land
Seasonal irrigation: 2640 hectare (13.66%) of total cultivated land
No irrigation facility: 15603 hectare (80%) of total cultivated land
2.12 Transportation
Koshi Rajmarga (Madan Bhandari Marga) is 64 Km black topped south to north
road that divides whole district into two halves.
3.12.1 Transportation facility in the district
Table 7: Transportation facility in Dhankuta
Description Value
VDC/Municipality with transportation facility 13+1
Length of road( in kilometer) Black topped 50.58
Gravel 48.68
Kacchi bato 113.8
Total 213.6
2.13 Communication
Postal Services: 38
Telephone:
• MARTS: 23
• PSTN : 1806
• PSTN (Hile): 1806
• CDMA
pre-paid: 1677
post-paid: 421
18 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
• GSM
pre-paid: 18135
post-paid: 248
• Sky Phone
pre-paid: 6548
post-paid: 35
Source: Nepal Telecom; Dhankuta
2.14 Water Supply and Sanitation
• Drinking Water Coverage: 82%
• Toilet Coverage: 21%
• Total completed Water Projects from DDC: 44
• Benefitted Population: 71599
2.15 Crime Incidents
Table 8: Crime incidents in Dhankuta
Fiscal year Homicide Organized/
economic
crime
Social
Offence
Crime related
to women &
child
Suicide RTAs
064/65 10 5 5 5 8 7
065/66 15 1 8 3 17 8
066/67 31 1 22 1 13 12
067/68
(till chaitra)
14 3 14 2 10 11
Source: District Police Office, Dhankuta
19 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
2.16 Demographic Characteristics
Table 9: Demographic characteristics of Dhankuta
Indicators District Figure
Population
• Male
• Female
• Total
87972
80860
168832
Sex Ratio (M:F) 108.8:100
Dependency Ratio
• Child Dependency
• Old Dependency
• Total
50.56
13.01
63.57
Total Households 29222
Average family size 5.78
Population Density 190.19 per sq. km
Fertility Status
• Crude Birth Rate ( CBR)
20.86 per 1000
Mortality
• Crude Death Rate (CDR)
5.30 per 1000
Literacy Rate
• Male literacy
• Female literacy
• Total Literacy Rate
74.75%%
66%
70.59%
20 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
2.17 Map of Dhankuta
Figure 1: Map of Dhankuta District
Note: The shaded areas represent the places of visits during our study period.
CHAPTER III
DISTRICT HEALTH SYSTEM
21 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
CHAPTER III
District Health System in Dhankuta
3.1 Introduction
As defined by the World Health Organization, the District Health System (DHS) is a
more or less self-contained segment of a national health system, which includes all the
institutions and individuals concerned with the improvement of health.
(District Health Planning Manual, 2002)
The district is the key level for the management of primary health care (PHC). Ideally, all
health-related activities taking place in the district should be coordinated into a District
Health System. The mix of manpower and facilities providing health care in districts
varies greatly from country to country. In the main communities, rural and urban, there
may be community health workers, clinics and health centers, together with traditional
and private medical practitioners. A government district hospital and the headquarters
staff for all the district health programmes are often located in the main town.
(Manual of Epidemiology for District Health Management, 1989)
The health care system of Dhankuta is the sum total of three main systems; Traditional
Health Care System, Modern Health Care System and Supportive System. Akin to other
Districts, Dhankuta also has a long history of traditional medical practices with faith
healers and ayurvedic practitioners playing a compassionate role in the provision of
health care. Nevertheless, Modern Health Care system is the major system of health care
delivery in government and private run health institutions within the district.
The comprehensive field practice was based on the study of district health system.
However we principally focused on the public health section of DHO under modern
health care system. Hence, not much emphasis was given on the traditional health care
system and only limited study was done on other supportive health care system.
22 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
The District Health Office is the centre of a network of activities concerned with health
that extend from the main district (headquarter) to the village level. It has the
responsibility to implement monitor and supervise preventive, promotive, rehabilitative
and curative health programmes within the district.
DISTRICT HEALTH CARE SYSTEM
Traditional Health Care System
Modern Health Care System
SupportiveSystem
AyurvedicHealth System
Homeopathic clinic
TraditionalHealingSystem
Koshi Zonal Ayurvedic
Ausadhalaya -1
AyurvedicDispensary -2
Private Ayurvedic
Clinics
Traditional Healers
District Public Health Office
District Hospital
Private Clinics
PHCC -2 HP -11 SHP -24
FCHVs -315 EPI Clinic -151
PHC- ORC -79
Government Organizations I/NGOs
DDC
DAO
DEO
DVO
DFO
DWDO
NRCS
BNMT
SOLVE
FPAN
Marie Stopes
Figure 1: District Health System of Dhankuta
The District Health Office manages, administers and coordinates district health matters
and serves as a link between the districts and higher levels; regional and central. It is
managed by a multidisciplinary team referred to as the District Health Management Team
(DHMT). The District Health Office in Dhankuta is headed by the Senior Public Health
Administrator.
23 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
The district health services extend from the community level health workers to the
hospitals. The district hospital is the main centre for curative health care and is the first
referral level. In organizing the district health services, the DHO also collaborates with
local government and non- government organizations, liase with community
representatives and organizations and practice intersectoral co-ordination.
Figure 2: The central role of the district health office within the district health system
24 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
3.2 District Health Management in System Model
District Health Management System in Dhankuta is dynamically proceeding through
various efforts and activities. The functioning of the management aspect of different
programmes in the district health office can be described by the Input, process and output
model below in the figure:
Figure 3: System Model of District Health System, Dhankuta
The health system model based on a System Approach illustrates the three important elements of a district health system - the community, the health care delivery system, and the environment in which the other two are located.
(Planning for Health Services at the District, 1997)
25 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
3.2.1 Service Inputs
i. Human Resources
Staffing Pattern of DHO
Table 10: Staffing pattern of DHO
Posts Sanctioned Fulfilled Vacant
Public Health Administrator 1 1 0
Medical Superintendent 1 0 1
Medical Officer 4 3 1
District Supervisors 8 7 1
Staff Nurse 6 0 1
Lab Technician/ Assistant 1 1 0
Radiographer 1 0 1
HA/ Sr. AHW 16 16 0
AHW 41 41 0
ANM 21 20 1
MCHW 24 23 1
VHW 37 28 9
ii. Budget
The overall budgeting & finance was under the control of finance section under
DHO. The total amount of released budget for DHO, Dhankuta (in the fiscal year
067/68) was Rs. 7,40,91,500. (Source: Account Section, DHO)
26 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
iii. Infrastructures
• Institutions
Table 11: Distribution of health institution in Dhankuta
Health Institutions Number
District Public Health Office (DPHO) 1
District Hospital 1
Koshi Zonal Ayurvedic Ausadhalaya 1
Marie Stopes Centre 1
District Public Health Clinic 1
Primary Health Care Centre (PHCC) 2
Health Posts (HP) 11
Sub- Health Posts (SHP) 24
Primary Health Care- Outreach Clinic (PHC-ORC) 79
EPI Clinic 151
DOTS Centre 14
DOTS Sub-centre 24
Private Hospitals 2
• Buildings
The DHO office was situated in two buildings. The account section was operating
in its own building while other sections were operating at the building of District
Hospital. The new DHO building was under construction. The District Hospital’s
building was sponsored by ADRA. Most of the PHCCs and HPs had their own
buildings but some SHPs were serving through the VDC buildings.
Dhankuta Model Hospital situated at the district headquarter was one of the two
private sector hospitals in Dhankuta district. It had been operating its activities
from its own building.
27 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
iv. Logistics
The available no. of logistics in District Health Office (including District
Hospital) can be described under following headings.
Table 12: Health Logistics in District Health Office
Logistics Number Remarks
District Store 1
Cold Chain Centers 1
Cold Chain Sub-centers 3
Deep Fridge 4
Refrigerators 4 Only 2 in operation
X-ray machines 1
Microscope 2
Vehicles 1 3 motorbikes
Ambulance 1
Seminar Hall 1
v. Drugs & Equipments
61 different types of drugs (excluding cold chain items) and surgical items were
available at the store room of DHO.
vi. Health Service Programs
Programs under DHO Dhading were reviewed by using information’s obtained by
Monthly Monitoring Profile of District Health Office Dhankuta. Major programs
running are as follows.
1. Child Health
• National Immunization Programme
• Nutrition
• Community Based Integrated Management of Childhood Illness (CB-IMCI)
• Community Based Neonatal Care Program ( CB- NCP)
28 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
2. Family Health and reproductive health
• Family planning
• Safe motherhood
• FCHV program
• Primary Health Care /Outreach Clinic
• Comprehensive Abortion Care Services
3.Disease control
• Tuberculosis Control
• AIDS & STD Control
• Malaria Control
4. Curative Services
• Out-patient Department Services
• Inpatient Department Services
• Emergency Services
• CAC/ PAC
• Emergency Obstetric Services
5. Supporting Programs
• Training
• Health Education, Information & Communication
• Logistics
• Laboratory Services
• Administrative Management
• Financial Management
29 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
3.2.2 Process
The DHO, Dhankuta performs a series of managerial and technical functions on a regular
basis to translate its inputs into valuable outcomes. The processes performed by DHO can
be summarized under the following headings:
i. Planning Monitoring and Evaluation
Planning, monitoring and Evaluation are the core functions of district health
management.
Figure 4: PME cycle of District Health Office, Dhankuta
Both top-down and bottom-up planning approaches can easily be coordinated because of direct contact at all levels. Communication with the target population and its participation in planning and organization are fairly easy to handle. Management (e.g. supervision) is more transparent and reliable. Coordination is easy to achieve between the various programmes and services at different levels. Intersectoral cooperation can take place (e.g. with agriculture, education, water, sanitation and housing sectors).
(Health Sector Reform & District Health System, WHO, 2004)
30 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
• Planning
Health Planning is the identification and elaboration (within existing resources) of means
and methods for providing in the future, effective health care relevant to identified health
needs for a defined population.
Planning of district health services in Dhankuta involves series of activities. The planning
in Dhankuta was done by taking into consideration, the government plans and policies,
regulations, short & long-term national plans, organizational structure, budget ceiling &
administrative capacity.
Figure 5: Planning cycle in district health services
District Health Planning contains characteristics of micro- as well as macro-planning; however, it is more akin to the former. Micro-planning, as its name implies, comprises of planning services and interventions at the micro level, that is regional or district levels in detail
(District Health Planning Manual, 2002)
31 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
The planning process was participatory and decentralized type where the various
stakeholders involved in situation analysis, prioritization & target setting. The baseline
information was first obtained from the community levels (VDCs). The prioritization and
target setting was done in consideration to following elements:
• Target population
• National Priority
• Skills
• Major public health issues
• Unmet need
• Effect impact
These priorities were passed to the illaka level, where similar activities were performed
and subsequently passed to the district level similarly and to the central level (as shown
in figure 7). Finally, the NPC endorsed the plan with necessary modifications.
NPC/ MOF
MOHP
RHD/ DOHS
District (DHO)
Illaka
VDC
Flow of Baseline information
Flow of budget ceiling
Figure 6: Micro planning in Dhankuta
32 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
After receiving the final set plans, the District Health Office set strategies and activities
to achieve the pre-determined objectives. Finally, the plan was brought into
implementation through DHO via all the health system operating in Dhankuta.
• Monitoring
Large numbers of approaches were employed by the DHO, Dhankuta in order to monitor
all the district health services and programs. Monitoring indicators were widely used to
measure the achievements of programme target. Monitoring had been performed by the
DHO on a regular as well as monthly basis. Participatory monitoring were done to
observe the performance and progress, verify the courses of action and to identify
deviations so as to provide necessary feedback.
Supervision
Supervision of district public health services had been performed using integrated
supervision checklist. Supervision of peripheral health institutions was done by DHO on
a periodic basis. Moreover, centre (MOHP/ DOHS) also supervised DHO at least once a
year, and by region (RHD, Dhankuta), at least three times a year.
• Evaluation
The district health office was concerned with the evaluation of two main aspects
• Programme Evaluation
• Performance Evaluation
Program evaluation was done by internal as well as external evaluators assigned by DHO.
The variety of methods like interview, observations, report review was done to evaluate
the public health programme and activities.
Performance evaluation was by self as well as participatory appraisal.
33 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
ii. Organizing
The government health system of the entire district in Nepal follows the similar
organization flow chart. The organization of health institutions in Dhankuta as no
exception to other District health systems, are shown below in the form of flow chart.
District Health Office District Health Office
Primary Health Care Centers- 2
FCHVs
Health Posts- 11
Sub- Health Posts-24
PHC/0RC- 79 EPI Clinics-151
Figure 7: Organization of health institutions in Dhankuta
34 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
The District Health Office is the central body within the district health system for a
network of health related activities. Public Health Section forms a portion of district
health office. District Hospital is another important component within the DHO. The
organogram of DHO, Dhankuta can be shown as follows:
District Public Health Office
Store Section
Statistical Section
Indoor
Laboratory
District Hospital
Administrative Section
Finance Section
Emergency
OPD
Primary Health Care Centre (PHCC)
Health Posts/ Sub Health Posts
Immunization Programme
Maternal & Child Health
CDD/ARI/Nutrition/ IMCI
Health Education/
Training
Family Planning
Disease Control Section
•TB/ Leprosy•HIV/AIDS & STIs•Malaria Control
PHC-ORC EPI Clinics FCHVs
Figure 8: Organogram of District Health Office, Dhankuta
35 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
iii. Staffing
The various level and mix of human resources were working in the DHO & within its
system. These staffs could be broadly categorized into two levels; Technical &
Administrative staffs.
The Administrative staffs involved the following:
Section officer
Accountant
Statistician
Store Keeper, etc.
There were different levels of technical staffs working in the DHO, some of which are as
follows:
Public Health Administrator
Health Assistants
ANM
AHW, etc.
• Career Opportunities
Training was the most effective motivating factors for the staffs in DHO, Dhankuta. The
numerous training activities had been organized for the staffs. Opportunities for inter-
districts were also provided to the staffs.
iv. Directing
• Decision making
The decisions on various public health issues & programmes were made on the basis of
consensus obtained by the discussions between DHOr and respective program
supervisors, and sometimes via meetings and discussions with various other line
agencies, NGOs and INGOs.
36 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
• Delegation
The supreme authority for the management of overall district health system lay on
District Public Health Officer. However, in the absence of DHOr, the authority was
delegated to the medical superintendent.
• Leadership
DHOr in Dhankuta was highly enthusiastic and committed to his roles and
responsibilities. He believed and followed the democratic approach for all forms of
managerial and technical activities to bring into operation. All the staffs were highly
influenced by his activities. His inspiration shaped the source of motivation for many
staffs.
• Communication
Communication system of DHO, Dhankuta was highly effective. The office was well
equipped with various means of communication. The DHO used letters for official and
formal communication. However, other sorts of informal communication were made via
telephone & internet.
The DHO office had good communication with all the peripheral institutions as well as
higher authorities (regional and central). The DHO also maintained inter-sectoral
communication with its supporting I/NGOs and line agencies.
v. Co-ordination
The DHO maintained an effective co-ordination both horizontally as well as vertically.
Horizontal co-ordination was with different government line agencies. The DHO had its
vertical co-ordination with RHD and MD under DOHS. Co-ordination with peripheral
staffs was good. However, co-ordination seemed weaker with one of the supporting NGO
i.e. FPAN because of which there were problems like inappropriate reporting, program
duplication, etc. The co-ordination with other I/NGOs were very good. The community
usually acted as dormant towards the public health programs conducted by DHO. Hence,
the co-ordination with the community was lacking.
37 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
vi. Recording and Reporting
• Health Management Information System
There were 38 different types of HMIS tools in operation for recording and reporting of
services. All the personnel responsible for recording and reporting were well trained on
HMIS. The reports were regularly received from peripheral institutions and then
forwarded to the RHD and HMIS section under DOHS.
The HMIS process in DHO, Dhankuta can be explained by the figure as follows:
Department of Health Services
Regional Health Directorate
District Public Health Office
District Hospital
PHCCs/ HPs
SHPs
EPI clinics/ PHC-ORC/ FCHVs
District
Illaka
VDC
Community
Regional
Central
Feedback
Reporting
12th of the succeeding month
7th of the succeeding month
3rd of the succeeding month
Last day of the same month
Figure 9: HMIS process in DHO, Dhankuta
38 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
• Logistic Management Information System
The recording and reporting of logistics in DHO, Dhankuta were done using various
LMIS forms like entry form, dispatch form and order form. Reports of every received
commodities and supplied logistics were sent by peripheral institutions to the district
store trimesterly using various LMIS and audit forms. The district sent a report to RMS
as well as LMD every three months and the feedback was sent by LMD to the district.
Store keeper was responsible for the LMIS in DHO, Dhankuta. Data-base and inventory
system were managed by a computer operator.
Regional Medical Store( Biratnagar)
District Medical Store(DHO, Dhankuta)
Sub-Health PostsHealth Posts PHCCs
Logistics Management Division(Teku)
Feedback
Reporting
Regional Health Directorate( Dhankuta)
Figure 10: LMIS process in DHO, Dhankuta
39 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
The reporting schedule of LMIS for DHO can be shown in the table as follows:
Table 13: LMIS reporting schedule in Dhankuta
LMIS flow Time of reporting
SHP to HP/PHC 3rd of Shrawan/ Kartik/ Falgun/ Baisakh
HP/PHC to DHO 7th
DHO to RMS & LMD
of Shrawan/ Kartik/ Falgun/ Baisakh
15th of Shrawan/ Kartik/ Falgun/ Baisakh
v. Budgeting
The budgeting of health sector within the district involves series of processes. The
budgetary ceiling will be provided by MOF which flows downwardly and subsequently
to the DHO. The budget release is done quarterly by the District Treasury and Account
Control Office.
Figure 11: Health budgeting process in Dhankuta
40 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
3.2.3Service Outputs
3.2.3.1 Child Health Programme
3.2.3.1.1 National Immunization Programme
The National Immunization Programme (NIP) is a high priority programme (P1) of
Government of Nepal, hence, a major programme under DHO. It has significantly
contributed to reduce the burden of vaccine preventable diseases and child mortality.
Nepal is one of the countries on track to achieve the Millennium Development Goal on
Child Mortality Reduction. The DHO has been taking the responsibility to ensure that a
successful immunization programme is implemented at the district and grass-root level.
Primary Health Care Centres (PHCs), Health Posts (HPs), and Sub-Health Posts (SHPs)
has been implementing National immunization programmes in their respective
municipalities and Village Development Committees (VDCs) by extending the EPI
clinics as per their micro plan.
The immunization coverage in the Dhankuta district can be summed up in the table
below:
Table 14: Immunization Coverage
Immunization 064/65 065/66 066/67 06768
(till chaitra)
Regional National
BCG 77.9% 70.27% 75.13% 61.33% 87.4% 84.9%
DPT-3/ Hep-B 3 75% 70.21% 65.27% 62.31% 83.3% 81.2%
Polio-3 74.1% 70.21% 70.11% 62.08% 82.9% 80.9%
Measles 70.9% 70.60% 72.26% 52.65% 78% 75.4%
The data on immunization coverage in Dhankuta since last four years shows a decreasing
trend. The coverage is lower as compared to national average.
41 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
Table 15: Vaccine Wastage
Vaccine 064/65 065/66 066/67 067/68
(till chaitra)
National
(065/66))
BCG 83.95% 85.85% 86.21% 84.18% 79.8%
DPT/Hep B 36.06% 44.02% 27.47% 9.53% 21.9%
Polio 39.30% 45.48% 37.55% 27.47% 25%
Measles 72.78% 73.47% 75.20% 75.37% 61.1%
The vaccine wastage rate as shown in the above table depicts that there has been a high
wastage of vaccine in the past three years from fiscal year 064/65 to 066/67. However the
data of 067/68 (available till chaitra) shows that the wastage rate has decreased to some
extent. The wastage of vaccine is higher than that of national average except for DPT/
Hep -B
Table 16: Immunization Drop-out Rate
Immunization 064/65 065/66 066/67 067/68
(till chaitra)
National
(065/66)
BCG vs Measles 8.9% -0.47% 3.82% 14.16% 11.3%
DPT 1 vs DPT 3 1.6% 0.06% 7.89% -4.91% 2%
The above table depicts that the BCG vs Measles drop-out rate is highly increased from
066/67 to 067/68. However DPT I vs DPT 3 drop-out is decreasing in 067/68.
42 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
• Problems and Constraints
Table 17: Problems and constraints in immunization programme
Problems Actions to be taken Responsibilities
Over estimation of target
population
-Periodic census should be taken by
local HFs and target should be set
by DHO.
-DHO and
Local HFs.
Insufficient fuel for cold
chain sub-center.
-Sufficient budget should be
allocated and released in time. Other
sources (eg. VDC budget) should be
explored.
-DHO
-VDC
-Local HFs
Vacant post of EPI Officer in
district
-DHOr should take steps to fulfill
the vacant post
-DHO
-DOHS/CHD
43 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
3.2.3.1.2 Nutrition
Malnutrition remains a serious obstacle to child survival, growth and development in
Nepal. The most common forms of malnutrition is protein-energy malnutrition (PEM)
The other form of malnutrition are iodine, iron and vitamin A deficiency. Each type of
malnutrition wrecks its own particular havoc on the human body, and to make matters
worse, they often appear in combination. Malnourished children are more likely to die
from common childhood illness than those adequately nourished. In addition,
malnutrition constitutes a serious threat especially to young child survival and is
associated with one third of child mortality.
Nutrition programme is one of the major child health programme run by DHO in
Dhankuta. The achievements of nutrition programme can be discussed in the table as
follows:
Table 18: Growth Monitoring Status of U5 children
Indicators 064/65 065/66 066/67 067/68
(till
chaitra)
Regional National
(065/66)
New Growth Monitoring
(coverage)
32.9% 30.18% 24.92% 17.15% 44.04% 44.81%
Proportion of
malnourished children
(among new cases);
Wt/Age
2.6% 3.74% 2.48% 0.55% 3.2% 4.7%
The new growth monitoring coverage shows a sequential reduction in the last four years.
The coverage seems poor as compared to national average.
The proportion of malnourished U5 children has decreased from 3.74% in 065/66 to
2.48% in 066/67 and still shows a decreasing trend in 067/68 which is lower than that of
national level.
44 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
Table 19: Achievements of child nutrition programme
Indicators 064/65 065/66 066/67 Regional National
(065/66)
Vitamin A distribution as
percent of children 6-59
months
94.84% 98.56% 97.03% 97% 92.11%
% of 6-59 months children
provided with Albendazole
92.59% 99.11% 99.57% - 95.47%
As shown in the table above, vitamin A distribution to children between 6-59 months had
decreased in FY 066/67 than that of FY 065/66 level. However, the coverage still seems
higher than that of the national level. But, the children of same age group provided with
deworming tablets seemed to have increased, which is contradictory in itself. The
coverage is however greater than the national average.
• Nutrition to pregnant mothers
Table 20: Achievements of nutrition programme for mothers
Indicators 064/65 065/66 066/67 067/68 (till
chaitra)
% of pregnant mothers receiving
iron tablets
48% 43.32% 57.44% 39.26%
% of pregnant women receiving
225 iron tablets ( Iron compliance)
13.4% 12.09% 22.01%
% of post-partum mother receiving
vit-A
45.5% 35.55% 43.53% 37.36%
% of post partum mother receiving
iron tablets
42.85% 42.39% 49.04% NA
45 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
The percentage of pregnant women receiving iron tablets has increased by 14% from FY
065/66 to FY 66/67 but shows a decreasing trend in the FY 067/68. The coverage of iron
supplementation seems unsatisfactory as it is lower to that of national and regional levels,
as shown in the table above. The iron compliance had increased nearly two times from
12.09% in FY 065/66 to 22.01% in FY 066/67. The iron supplementation during post-
partum period also showed an increasing trend.
• Problems and Constraints
Table 21: Problems and constraints in nutrition programme
Problems Actions to be taken Responsibilities
Insufficient no. of Salter
scales/available Salter
scales are not functioning
properly
-Older Salter scales should be repaired
and adequate no. of Salter scales should
be supplied.
-Local HIs
-DHO/PHO
Over estimation of target
population
-Periodic census should be taken by
local HFs and target should be set by
DHO.
-DHO and
Local HFs.
3.2.3.1.3 Community Based Integrated Management of Childhood Illness (CB-
IMCI)
Community Based Integrated Management of Childhood Illness (CB-IMCI) is an
integrated package of child-survival programmes and addresses major killer diseases like
pneumonia, diarrhoea, malaria, measles, malnutrition in under 5 year children.
• ARI Control
Acute Respiratory Infection (ARI) as one of the major killer of children under 5 years, in
Nepal. CB-IMCI programme in Dhankuta was first implemented in fiscal year 2059/60
46 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
Table 22: Service statistics of ARI control programme
Indicators 064/65 065/66 066/67 National
ARI Incidence by HF (per 1000) 289 412 450.55 340
ARI Incidence by Community
(VHW/MCHW/FCHV) per 1000
616 648.56 895.25 660
% of new Pneumonia 55.2% 55% 52.30% NA
The table 22 shows that reported cases of ARI by both health facility and community had
increased in 066/67 than that of past two years. The reported incidence seemed higher
than that of the national figure. This increase could either be due to improvement in the
recording and reporting system or actual increase in the cases of ARI.
Despite the increase in ARI incidence, the percentage of new pneumonia cases has
decreased from 55.2% in FY 064/65 to 52.30% in FY 066/67.
• Problems and Constraints
Table 23: Problems and constraints on ARI control programme
Problems Actions to be taken Responsibilities
HWs did not follow the
WHO classification for
ARI categories.
-Written information/order to follow
WHO classification to all health
facilities from DHO.
-DHO
-ARI supervisor
47 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
• Control of Diarrhoeal Diseases (CDD)
Diarrhoea is one of the leading killer diseases under five children in Nepal. CB-IMCI
programme intensely focuses on management of Diarrhoeal diseases among the under
five year’s children. Standard case management of diarrhoea with Oral Rehydration
therapy and Zinc tablet along with counselling for continued feeding has been provided
by DHO in all the health institutions and community level of Dhankuta district.
Table 24: Service statistics of CDD
Indicators 064-65 065-66 066-67
CDD Incidence by HF (per 1000) 129 123.70 165.13
CDD Incidence by Community (per 1000) 343 382.99 459.63
Severe Dehydration 0.69% 0.02% 0.11%
% of diarrhoeal cases treated with
ORS/Zinc
99.40% 98.27% 91.01%
The reported incidence of diarrhea by both health facility and community shows an
increasing trend. The proportion of severe dehydration although minimal (as compared to
national level i.e. 0.6%), had also increased from 0.02% in FY 065/66 to 0.11% in
066/67. The cases of diarrhoea treated by ORS & zinc had decreased in FY 066/67 as
compared to previous two years.
3.2.3.2 Family Health & Reproductive Health Programme
3.2.3.2.1 Family Planning
Family Planning Programme in Dhankuta has been operating to expand and sustain
adequate quality family planning services to communities through the district health
service network such as hospital, primary health care (PHC) centers, health posts (HP),
sub health posts (SHP), primary health care outreach clinics (PHC/ORC) and mobile
voluntary surgical contraception (VSC) camps. Female community health volunteers
(FCHVs) are mobilized to promote condom distribution and re-supply of oral pills.
48 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
Table 25: Service statistics of family planning programme
Indicators 064-65 065-66 066-67
Contraceptive Prevalence Rate (CPR) 30.83% 37.52% 34%
New acceptors (as % of MWRA) 8.71% 11.71% 11.1%
Couple Years of Protection (CYP) as % of MWRA 25.75 25.19 21.85
The trend of past three years from FY 064/65 to 065/66 shows that there was an increase
in CPR from 30.83% in 064/65 to 37.52% which had later decreased to 34% in FY
066/67. The CPR is still below to that of regional as well as national level.
The percentage of new acceptors among MWRA had however remained similar in both
the FY 065/66 & 066/67.
Table 26: Acceptors of family planning devices
Indicators
064-65 065-66 066-67 067-68
(till chaitra)
New
acceptors
Current
users
New
acceptors
Current
users
New
acceptors
Current
users
New
acceptors
Current
users
Pills 2.2% 3.9% 4.03% 5.4% 3.72% 5.4% 2.70% NA
Depo 5.82% 13.3% 6.85% 14.7% 6.60% 12% 4.66% NA
IUD 0.39% 0.84% 0.38% 1% 0.10% 0.97% 0.22% NA
Norplant 0.12% 0.81% 0.45% 1.32% 0.66% 1.69% 0.28% NA
As shown in the above table the new acceptors of pills & depo which had increased
during FY 065/66 than that of 064/65 has again shown a decreasing trend. Conversely,
there is increasing new acceptors for IUD as shown by the data from FY 066/67 to
067/68. The new acceptors for Norplant have been decreasing in 067/68.
49 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
• Problems and Constraints
Table 27: Problems and constraints in family planning programme
3.2.3.2.2 Safe Motherhood
The goal of the National Safe Motherhood Programme is to reduce maternal and neonatal
mortalities by addressing factors related to various morbidities, death and disability
caused by complications of pregnancy and childbirth. Hence, DHO, Dhankuta has been
determined to reduce maternal morbidity and mortality through safe motherhood
programme.
• Antenatal Care
Table 28: Trends of ANC visits
Indicators 064-65 065-66 066-67 067-68
% of first ANC visit 32.80 47.10 62.47 42.56
% of four ANC visit (among 1st 48.10 visit) 54.68 56.78 58.33
The above bar diagram depicts that the percentage of first ANC visit has decreased by
10% from the FY 066/67 to FY 067/68. However, the percentage of all four ANC visits
among the first visits shows an increasing trend.
Problems Action to be taken Responsibilities
Poor recording and reporting by
FPAN
Appeal for co-ordination should
be done
DHO
50 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
• Delivery Care
Table 29: Delivery service statistics in Dhankuta
Indicators 064-65 065-66 066-67 067-68
(till chaitra)
% of delivery conducted by SBA 7.9% 7.8% 11.4% 8.7%
% of delivery conducted by HW
(including SBA)
17.4% 14.8% 17.58% 13.57%
Proportion of mothers having
obstetric complications from
B/C EOC centers
0.34% 0.89% 3.58% 2.38%
The delivery conducted by health workers (including SBAs) had increased from 14.8% in
FY 065/66 to 17.58% in FY 066/67 but the available data till the chaitra of FY 067/68
shows that the delivery by HW has been decreasing. The reported cases from BEOC/
CEOC centers show that the proportion of women having obstetric complications during
delivery is at rise.
• PNC Care
Table 30: Trends of PNC visits
Indicators 064-65 065-66 066-67 067-68 (till chaitra)
% of first PNC (as of
expected pregnancy)
34.1% 33.88% 44.89% 33.27%
The PNC coverage as similar to ANC has also increased in the FY 066/67 but at decrease
in FY 067/68 as shown by the data available up to chaitra. As explained by the Family
Health Section of DHO, the decrease in the coverage could probably be due to over
estimation of target population (MWRA).
51 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
• BEOC services
Only basic emergency obstetric care was available in district hospital as well as in
Primary health care centers.
• CAC services
CAC service was available in district hospital and Marie Stopes Center. In the FY 066/67
878 people had received this service.
• PAC services
PAC service was available at the Marie Stopes Center as well as at the district hospital.
• Problems and Constraints
Table 31: Problems and constraints of safe motherhood programme
Problems Action to be taken Responsibilities
Poor environment (lack of
physical facilities & others
like blood bank) to provide
quality safe motherhood
services in Health institution.
Provide enabling environment
like physical infrastructure,
furniture and instruments
MoHP,
FHD/RHD/DHO/ all
HIs, HFMC.
52 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
3.2.3.3 Disease Control Programme
3.2.3.3.1 Malaria Control
The high risk of getting malaria is attributed to the abundance of vector mosquitoes,
mobile and vulnerable population, relative inaccessibility of the area, suitable
temperature, environmental and socio-economic factors. Currently malaria control
activities are carried out in 65 districts at risk of malaria. The Malaria Control
Programme in Nepal was initiated in 1954. The Malaria Eradication Project that was
launched in 1958 was later reverted to control program in 1978. Roll Back Malaria
(RBM) was launched in 1998. Dhankuta is one of the 52 malaria endemic districts of
Nepal.
Table 32: Service statistics of Malaria control programme
The malariometric indicators in Dhankuta depicts that there are no reported cases of
malaria as shown by the data from FY 064/65 to 066/67. However, hospital record
reported one case of malaria in 2068.
3.2.3.3.2 National Tuberculosis Control Programme
The National Tuberculosis Programme (NTP) is an approach within the national health
system for control of tuberculosis (TB). Tuberculosis (TB) is a major public health
problem in Nepal. DOTS have been successfully implemented throughout the country
Indicators 064/65 065/66 066/67
Annual Blood Examination Rate (ABER) 1.52 0.59 0.19
% of PF among new cases 0 0 0
Malaria Parasite Incidence (per 1000) 0 0 0
Clinical Malaria Incidence 0.33 0.42 0.36
Slide Positivity Rate 0 0 0
Total no. of Malaria cases 0 0 0
53 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
since April 2001, for the effective control of TB. Hence, TB Control is also one of the
priority programme for TB control in Dhankuta.
Table 33: Achievements of Malaria control programme
Indicators 064-65 065-66 066-67 Regional National
(065/66)
Case Finding Rate (CFR) 41.5% 27% 33% 64% 75%
Cure Rate 88% 90% 91% 91% 89%
The TB case finding rate in Dhankuta seems lower than that of regional and national
level. However, the cure rate coincides with the regional level.
3.2.3.3.3 Leprosy Control Programme:
Since many decades leprosy has been considered as one of the main public health
problem it has been in top priority of government’s plan and policy so as to eliminate
leprosy from the country. There have been continuous efforts from the DHO, Dhankuta
to reduce its prevalence rate (PR) and eliminate the disease from the country for once and
all.
Table 34: Service statistics of Leprosy control programme
Indicators 064/65 065/66 066/67
New Case Detection Rate 0.16 0.21 0.05
RFT 100% 100% 100%
Prevalence Rate (per 1000) 0.16 0.21 0
Disability Grade 2 0 50% 0
There was only one reported case of leprosy in FY 066/67, Leprosy is eliminated from
Dhankuta district but NCDR was 0.05%.
54 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
3.2.3.3.4 HIV/AIDS and STI Control
Nepal is categorized as a “Concentrated” epidemic country in terms of HIV/AIDS.
Dhankuta is one of the HIV/AIDS prone districts of Nepal. Rapid urbanization and
increasing number of seasonal migrants has increased the risks of STIs and HIV/AIDS in
Dhankuta.
Although there were no reported cases of HIV/AIDS during the past years, four new
cases were reported in 067/68, of which 3 were females and 1 was male.
3.2.3.4 Female Community Health Volunteer (FCHV) Programme
The major role of the FCHV is to promote health and healthy behaviour of mothers and
community people for the promotion of safe motherhood, child health, family planning,
and other basic health services with the support of health personnel from the SHPs, HPs,
and PHCCs. Besides the motivation and education, the FCHVs re-supply pills and
distribute condoms, ORS packets and vitamin A capsules; and they also treat pneumonia
cases and refer more complicated cases to health institution.
Table 35: Service statistics of FCHV programme
Indicators 064-65 065-66 066-67
Average no. of people served by
FCHVs
172 217.30 262.31
% of mother group meetings
conducted by FCHVs
78.81% 73.49% 88.15%
% of report received from FCHV 93.25% 93.99% 95.24%
The service statistics on FCHV programme shows a progressive trend. The average no. of
people served by FCHVs in FY 066/67 had increased than the no. of people served
during FY 065/66. The reporting has also increased as compared to previous years.
55 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
• Problems and Constraints
Table 36: Problems and constraints of FCHV programme
3.2.3.5 Primary Health Care Outreach Clinic (PHC-ORC) Programme
Primary Health Care Outreach clinic (PHC-ORC) program was established in 1994 (2051
BS) with an aim to improve access to some basic health services including family
planning and safe motherhood services for rural households. PHC-ORC clinics are the
extension of HPs and SHPs at the community.
Table 37: Service statistics of PHC-ORC
Indicators 064-65 065-66 066-67 National
(065/66)
Average no. of people served by PHC/ORC 10 11 15 17
% of PHC/ORC held 83.71% 85.9% 81.65% 80%
The average number of people served by outreach clinics although shows a progressive
trend as shown in the table above, it is yet lower than that of the national average. The
percentage of outreach clinics conducted is however similar to the national figure.
Problems Action to be Taken Responsibilities
Aged and drop out FCHV. Replace them with the permission
of Mother Group and train them.
DHO/FHD
56 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
• Problems and Constraints
Table 38: Problems and constraints of PHC-ORC
Problem constraints Action to be taken Responsibility
Some PHC/ORCs are
not functioning regularly
Reactivate and orient management
committee for regular conduction of
PHC/ORCs with the support of I/NGOs
DHO/HFs
Inadequate supervision
at all levels
Ensure regular supervision as per revised
strategy
DHO/PHO/
HPIs/SHPIs
Inadequate awareness
among the communities
about PHC/ORCs.
Conduct orientation program for community
awareness with the support of I/NGOs
DHO/VDCs
3.2.3.6 Curative Services
3.2.3.6.1 Introduction
The district hospital is the referral apex in the district where patients are referred from
other health facilities. Being part of the district health system, the district hospital is
determined to provide the identified and prioritized essential health packages. Further, it
is concentrated on providing the level of technological medical care that lower levels
cannot provide.
District Health Office in Dhankuta is committed to improving the health status people by
delivering high-quality health services throughout the district. Curative (out-patient, in-
patient and emergency) services are highly demanded component of health services by
the people. The curative health services in Dhankuta were made available at all health
institutions- district hospital, primary health care centres (PHCCs), health posts (HPs),
sub health posts (SHPs) and ayurvedic dispensaries (both zonal and peripheral). Apart
57 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
from government institutions, these services were also made available through private
hospitals & clinics.
3.2.3.6.2 Available health services at the District Hospital
• Indoor
• OPD
• Emergency Services (24 hours)
• B/CEOC
• CAC/PAC
• X-ray/ USG Services
• CAC/PAC
Table 39: Service statistics in District Hospital, Dhankuta
Indicators 064/65 065/66 066/67
Total no. of OPD cases 20901 24889 25054
Total no. of emergency cases 2727 3807 5365
Total no. of inpatients discharged 827 855 894
Total no. of delivery conducted 160 190 229
The table as shown above shows that no. of patients served by the district hospital in the
OPD, IPD as well as emergency has increased in the recent years. Moreover, the no. of
delivery attended at the hospital shows an increasing trend.
Table 40: Other service statistics in District Hospital
Indicators 064/65 065/66 066/67
No. of sanctioned beds 50 50 50
No. of available beds 22 22 22
Total OPD visits as % of total population 11.24 11.88 13.25
% of emergency visits (among total visits) 11.54 13.26 17.16
Bed occupancy rate 29.4 32.61 40.21
58 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
Delivery conducted (as a % of expected pregnancy) 2.34 2.72 4.13
Death rate (among inpatients) 0.84 0.46 0.44
% of surgery (among in-patients) 2.05 0.93 0.003
Proportion of communicable diseases among in-
patients
17.89 14.03 20.02
Proportion of non-communicable diseases among
in-patients
31.8 33.09 28.41
% of referred among in-patients 14.38 16.84 10.29
Daily average in-patients admitted 2.27 2.37 2.46
The statistics available at the district hospital shows an increasing trend of bed
occupancy. The proportion of communicable diseases in the FY 066/67 has increased as
compared to the previous year. In contrast to this, the proportion of non-communicable
diseases has decreased in last year (FY 066/67).
3.2.3.6.3 Top five causes of morbidity and mortality in District Hospital
• Top five causes of morbidity (FY 066/67)
Pneumonia
Enteric Fever
COPD
Acute Gastroenteritis
LRTI/ ARI
• Top five causes of morbidity (FY 066/67)
COPD-1
Severe Pneumonia-1
Cirrhosis of Liver-1
Fever-1
Total Deaths-4
59 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
3.3. Top ten diseases in Dhankuta
Table 41: Top ten diseases in Dhankuta
067-68 (till chaitra) Total New Cases (066/67)
Skin Diseases 15839
ARI 12513
Diarrhoea 9226
Worms 7301
PUO 6520
Gastritis 5325
Sore eye & eye-complaints 4273
Ear infection 3554
Fall/ Injury/ Fractures 2756
COPD 2417
3.4 SWOT Analysis of District Health System
With the SWOT analysis of Dhankuta district health system, specific components are
reviewed with respect to their strengths, their weaknesses, the opportunities they present
for the improvement or health care or betterment of health status, and the potential threats
that may prevail for the system or system component under scrutiny, as well as the threats
that may emanate from the system. The SWOT for the district health system, Dhankuta,
can be presented as follows:
‘SWOT’ Analysis is a useful analytical tool to qualitatively and quantitatively examine and assess a system, such as the district health system with respect to all of its individual system components.
(District Health Planning Manual, 2002)
60 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
Table 42: SWOT analysis of district health system
SWOT Components Findings/ Attributes
Strengths Service Inputs Sufficient logistics, trained paramedical staffs
available
Service Distribution All outreach clinics functional, paramedical
staffs posted at all health facilities, better
communication
Management &
Organization
Drugs available, regular reporting, referral
facilities available
Weakness Service Inputs Untimely release of budget, Vacant post of EPI
Officer
Service Distribution No ambulance services in PHCC
Management and
Organization
No regular supervision in far flung areas
Opportunities Ecosystem,
Environmental
factors
District hospital is sensitized to the need for
better maternal care (in delivery and abortion
services),support have become available from
NESOG
Co-ordination BNMT that remained dormant for certain
duration is due to re-vitalize
Service Inputs Establishment of blood bank at district hospital
is in the new program
61 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
Threats Political factors Political disturbances and strikes affect service
delivery and transport of logistics
Community
Participation
Reluctance of community to participate actively
in programs organized by DHO
System factors Some health facilities are inaccessible in rainy
season.
3.5 Recommendations
The vacant posts in DHO should be fulfilled for efficient and effective
functioning of the DHO.
Ambulance services should be made available at both PHCCs
Continuous supervision should be done irrespective of geographical constraints
and accessibility.
CHAPTER IV
VISITED ORGANIZATIONS
62 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
CHAPTER IV
VISITED ORGANIZATIONS
4.1 Peripheral Health Institutions
4.1.1 Dandabazar Primary Health Centre
4.1.1.1 Introduction:
Dandabazar PHCC is one of the two PHCCs of Dhankuta district, located at a distance of
50 km from the district headquarter and 14 km from Vedetar, the southern VDC of the
district. The PHCC established in 2053 B.S. is one of the important centres with varieties
of health services for numbers of VDCs located in the south-west of Dhankuta district.
4.1.1.2 Catchment Areas
Dandabazar VDC Patigaun VDC
Rajarani VDC Maunabudhuk VDC
Singhdevi VDC
4.1.1.3 System Model of Dandabazaar PHCC
4.1.1.3.1 Input Indicators
• Building
The Dandabazar PHCC is currently operating its services from its four different
building. However, three of them were rented. Altogether there were 21 rooms
which were sufficient for delivery of different services through different rooms.
The PHCC also owned a residential quarter. The new PHCC building was under
construction on a walking distance from the currently operating center.
63 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
• Logistics:
All the logistics were sufficiently available in the PHCC. There was a separate
store room for the storage of drugs. However, some drugs that were made
available by the district medical store to PHCC were too close to their expiry. No
ambulance services were provided by the Dandabazar PHCC.
• Human Resources
Table 43: Staffing pattern of Dandabazar PHCC
Posts Sanctioned Fulfilled Vacant Remarks
Medical officer 1 1 0
Public Health Officer 1 1 0
Staff Nurse 1 0 1
AHW 2 2 0
ANM 3 2 1 1 contract
Lab-assistant 1 1 0
VHW 1 1 0
Office assistant 2 2 0
• Other Human Resources
EPI clinics: 3
PHC-ORC: 3
FCHVs: 9
64 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
4.1.1.3.2 Process
4.1.1.3.2.1 Health Services Provided by Dandabazaar PHCC
• National Immunization Programme
There were 3 EPI clinics for the conduction of NIP. The PHCC was one of the
four cold chain sub-centers of Dhankuta district. Cold chain in Dandabazaar VDC
was maintained using refrigerator. However, the continuous power failure was
one of the challenges for appropriate maintenance of cold chain.
• Nutrition
Dandabazar PHCC was providing continuous nutrition services such as child
growth monitoring, Vit-A supplementation to both post-partum mothers and
children & iron- tablet supplementation to pregnant and post-partum mothers.
• Family Planning & Safe Motherhood Programme
Dandabazar PHCC had been working on various components of family planning
& safe-motherhood programme. The prime services included distribution of FP
devices, FP counseling, routine ANC check-ups, safe delivery services, PNC
services, medical abortion, BEOC and TT immunization.
• Laboratory Services
Dandabazar PHCC was well equipped with laboratory equipments. Hence, it was
thriving in effective delivery of services like sputum test, malaria parasite test and
routine examination of stool & urine.
• Other Services
CB-IMCI
Disease control Program
FCHV Services
PHC ORC Program
65 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
4.1.1.3.2.2Managerial Aspects
There was a PHCC management committee in Dandabazar PHCC which was
responsible for planning, decision making and other managerial aspects involved
in PHCC. Training on various aspects was provided by the district on different
times for the PHCC staffs. The recording and reporting were done using HMIS
tools and timely reporting was done to the district.
Waste management in PHCC was done using incinerator.
4.1.1.3.3 Output Indicators
Table 44: Service indicators of Dandabazar PHCC
Indicators Percentage (066/67)
EPI coverage
BCG 107.72%
DPT/ Hep-B III 89.58%
Polio III 82.24%
Measles 97.3%
TT- 2 66.34%
BCG vs Measles drop-out 9.7%
DPT- I vs DPT- III 4.1%
Nutrition Programme
New Growth monitoring 31.68%
% of malnourished (among new visits) 2.48%
ARI Control
ARI Incidence (by PHCC) 794.07/1000
ARI Incidence by community 1190.23
Control of Diarrhoeal Diseases (CDD)
Diarrhoeal Incidence 198.95/1000
66 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
Reproductive Health
1st 70.96% ANC visit
4 ANC visits (among first visit) 76.74%
Institutional Delivery 75.61%
Family Planning New Acceptors Current Users
Pills 2.51 2.5
Depo 6.13 7.9
IUD 0.19 0.46
Norplant 0.139 0.19
Contraceptive Prevalence Rate (CPR) 11.06
FCHV & PHC ORC Program
% of report from FCHVs 90.12%
Average no. of people served by FCHVs 130.81
% of mothers group meeting conducted 91.05
% of PHC ORC held 80.13
4.1.1.3.4 Problems and Constraints
• Lack of trained human resource for logistics management
• Cold-chain maintenance problem due to repeated interruption of power supply
• Availability of safe water
• Lack of Ambulance services
4.1.1.3.5 Recommendations
• The person responsible for store management should be trained on logistics
management and LMIS.
• Ambulance services should be made available at the PHCC.
• Alternatives should be managed for cold-chain maintenance during power
failure.
67 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
5.2 Pakhribas Health Post
5.2.1 Introduction
Pakhribas HP is one of the 11 Health Posts located in ward no 9 of Pakhribas VDC
which is about 50 metre from highway and 18 kilometers from Dhankuta
Headquarter.
5.2.2 Catchment Areas
Pakhribas Muga,
Falatae, Sanna
Ghorkakharka.
5.2.3 Physical Infrastructures
Pakhribas HP had its own Pucca building with tin roof. It has total of 7 rooms which
were furnished and well ventilated, medical equiped and supply of electricity. 7 room
include 1 store,1 dispensary room,1 ANC/delivery/PNC room,1OPD room,1 dressing
room,1 family planning and counseling,1 vaccine store room and also available of
waiting hall.
5.2.4 Health Activities /Services Provided by Pakhribas HP
Following activities were being conducted regularly by Pakhribas Health Post.
1. OPD service
2. EPI
3. Family planning program
4. Safe motherhood program
5. Nutrition program
6. Disease control
7. PHC/ORC
8. Health Education program
68 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
5.2.5 Management aspects
• Planning: Health Post had formulated its own annual work plan according to
the target given for different programs by DHO.
• Staffing
Table 45: Staffing situation of Pakhribas HP
Post Sanctioned
post
Fulfilled
post
Vacant
post
Remarks
Health
Assistant
1 1 0 -
AHW 1 0 0 -
ANM 1 3 0 2 ANM
VHW 1 0 0 -
Peon 2 0 0 -
Total 6 4 0 -
• Meeting
HP, SHP staff meeting
FCHV meeting
FCHVs review meeting.
• Communication: Communication with DHO, SHP and other sector was done
in written form and also verbally in some cases.
• Coordination: Good coordination was found with SHPs of the catchments
area. Similarly coordination with DHO was also found to be quite good. There
were no INGOs and NGOs working in the catchments area of HP.
69 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
• Recording and reporting: Recording and reporting of the health activities
was done on regular basis. Report was sent to the DHO office before 7th
of
every month. Immunization chart was properly filled up.
5.2.6 Service Statistics of Pakhribas HP
Table 46: Service indicators of Pakhribas HP
Indicators Percentage (066/67)
EPI coverage
BCG 69.34
DPT/ Hep-B III 54.72
Polio III 59.36
Measles 69.52
TT- 2 30.28
BCG vs Measles drop-out -0.3
DPT- I vs DPT- III 19.2
Nutrition Programme
New Growth monitoring 31.28
% of malnourished (among new visits) 4.57
ARI Control
ARI Incidence (by PHCC) 386.26/1000
ARI Incidence by community 770.15/1000
Control of Diarrhoeal Diseases (CDD)
Diarrhoeal Incidence 648.27/1000
Reproductive Health
1st 49.85 ANC visit
4 ANC visits (among first visit) 34.05
Institutional Delivery 61.11
70 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
Family Planning New Acceptors Current Users
Pills 1.59 2.6
Depo 5.30 8.6
IUD - 0.22
Norplant 0.393 0.66
Contraceptive Prevalence Rate (CPR) -
FCHV & PHC ORC Program
% of report from FCHVs 86.85
Average no. of people served by FCHVs 187.60
% of mothers group meeting conducted 83.33
% of PHC ORC held 75.49
5.2.7 Strengths
• Rooms are sufficient as per the need with sufficient space.
• Equipments and drugs were in sufficient amount throughout the year.
• The office and rooms were well furnished.
5.2.8 Constraints
• Poor access of the HP services to the people due to geographical difficulty.
• Dispensary room was not managed properly.
71 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
5.3 Parewadin Sub-Health Post
5.3.1 Introduction
Parewadin Sub-Health Post established in 2050 BS was one of the 24 SHPs in
Dhankuta district. It was located at ward no. 5 of Parewadin VDC. The sub-health
post was situated in its own building.
5.3.2 Catchment Areas
Parewadin VDC Tankhuwa VDC
Murtidhunga VDC Hattikharka VDC
Aangdim (Terathum)
5.3.3 Infrastructures
• Building:
Parewadin sub health post has its own well constructed building with well
ventilated rooms covering in a healthful environment. Separate rooms were
allocated for OPD check up, MCH services, store, injection and dressing. The
building was further in the phase of maintenance.
• Drugs/Store:
Drug required in the SHP level was found to be sufficient in quantity and quality.
• Human resources:
All the post sanctioned in SHPs were fulfilled.
72 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
5.3.4 Health Activities /Services Provided by Parewadin SHP
Following activities were being conducted regularly by Parewadin Sub- Health Post.
1. Daily patient check up.
2. Injection/Dressing and Dispensing drugs.
3. ANC/PNC/NC services.
4. EPI services.
5. FP services (condom, pills and depo.)
6. PHC/ORC (clinics/month.)
7. EPI –Clinics (clinics/month)
8. Nutrition programs
• Growth monitoring.
• Vit. A Distribution and deworming.
9. Disease control:
• IMCI Programme
• TB and leprosy control programme.
5.3.5 Management aspects
• Planning:
No annual and monthly planning system was found. Annual target provided by
DHO is available.
• Organization:
Organizational structure is as per national health policy 1991.
• Direction:
Direction of DHO through verbal on direct meeting and sometimes written
through formal letters.
73 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
• Staffing:
All staffs are fulfilled.
• Co-ordination:
Vertical co ordination with Illaka Health Post Tankhuwa and DPHO. Horizontal
co ordination with VDC office, Schools, etc.
5.3.6 Problems and Constraints
• Over-expectation of health services from the clients.
• Poor management of store.
• Untimely availability of budget.
5.3.7 Recommendations
• PHC/ORC should be conducted regularly by utilizing staffs with proper
coordination
• Store room should be properly arranged
74 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
4.2 Supporting Organizations
4.2.1 Nepal Red Cross Society (NRCS)
4.2.1.1 Introduction
NRCS is one of the largest humanitarian organizations established with district
chapters in each of the 75 districts of the country. NRCS, Dhankuta was
established in 2038 B.S. It has been serving the people of Dhankuta district with
its 4 sub-branches, 30 sub chapters, 2 Youth Red Cross Circles and 57 Junior Red
Cross Circles.
4.2.1.2 Vision
To improve the health status of the vulnerable people
4.2.1.3 Mission
NRCS is committed to deliver quality services for improving health status of the
vulnerable people by mobilizing its nationwide network of volunteers and staffs,
and in partnership with communities and other stakeholders.
4.2.1.4 Objectives
• To provide health service to the people, whenever they are in need
• To provide rescue operation in disaster condition
• To assist in social services.
4.2.1.5 Major Activities
• Ambulance Services
• Emergency relief services
• First-aid treatment services
• Health Education
• Training & Awareness on HIV/AIDS & FP
• School Based Disaster Management Program
75 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
• Construction of Latrines
• Community Empowerment by providing training on improved stoves
4.2.1.6 Strengths, Weakness, Opportunities & Challenges
Strengths
Nationwide network of volunteers and staffs
High community acceptance
• Weakness
Problems of funding
No proper blood transfusion services due to lack of blood bank in the
district.
• Opportunities
Partnership with other organizations in specific projects (ADRA in
awareness & training in HIV/AIDS)
• Challenges
Geographical hurdles
Political instability
4.2.1.7 Recommendations
• NRCS need to take initiatives to establish blood bank within the district
76 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
4.2.2 Society for Local Volunteer’s Effort (SOLVE)
4.2.2.1 Introduction
Society for Local Volunteer’s Effort was established in 1989 with its central office
in Dhankuta and contact office in Subidhanagar in Kathmandu. It is based on the
volunteer concept of an active youth, established with the purpose of alleviating
poverty among various unprivileged and excluded communities in line with prime
objectives of National Planning Commission.
4.2.2.2 Vision
• To envision Nepalese communities which are equitable and capable of meeting
their basic needs with their resources.
4.2.2.3 Mission
• To work with groups to empower people and encourage capacity growth in
communities.
4.2.2.4 Key Activity Areas
• Conducting micro-finance for poor women households
• Developing agriculture and micro-irrigation
• Developing micro-enterprise
• Rural water supply and sanitation
• Maternal and Child Health
• Environment and renewable energy
• Developing community literacy
• Child education and rights
• Building nation and governance
• Building peace and management of peace
4.2.2.5 Reporting System
Monthly reporting to BBC
77 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
4.2.2.6 Strengths, Weakness & Challenges
• Strengths
Need based program
Community participation
• Weakness
Programs guided by donor agency
Lack of competent manpower
• Challenges
Political influences
4.2.2.7 Recommendations
• Competent staffs should be recruited.
78 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
4.2.3 Family Planning Association Nepal (FPAN)
4.2.3.1 Introduction
FPAN, Dhankuta was established in 2035 B.S. It implements its program in
partnership with large number of NGOs, CBOs, DHO and other line agencies of
government for the implementation of sexual and reproductive health program in
Dhankuta.
4.2.3.2 Mission
FPAN is committed to improve the quality of lives of individuals through SRH
information and services especially for poor, marginalized and vulnerable people in
under-served areas. It defends to the right of all young people to enjoy their sexual
lives free form ill health, unwanted pregnancy, violence and discrimination, to
empower women to exercise their SRH rights to terminate unwanted pregnancies
legally and safely at affordable cost, and to eliminate STIs and to eradicate
HIV/AIDS.
4.2.3.3 Objectives
• To increase access of gender sensitive STI services and STI & HIV/AIDS
education to vulnerable population.
• To increase the access of safe abortion services.
• To strengthen recognition of SRHR, including policy and legislation, which
promotes, respects, protects and fulfils these rights.
• To increase availability of gender sensitive SRH information and services
including family planning in rural setting.
4.2.3.4 Program Activities
• Family Planning services
• MCH services and education
• Advocacy on SRHR
79 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
• STI services
• VCT services
• HIV prevention, care and support
• Safe abortion services
• Capacity building training
4.2.3.5 Problems & Constraints
• Resource constraints
• Reluctance of health personnel to work in remote areas
• Out migration of adolescents and youths in rural VDCs
• Need of additional training on sexual and reproductive health
4.2.3.6 Recommendations
• Incentives scheme should be provided for health personnel working in remote
areas so as to motivate them to work.
80 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
4.2.4 Britain Nepal Medical Trust (BNMT)
4.2.4.1 Introduction
Britain Nepal Medical Trust is a service oriented NGO established in 1967. The
major areas of BNMT are TB and Leprosy control, community empowerment for
community health development & drug management for sustainability of
availability of drug in the community. BNMT has been operating its program on TB
control in Dhankuta district since 1970. However it begun its co-ordination with the
DHO in various other priority health programmes in the district only in 2003.
4.2.4.2 Vision
• Improved health status of people of Nepal
4.2.4.3 Mission
• Helping the people of Nepal to improve their health through supporting
sustainable health services, capacity building and people’s empowerment.
4.2.4.4 Goal
• Improved ability of communities in the Eastern Development Region to manage
and address their basic right to health.
4.2.4.5 Objectives
• Strengthen the capacity of local institutions
• Empowering communities
• Develop innovative models and approaches
• Completing handover of existing programmes
81 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
4.2.4.6 Strategies
• Capacity building and strengthening partners
• Community based program
• Poverty and equity
• Addressing emerging health need
4.2.4.7 Program activities
BNMT has been helping Dhankuta in the following priority (P1) programmes of
Nepal Government.
• TB control programme
• HIV/AIDS & STI programme
• Essential Drug Programme
• Reproductive Health- Safe Motherhood
• Infectious diseases- ARI & Diarrhoea control
4.2.4.8 Problems & Constraints
• Lack of funding by donor agency
• At the verge of insolvency
4.2.4.9 Recommendations
• BNMT should appeal for support so as to rejuvenate its activities in the district.
CHAPTER V
EPIDEMIOLOGICAL STUDY
82 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
CHAPTER V
EPIDEMIOLOGICAL STUDY ON PNEUMONIA
5.1 Introduction
Pneumonia is a common illness in all parts of the world. It is a major cause of death
among all age groups. In children, many of these deaths occur in the newborn period. The
World Health Organization estimates that one in three newborn infant deaths is due
to pneumonia. Over two million children under five die each year worldwide. WHO also
estimates that up to 1 million of these (vaccine preventable) deaths are caused by the
bacteria ''Streptococcus pneumoniae'', and over 90% of these deaths take place in
developing countries.
5.2 Objectives
5.2.1 General Objectives
• To study the epidemiology of pneumonia among IPD cases in Dhankuta District
Hospital.
5.2.3 Specific Objectives
• To study the magnitude of pneumonia in Dhankuta.
• To find the distribution of pneumonia by person and time.
5.3 Rationale
• Pneumonia is a leading killer disease under five children in Nepal.
• High incidence of Pneumonia was evidenced by the three year data trend among IPD
cases of District Hospital from FY 064/65 to 066/67.
• Pneumonia control among under five children is a national priority programme that has
been effectively conducted in Dhankuta through all levels.
83 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
5.4 Methodology
• Study area: District Hospital was selected as the area of our epidemiological
study.
• Study population: Indoor patients of district hospital who were diagnosed as
Pneumonia cases were studied to explore the magnitude and distribution of
pneumonia within the district
• Study Design: Retrospective study was done in which 3 years information was
reviewed.
• Study technique: Secondary data review was done from indoor patient register.
• Source of data: The data was made available from medical record section of
district hospital.
5.5 Study variables:
• Time Variables: Month/year
• Place variable: There were no clear data available to study the distribution of
Pneumonia with respect to geographical locations. Hence we couldn’t explore the
place-wise distribution of pneumonia in Dhankuta.
• Person variables: Age and Sex
5.6 General Epidemiological Characteristics of Pneumonia
5.6.1 Agent Factors
• Common Bacteria
H. Influenza
S. Pneumoniae
Staphylococci species
• Common Viruses
Adenoviruses
Enteroviruses
Influenza A,B,C
84 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
• Other Agents
Mycoplasma pneumoniae
5.6.2 Host Factors
• Small children can succumb to the disease within a matter of days and
case fatality rates are higher in young infants and malnourished children.
• Adult women experience more illness than men, probably because of more
exposure to children.
5.6.3 Environment Factors
• Cold climatic conditions, poor housing, poor nutrition
• Intense indoor air pollution
5.6.4 Mode of Transmission
• By air borne route via person to person contact.
5.7 Findings and Discussions
5.7.1 Time Distribution
This diagram shows the monthly trend of ARI of 2064/65 to 2066/67 in district hospital
indoor. Although no clear trend was observed, in Dhankuta district hospital the number
of cases were higher during Mangsir and Falgun. However, during the FY 065/66 the
pneumonia cases were higher during Bhadra. This was due to the epidemic of pneumonia
during that period.
85 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
Figure 1: Time Distribution of Pneumonia
5.7.2 Sex- Distribution
The bar graph shows the sex wise distribution of Indoor Pneumonia cases in Dhankuta
district hospital in which male were more affected and admitted in indoor then the female
since last three years. This may be due to high mobility pattern of male then female in our
society due to high chance of exposure with risk factor of Pneumonia.
Figure 2: Sex Distribution of Pneumonia
05
101520253035404550
064/65
065/66
066/67
57.58%50.80%
62.16%
42.42%49.20%
37.84%
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
064/65 065/66 066/67
Male
Female
86 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
5.7.3 Age-distribution
The diagram given below shows the most of the cases of pneumonia affects children than
other age groups. In Dhankuta district hospital, the proportion of pneumonia cases in
children of less than five years were about two-third times greater than the total sum of
rest of age group in all three fiscal years.
Figure 3: Age Distribution of Pneumonia
5.8 Conclusion
The epidemiological study revealed that pneumonia was higher during winter season
(Mangsir and Falgun). Male were more prone to pneumonia in Dhankuta. Infants
were highly suffered from pneumonia as compared to other age-groups.
5.9 Recommendations
• Further study on epidemiological features regarding pneumonia is necessary to
explore more comprehensive picture of pneumonia distribution within the district.
• Complete records on district hospital should be made available.
0
10
20
30
40
50
60
<1 yrs 1-4 yrs 5-14 yrs 15-59 yrs 60+ yrs
064/65
065/66
066/67
CHAPTER VI
CRITICAL REVIEW
87 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
CHAPTER VI
CRITICAL REVIEW
6.1 Critical Review on Logistics Management
-Prabesh Ghimire
6.1.1 Introduction
The logistics management system is a management activity which includes the total flow
of products (commodities, essential drugs, vaccines, contraceptives, medical equipments
and instruments, HMIS/LMIS forms/ formats/ registers and other allied materials) from
the acquisition of raw materials to the delivery of finished goods to the users, as well as
the related flow of information that both controls and records the movement of those
products.
An efficient management of logistics is crucial for effective and efficient delivery of
health services as well as ensuring rights of citizens of having quality of health care
services. The objective of logistic management in Dhankuta is to plan and carry out the
logistics activities (including maintenance) for the uninterrupted supply of essential
medicines, vaccines, contraceptives, equipments, HMIS/LMIS forms and allied
commodities for the efficient delivery of healthcare services from all governmental health
institutions in the district.
6.1.2 Rationale
• An essential aspect of district health management
• The topic of interest
6.1.3 Objectives
• To review the logistics management system of Dhankuta district.
• To study the logistics management information system in Dhankuta.
88 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
6.1.4 Methodology
• Study Type: Cross-sectional descriptive study was done to
review the logistics management system of
district.
• Study area: Store section of District Health Office as well as
peripheral institutions was selected for the study.
• Study Duration: The study was done for 3 days.
• Data collection tools: Secondary Data Review Format
Interview Guidelines
• Data collection techniques: Data review was done for collection of information.
Interview was also done with storekeeper on
logistics system.
6.1.5 Findings
• Logistics flow system
All varieties of logistics ranging from essential drugs and vaccines to contraceptives,
medical equipments, instruments and commodities are supplied to the District Health
Office, Dhankuta by Logistics Management Division (LMD) under Department of
Health Services via Regional Medical Store in Biratnagar. These logistics are supplied
by the District Store to the peripheral institutions based on PULL system.
89 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
Port
Central Warehouse (Teku)
Regional Medical Store
(Biratnagar, Koshi)
District Store(DHO, Dhankuta)
PHCCs SHPsHPs
Community Health Workers
Clients/ Consumers
Logistic Management Division (DOHS)
Regional Health Directorate (Dhankuta)
Figure 1: Logistics Flow System
• Store Management
The storage of logistics in the district store was done using FEFO mechanism. The
stock of logistics in the district store as well peripheral institutions was maintained
with EOP and ASL. EOP for district store and peripheral institutions is 3 months and 1
month respectively. However the ASL is 5 months and 3 months respectively.
• Recording reporting
The recording and reporting of logistics were done using various forms like entry
form, dispatch form and order form. Reports of every received commodities and
supplied logistics are sent by peripheral institutions to the district store trimesterly
90 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
using various LMIS and audit forms. The district sends a report to RMS as well as
LMD every three months and the feedback is sent by LMD to regional and district
logistic management section.
Regional Medical Store (Biratnagar)
District Medical Store(DHO, Dhankuta)
Sub-Health PostsHealth Posts PHCCs
Logistics Management Division(Teku)
Supervision
Reporting
Figure 2: Logistics Management Information System in Dhankuta
• Supervision
There is a periodic supervision of PHCCs regarding logistics management. However,
there are no provisions of supervision for HPs and SHPs from DHO.
• Training
The in-charge of the district store has been trained for the logistics management.
Moreover, the heads of all peripheral institutions have also been trained on effective
logistic management & PULL system.
91 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
6.1.6 Observation Findings
During our observation of the district store, we found that the time being for the supply of
logistics to the peripheral health institutions, the packaging and store seemed unmanaged.
The physical condition (temperature) was also not adequate for drug storage. However,
the inventory system was well maintained. There was a good recording and reporting
regarding logistics management.
Regarding the transportation, there is only one vehicle for the use by DHO, DH as well as
peripheral health services. Hence, the shortage of vehicle was experienced time and
again.
6.1.7 SWOT on Logistics Management
Strengths
• Pull system was on practice.
• 100% reporting was found on logistics management.
• Timely supply of logistics.
• ASL & EOP were well maintained at the district.
Weakness
• Poor maintenance of store.
• Limited vehicle for logistics supply.
• Lack of supervision for HPs and SHPs.
Opportunities
• Established of new DHO building.
Threats
• Nepal bandha affected logistics supply time and again.
92 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
6.1.8 Recommendations
• The number of vehicles for DHO should be increased
• There should be provisions of supervision also for the health posts and sub-health
posts.
• Store should be maintained according to the standard guidelines.
93 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
6.2 Critical Review on Integrated Management of Childhood Illness
-Rabina Kumari Rajak
6.2.1 Introduction
Community Based Integrated Management of Childhood Illness (CB-IMCI) is an
integrated package of child-survival programmes and addresses major killer diseases like
pneumonia, diarrhoea, malaria, measles, malnutrition in under 5 year children. The goal
of CB-IMCI programme is to reduce the morbidity and mortality among children under-
five age. CB-IMCI programme in Dhankuta was first implemented in fiscal year 2059/60.
It was implemented with the objectives to improve the utilization and behavioral
practices of the community and family for early referral and treatment of sick newborn
and child.
6.2.2 Rationale
• CB-IMCI is an integrated programme that addresses five major killer diseases.
• The diarrhoea incidence has increased to maximum in FY 066/67 (165.13/ 1000)
as compared to previous years.
• ARI incidence has been increasing in Dhankuta.
• Growth monitoring coverage has been decreasing in Dhankuta.
6.2.3 Objectives
• To review the CB-IMCI programme in Dhankuta.
• To identify the possible reasons increasing incidence of diarrhoea.
• To analyze the causes associated with the high incidence of ARI.
• To seek the hindrance factors for the coverage of growth monitoring.
6.2.4 Methodology
• Study Type: The critical appraisal on CB –IMCI was done using
cross-sectional descriptive study design.
• Study area: The study was done in the IMCI section of DHO.
94 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
• Study Duration: The study was performed for 2 days.
• Data collection tools: Secondary data review format and interview
guidelines were used for collection of data.
• Data collection techniques: Data review
Interview with IMCI supervisor
• Source of data: Monthly monitoring and annual performance
review worksheet was used
6.2.5 Findings
Table 47: Data trends on ARI Incidence
Indicators 064/65 065/66 066/67 National
ARI Incidence by HF (per 1000) 289 412 450.55 340
ARI Incidence by Community
(VHW/MCHW/FCHV) per 1000
616 648.56 895.25 660
% of new Pneumonia 55.2% 55% 52.30% NA
The above table shows that reported cases of ARI by both health facility and community
had increased in 066/67 than that of past two years. The reported incidence seemed
higher than that of the national figure. This increase could either be due to improvement
in the recording and reporting system or an actual increase in the cases of ARI.
Despite the increase in ARI incidence, the percentage of new pneumonia cases has
decreased from 55.2% in FY 064/65 to 52.30% in FY 066/67. This could have happened
possibly because much of the people are well familiar with pneumonia. So, they arrive
early to health centers. However, other ARI diseases are still unfamiliar. Hence, ARI
incidence could have increased.
95 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
Figure 3: Trends of Diarrhoeal Incidence
The reported incidence of diarrhea by both health facility and community shows an
increasing trend. The maximum incidence of ARI was evidenced in Budhabare HP
(2142.86 per 1000). According to the IMCI section, the increase as shown by the data
trend is not actually the true one. It has actually been due to two main reasons.
• Out-migration of target population (U5 children)
• Over-estimation of target population of Dhankuta district.
Figure 4: New Growth Monitoring Coverage in Dhankuta
472.24506.69
624.76
129
123.7165.13
0
100
200
300
400
500
600
700
064/65 065/66 066/67
CDD Incidence (by HF & Community)CDD Incidence (by HF)
0%5%
10%15%20%25%30%35%40%45%
064/65 065/66 066/67 067/68 Regional National
32.90%30.18%
24.92%17.15%
44.04% 44.81%New Growth Monitoring (coverage)
96 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
The percentage of new growth monitoring shows a decreasing trend. This is possibly
because of the improvement in the recording system. The repeated entry of same children
which could occur during previous years has been minimized by recording them in the
same recording sheet.
6.2.6 SWOT analysis of IMCI programme
Strengths
• Good community participation
• Highly motivated FCHVs
• Good reporting on IMCI indicators
Weakness
• Delayed release of budget
• Lack of public awareness
Opportunities
• Support of NGOs
• Implementation of CB-NCP
Threats
• Geographical hurdles
6.2.7 Recommendations
• Adequate & timely release of budget should be done.
• Community awareness about IMCI should be focused.
97 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
6.3 Critical Review on National Immunization Programme (NIP)
-Shreetina Keshari Tuladhar
6.3.1 Introduction
The National Immunization Programme (NIP) is a priority program of Nepal
Government. EPI is considered as one of the most cost effective health interventions
since the beginning of the service. The overall goal of the EPI is to reduce child
morbidity and mortality associated with Vaccine Preventable Diseases (VPDs). The
target population for BCG, DPT, OPV and Measles are infants under one year (12
months) of age.
6.3.2 Rationale of the study
• BCG Vs Measles dropout rate Dhankuta was higher i.e. 14.16%.
• Immunization coverage was lower i.e. BCG coverage was 75.13%, DPT/Hep.3
was 65.27 %, Polio3 70.11% and Measles was 72.26% as compared to the national
achievement.
• It was one of the priority programs of Nepal.
6.3.3 Objective of the study
• To find out current status of immunization coverage
• To find out the factors behind low immunization coverage
• To find out the factors behind high dropout rate of immunization
• To analyze EPI in terms of SWOT i.e. Strength, Weakness, Opportunity and
Threat
98 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
6.3.4 Methodology
• Study method: Descriptive and explorative study was used
to critically appraise the status of NIP in the
district.
• Data Collection Techniques: Secondary Data Review and Interview with
EPI Supervisor was done so as to collect the
information
• Data Collection Tools: Secondary Data Analysis Format
Interview Guidelines
• Study Duration: The study was carried out for three days.
6.3.5 Findings and discussion
Table 48: Four years trend analysis on immunization
Program Activities Programme Output (Coverage percentage)
2064/65 2065/66 2066/67 2067/68
BCG 83.95% 85.85% 86.21% 84.18%
DPT3 36.06% 44.02% 27.47% 9.53%
Polio-3 39.30% 45.48% 37.55% 27.47%
Measles 72.78% 73.47% 75.20% 75.37%
The table presents the immunization coverage of BCG, DPT3, OPV3 and Measles in
Dhankuta from F/Y 2064/65 to 2067/68 (till chaitra). The four-year trend analysis shows
the coverage of all immunization were below the national level. In the F/Y 2066/67 the
BCG coverage was 86.21%, which decreased to 84.18% in the F/Y 2067/68. The
coverage of DPT3 and OPV3 were also in decreasing order from F/Y 2065/66 to
2067/68. However, the coverage of Measles had slightly increased in F/Y 2067/68 than
that of 2066/67.
99 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
The immunization coverage was lower in four years trend as compared to the national
coverage. The low coverage of immunization shows the inaccessibility of immunization
services to the target population. However, during the discussions on the subject it was
found that target population estimated by Government of Nepal on NIP was higher with
regard to the actual population receiving the NIP services. While looking at the health
institution wise NIP coverage it was found that the coverage was also below the target
level.
Table 49: Immunization Drop-out Rate
Immunization 064/65 065/66 066/67 067/68
(till chaitra)
National
(065/66)
BCG vs Measles 8.9% -0.47% 3.82% 14.16% 11.3%
DPT 1 vs DPT 3 1.6% 0.06% 7.89% -4.91% 2%
The above table depicts that the BCG vs Measles drop-out rate is highly increased from
066/67 to 067/68. However DPT I vs DPT 3 drop-out is decreasing in 067/68.
6.3.6 SWOT Analysis of EPI Program
Strength
• Sufficient logistic supply in the DPHO
• Timely distribution of vaccines and other logistics from DPHO to other institutions
Weakness
• Some refrigerators & deep-fridge were non-functional at cold-chain centre.
• Vacant Post of EPI Supervisor.
Opportunities
• Support of FCHVs in National Immunization Day.
• Community participation in EPI.
100 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
Threats
• No electric back-ups during power cut.
6.3.7 Recommendations
• Vacant post of EPI supervisor should be fulfilled
• Non-functional deep fridges and refrigerators should be maintained
• DHO should find the alternatives during power-cuts
101 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
6.4 Critical Analysis on Recording and Reporting
-Naresh Bhatta
6.4.1 Introduction
Before the integrating of all health programs in 1993 various vertical projects were using
their own recording and reporting system. More than 110 different forms, cards, registers
and reports formats were on use. There is lack of standardization, duplication and
collection of unnecessary information.
During the fiscal year 1986/87, all the vertical programs were integrated at the district level
but information system was not integrated till 1993. During the fiscal year 1993/94, the
ministry of health was restricted and department of health reinstated. A central MIS section
was established in order to develop integrated health management information system at all
levels for better coordination, planning, monitoring and evaluation of ongoing program
integrated at various levels. Government has established a systematic channel for recording
and reporting. Record is kept in different forms and registers likewise; reporting is done in
different formats from periphery to center in timely basis.
6.4.2 Rationale of the study
• Essential functions of management.
• Decreasing reporting status on lower level health facilities.
• Topic of personal interest.
6.4.3 Objectives
• To find out the actual recording and reporting status of DHO and different
institutions.
• To explore the Problem, obstacles for timely recording and reporting task.
102 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
6.4.4 Methodology
• Study design: Descriptive study was done so as to review the
recording and reporting status of the district.
• Study area: The study was done in the statistical section of
DHO.
• Study duration: The study was performed for 3 days.
• Data collection technique: Record review and interview with DHO,
statistician, in-charge of health institutions and
storekeeper was done to review recording and
reporting status within the district
• Data collection tools: Interview guidelines designed to interview
statistician was used for the collection of
information.
6.4.5 Findings and Discussions
Table 50: HMIS reporting form different institutions
Institutions Reported percentage in fiscal year
065/66 066/67 067/68 (Up to chaitra)
Hospital 100 100 100
PHCC 100 100 100
HP 100 100 100
SHP 100 100 95.7
PHCC/ORC 89 82 57.7
FCHV 94 95 67
EPI 92 93 86
103 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
Table 51: HMIS reporting status of different organizations
Institutions Timely Reporting percent
065/066 066/67 067/68 (up to
chaitra)
Dandabazar PHC 75 92 100
JitpurPHC 33 75 75
Belhara HP 67 83 50
Tankhuwa HP 67 92 100
Hattikharka HP 58 83 87.5
Chanuwa HP 50 83 62.5
Pakhribas HP 25 92 87.5
Ankhisalla HP 17 83 37.5
Ahela HP 50 67 62.5
Budhimorang HP 83 100 100
Maunabadhuk HP 50 100 75
Atharasaya HP 50 67 75
Budhabara HP 50 67 25
Hospital 87.5
6.4.6 Discussion
The recording and reporting status of only few HIs were found to be satisfactory. The
reporting from SHP, PHC-ORC, EPI clinics and FCHV has decreased in FY 067/68 as
compared to FY 066/67. The Timely recording and reporting varied markedly among
different health institutions and months. Budhimorang HP had the highest (100%) timely
recording and reporting status.
Vacant post in peripheral HIs showed to have affected the whole recording and reporting
process. The recording and reporting process from lower level health workers (VHWs and
104 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
FCHVs) is still at questions of validity and reliability. The private sector health institutions
are still beyond the coverage of HMIS system.
6.4.7 SWOT analysis
Strength
• There is one statistician working in the district and good recording and reporting
in the district health office.
• Computer application in the district office in coordination with hospital in spite of
computer illiteracy of statistical assistant
• Quarterly and annual review meeting in the district in which reports are also
verified up to HP level.
• Monthly monitoring sheets are filled and used in DHO and some HFs.
Weakness
• Lack of formalized performance based appraisal system.
• Lack of training in LMIS and staffs of peripheral health facilities are not aware
about the importance of timely reporting.
• Not covering the private sector health institution of the HMIS system
Opportunity
• Strengthen integrated supervision and formation of subcommittee of district
supervisor to facilitate the function of SHP, HP and PHC.
• Community participation through strengthened HF management committee.
• Different NGOs are interested to work in coordinated manner with DHO in the
section of reporting and data use.
105 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
Threats
• Geography and communication system
• Transparency gap of programs
• Political interference
6.4.8 Recommendations
• HMIS and LMIS training should be given to root level i.e. HP and SHP.
• Initiation of covering the private sectors HIS within HMIS by regulating the
licensing and renewal of such health institutions.
• Performance based appraisal system needs to be strengthened for monitoring the
health workers for recording and reporting system.
106 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
6.5 Critical Review on Staffing Situation
-Uttam Gautam
6.5.1 Introduction
The staffing function of management is concerned with people. People as human
resources are vital for achieving the goals of any health institutions. The institutional
performance largely depends on the individual performance of each and every health
worker at each level.
Staffing is a process of acquiring, developing, utilizing and maintaining an effective
workforce. It fills up the slots in the organizational structure of any institutions.
The main aim of district health system to provide preventive, promotive and curative
services to the people living in the district is only fulfilled if there are right numbers of
people in the right place at right time having right skills and right motivation and
attitudes.
6.5.2 Rationale of the study
• There is difference in staffing situation between health institutions in highway
areas and other areas of the district.
• Unmanned and vacant posts in health institutions.
• A subject of interest to self.
6.5.3 Objectives
• To find out the present staffing situation under DHO, Dhankuta.
• SWOT analysis of staffing situation.
• To explore the obstacles in fulfilling the staffs in health institutions.
6.5.4 Methodology
• Study type: The staffing situation in Dhankuta was reviewed
using descriptive and cross sectional study design.
107 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
• Study area: The study was done in administration section of
District Health Office.
• Study duration: The study was done for the duration of 2 days.
• Data collection tools: Interview guidelines
Secondary data format
• Data collection techniques Interview was done with DHOr and Nayab Subba.
Review of Attendance Register of staffs was also
done.
6.5.5 Findings
Table 52: Post wise staffing situation
Posts Sanctioned Fulfilled Vacant
Public Health Administrator 1 1 0
Medical Superintendent 1 0 1
Medical Officer 4 3 1
District Supervisors 8 7 1
Staff Nurse 6 5 1
Lab Technician/ Assistant 1 1 0
Radiographer 1 0 1
HA/ Sr. AHW 16 16 0
AHW 41 41 0
ANM 21 20 1
MCHW 24 23 1
VHW 37 28 9
6.5.6 Discussion
The staffing situation of DHO, Dhankuta was found to be satisfactory because only 10%
of the total sanctioned posts were vacant. Sanctioned posts were vacant mainly in remote
108 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
areas. Posts of malaria inspector, EPI supervisor in public health section and radiographer
in hospital were remained vacant since long period of time affecting the quality of
services.
There were no special provisions of incentives and other facilities for health workers in
remote areas due to which some of the health workers were reluctant to go in such areas.
6.5.7 SWOT Analysis
Strengths
• About 90% of the sanctioned posts were fulfilled
• All the sanctioned posts of HA/ Sr. AHW were fulfilled
Weakness
• Staff placements were not done systematically (untimely transfer and untimely
deputation).
• Long time vacant posts in DHO (malaria inspector, EPI supervisor) and hospital
(radiographer).
• No incentives for health workers at far-flung areas.
Opportunities
• Community participation in health institution management committee
Threats
• Geographical difficulties
• Political influence
6.5.8 Recommendations
• DHO should ensure the management of the vacant and unmanned posts.
• There should be provision of special incentives and other opportunities like training
for health workers at far-flung areas.
109 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
6.6 Critical Analysis on Case finding in National TB Programme
-Anu Gomanju
6.6.1 Introduction
Tuberculosis is one of the major public health problems in Nepal. About 45 percent of the
total population is infected with TB, out of which 60 percent are adult. In Nepal,
introduction of treatment by Directly Observed Treatment Short Course (DOTS) has
already reduced the number of death. Expansion of this cost effective and highly
successful treatment strategy i.e. DOTS, which already has proven its efficacy in Nepal,
will have a profound impact on mortality and morbidity. The national tuberculosis
programme’s (NTP) long term goal is to reduce the transmission of TB to such a level
that it is no longer a pub;ic health problem. The NTP has coordinated with the public
sectors, private sectors, local government bodies, I/NGOs, social workers, educational
sectors and oher sectors of the society in order to expand DOTS and sustain the present
significant results achieved by NTP.
At district level, the district health office/district public health office is responsible for
planning and implementing of the NTP activities within the district. For proper
monitoring of the programme different indicators has been developed by NTP. Case
detection ratio is one of the indicators. Case detection ratio is the number of new
pulmonary smear positive cases detected, expressed as percentage of the estimated new
smear positive cases. It provides a measure of case finding coverage. The national target
is to achieve a case detection ratio of 70% and it was below national targets in Dhankuta
district.
6.6.2 Rationale
• With respect to the national target, the case detection ratio of Dhankuta district is
low.
• Despite adequate training and logistic supply program achievement is weak in this
indicator.
110 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
6.6.3 Objectives
• To find out root causes of low case finding of TB in Dhankuta district..
• To analyze the problem in terms of SWOT i.e. strength, weakness, opportunity
and threat.
• To recommend the DHO, Dhankuta regarding action to be taken to improve the
situation.
6.6.4 Methodology
• Study method: Descriptive method was employed to review case
finding status of National TB Programme.
• Study duration: The study was conducted for 3 days.
• Data collection techniques: Secondary data analysis from TB register and
HMIS 32 was done. Interview was also done with
TB/Leprosy supervisor and HP/SHP in charges
• Data collection tools: Formats for secondary data review and interview
guidelines were used for collection of information.
• Data Sources: Monthly monitoring sheet was used as the source
for collection of information.
6.6.5 Findings and discussion
• The case detection ratio of district was continuously lower than national target
for last ten fiscal years.
111 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
Figure 5: Year wise TB Case Detection Ratio
• There was cent percent DOTS coverage in Dhankuta district. Ninety-one percent
of health worker in district had taken DOTS modular training.
• There were 3 DOTS treatment centers with microscopy, 11 DOTS treatment
centers and 24 DOTS treatment sub-centers. Among treatment centers in district,
those with microscopy facility (Jitpur PHCC, Dandabazar PHCC and Dhankuta
hospital) had achieved case detection ratio near national target level.
• About 56% of total new smear positive cases were registered in DOTS treatment
centers having microscopy facility.
3230
27
55
37
3537
43
28
33
0
10
20
30
40
50
60
57/58 58/59 59/60 60/61 61/62 62/63 63/64 64/65 65/66 66/67
Case Detection Ratio
112 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
Table 53: DOTS treatment centre wise case detection ratio (FY 2066/67)
DOTS treatment
centres
Estimated new
smear positive
cases
Detected new
smear positive
cases
Case detection
ratio
Chanuwa HP 8 1 11.8
Jitpur PHCC 9 6 67.0
Hattikharka HP 4 2 53.7
Pakhribas HP 13 3 23.3
Tankhuwa HP 13 3 23.3
Aankhisalla HP 16 1 6.40
Belhara HP 4 1 77.5
Aahale HP 6 1 17.7
Dandabazar PHCC 6 4 68.0
Budhimorang HP 4 0 0.00
Maunabudhuk HP 6 1 16.8
Atharasaya HP 7 9 41.6
Budhabare HP 1 0 0.00
Dhankuta hospital 14 10 73.00
Total 112 36 32.14
• The reported incidence of new smear positive cases in F/Y 2066/67 was found
higher among young age (about 20% in 0-24 years age group) indicating
transmission of TB not decreasing.
• Preparation and movement of slide for AFB test was not well functioned mainly
due to the geographical difficulties.
113 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
6.6.6 SWOT analysis
Strength
• Modular training was provided to most of the health workers.
• Sufficient budget and logistic supply.
• Quarterly review meetings were regular.
Weakness
• Inadequate number of microscopy centre.
• Lack of regular HMIS feedback in TB program.
Opportunity
• Good support of DDC and I/NGOS (BNMT)
• Committed DPHO team.
• DOTS committee at different level.
Threats
• Geographical and climate factors
• Political instability
6.6.7 Recommendations
• DOTS treatment centre with microscopy need to be expanded.
• Vaccine mobilization date and staff review meeting days can be used as
opportunities to use slide transportation
• Regular feedback from DHO in TB control program should be given.
114 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
6.7 Critical Analysis on Primary Health Care Outreach Clinics Programme
-Dinesh Rupakheti
6.7.1 Introduction
Primary Health Care- Outreach Clinics (PHC-ORC) are the extension of Primary Health
Care Centers (PHCCs), Health Posts (HP), and Sub Health Posts (SHP) at the community
level. Primary Health Care outreach Clinics (PHC/ORC) were established in 1994 (2051
BS) with an aim to improve access to some basic health services including family
planning and safe motherhood services for rural households. VHWs and MCHWs or
ANMs provide basic PHC services (FP/ANC) services / Health Education/ Minor
Treatment) to a pre- arranged place close to communities (two to five catchment areas per
VDC) on a predetermined day once in a month. In principle, then clinics will be held at
locations not more than half an hour’s walking distance for the population residing in that
area.
6.7.2 Rationale
Only 81.6% PHC/ ORC clinics were conducted in FY 2066/067 compared to 85.9% in
FY 2065/066. The conduction of PHC/ORC is in decreasing trend in Dhankuta district.
6.7.3 Objectives
• To find out the current status of PHC/ORC programme.
• To find the factors affecting PHC/ ORC programme.
• To analyze the PHC/ORC programme in terms of SWOT i.e. strength, weakness,
opportunities, and threats.
• To recommend the DHO for improving PHC/ORC programme.
6.7.4 Methodology
• Study design: Descriptive and analytical study design was used
for critical analysis of PHC/ ORC programme.
• Study area: Dhankuta district was selected as the area of study.
• Study duration: The study was done for the period of 3 days.
115 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
• Data collection technique: Record review and in depth interview with DHOr,
District supervisor, HIs incharge, VHW, MCHWs,
ANMs was done.
• Data collection tools: Record review format and interview guidelines
were used for review of information.
6.7.5 Findings
Table 54: Trends in PHC/ ORC conducted in Dhankuta district
Indicators 064/65 065/66 066/67
Total no. of PHC/ ORC held in a year
1326 1371 1264
% of PHC/ORC held
83.71% 85.90% 81.65%
Average no. of people served by PHC/
ORC
13742 15334 18965
Total no. of people served by
PHC/ORC
10 11 15
• The table shows the decreasing trend of conduction of PHC/ORC and increasing
trend of average number of people served by them.
• Supervision of PHC/ORC was only 1.82% in FY 2066/067.
• No any funds collected since last three years through registration fees from users.
• Altogether, five posts of VHWs were vacant in districts.
116 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
6.7.6 SWOT analysis of the PHC/ORC Programme
Strength
• The percentage of PHC/ ORC conducted is higher than national level.
• The average number of people served by PHC/ ORC is in increasing trend.
Weakness
• Supervision of the PHC/ ORC clinic is inadequate.
• There are irregularities in conducting PHC/ ORC clinics.
• There is no equity in incentives among health worker conducting PHC/ORC.
• Vacant posts of VHWs in some VDCs.
• The community based organization (CBOs) and other local resources are not
mobilized.
Opportunities
• VDC can be involved for support.
• The dissemination of Revised PHC/ORC Strategy can help to make the program
effective.
Threats
• The difficult terrain has hindered the overall success of the programme.
• Many people are still unaware of the actual services provided by PHC/ORCs.
• Many people still prefer specialized services.
6.7.7 Recommendations
• The supervision of the PHC/ORC needs to be increased.
• There should be equity in incentives among health workers conducting
PHC/ORC.
• The vacant posts of the VHWs need to be filled.
117 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
6.8 Critical review on Integrated Supervision
-Anil Dhungana
6.8.1 Introduction
Supervision is a process by which workers are helped by a designated staff member to
learn according to their needs to make the best use of their knowledge and skills, and to
improve their abilities so that they do their jobs more effectively and with increasing
satisfaction to themselves and the agency. -Margaret William
It is the process of assisting, supporting and monitoring for the purpose of increasing
skills and performance of the staffs for achievement of organizational goal.
Without supervision, even the best planned operations do often achieve only limited
results. Supervision keeps the planned action on the right track, identifies and corrects
deviations, addresses the problems as they arise at the implementation itself, informs the
responsible officials about the actual status of programme implementation, energizes
staffs to carry on with their good work, and supports them for enhancing their
performance.
Integrated supervision is a process of guiding, supporting, motivating and monitoring of
all programs at once for the purpose of improving skills and performance of staffs.
Integrated supervision is one of the new concept and priority programs of Ministry of
Health, Government of Nepal which has been practicing from fiscal year 2052/53 where
the entire programme could be supervised at once. It is one of the crucial parts of
managerial function which guides, supports, motivates and monitors all programs at once
for the purpose of improving skill and performance of the staff.
In the district, supervision schedule should be planned at all levels before the programme
implementation. Necessary supervision trainings need to be provided to the staffs from
time to time for maintaining integrated supervision.
118 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
Table 55: Routine supervision strategy in district level From To Times in a year/unit
District PHCC/HP 12
PHCC/HP SHP 12
SHP Wards 12
6.8.2 Rationale of the study
• Integrated supervision being one of the priority programs of MOH, Government
of Nepal.
• Integrated supervision to peripheral institutions was poor (PHC-60%, HP-33%,
SHP-5%, ward-0 % in 063/064).
• Compulsory recording and reporting of checklist not maintained.
6.8.3 Objectives
6.8.3.1 General Objective
• To identify critical points associated with low status of integrated supervision in
the district
6.8.3.2 Specific Objectives
• To document the key findings in integrated supervision
• To analyze the integrated supervision in terms of SWOT
• To identify critical points and provide possible suggestions for bringing
desirable changes in supervision status of the district
6.8.4 Methodology:
• Study area: Overall Dhankuta district was selected as the area of
study.
119 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
• Study method: Descriptive study design was used for critical
review of supervision status.
• Study unit: DHOr, District Supervisor, Health Institution in-
charges.
• Data collection techniques: Secondary data analysis and interviews with
programme supervisors and HP/SHP in- charges
was done.
• Data collection tools: Data review format and interview guidelines were
designed to collect information.
• Study duration: The study was done for 3 days.
6.8.5 Finding and discussion
Table 56: Supervision status of the district
Institution/HWs
supervised
Times/unit
No. of
HI/HWs
Required
times/year
No. of supervision
Times/year % of required
time/year
64/65 65/66 66/67 64/65 65/66 66/67
PHCC
12 2 24 24 27 52 100 112.5 216.7
HP
12 11 132 89 120 81 67.4 90.9 61.3
SHP
12 24 288 112 181 181 38.9 62.8 62.8
EPI clinic
12 149 1788 2 4 12 0.11 0.2 0.7
PHC/ORC
12 128 1536 1 11 28 0.1 0.7 1.8
FCHV 12 315 3780 0 56 66 0 1.5 1.7
120 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
The table shows that the frequency of supervision has been increasing but the status of
the supervision seems poor below illaka level. The supervision schedule was not
followed properly in peripheral region as the provision incentive for supervision(TADA)
was provided if the distance of the HIs were more than 6 miles. Though the supervision
schedule and checklist was prepared by DHO, they were not followed properly. Also the
supervision checklist was not fully able to meet the need of the district. Due to no regular
orientation and training to supervisors, the integrated supervision was affected resulting
poor implementation of integrated supervision.
Thus, the supervision was poor not only in quantity and but also in quality below the
illaka level.
6.8.6 SWOT Analysis
Strength
• Feedback mechanisms
• Regular supervision
• Annual budget allocation
• Supervision schedule prepared by DHO
Weakness
• Poor supervision in far-flung areas
• Implementation of Integrated supervision not effective
• Supervision scheduled not followed below illaka level
• Post supervisory meeting not regular
• No regular training and orientation on integrated supervision to all staffs
Opportunities
• Provision of TADA allowances
121 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
Threats
• Nepal Banda
• Geographical hurdles
6.8.7 Recommendations
• Integrated supervision checklist should be strictly used during supervision.
• Adequate training and orientation to supervising staffs for the clarity of its
concept, purpose, supervisory roles and responsibilities.
• Post supervisory meetings should be conducted regularly.
CHAPTER VII
MINI- ACTION PROJECT
122 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
CHAPTER VII
MINI ACTION PROJECT
7.1 Introduction
Mini action project is a miniature form of project that is usually conducted in the short
interval of time with a maximum utilization of locally available resources and technique in
the district. This type of exercise is beneficial in developing skills in real situation of
problem where the required resources may not be available, and it also helps to develop
consistence and self-reliance of an individual.
During the field study, the issue of recording and reporting was raised in many instances
from time to time in different level of health care delivery system in the district. We
decided to conduct Min Action Project on improving recording and reporting status of the
district. Criteria of identifying the subject were based on the experiences shared by
statistician Mr. Purna Shekhar Shrestha that most of the people responsible for recording
and reporting have not obtained refresher training for a long time and some of them are
unwilling to report timely to the district. Finally we decided to organize an orientation
program in recording and reporting.
7.2 Rationale
• One of the major health management components reflecting the performance of the
overall district
• Reluctance of some health workers in timely reporting
• Non- reporting from private hospitals and few NGOs.
• Interest of DHO staffs.
7.3 Objectives
7.3.1 General objective
• To strengthen the recording and reporting status of the health institutions in
Dhankuta
123 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
7.3.2 Specific objectives
• To aware the health workers about the situation of recording and reporting.
• To explore possible causes responsible for reluctance among health workers in
reporting.
• To identify the reasons for non-reporting from private hospital and NGOs.
• To update the health workers on revised version of Integrated HMIS tools.
• To find out the possible solutions.
7.4 Date Venue and Time
• Date: 2068-
• Venue: Seminar hall of District Health Office, Dhankuta
• Time: 10:30- 12:15
7.5 Methodology
• Methods: Mini-lecture and Group discussion
• Media: Pen, Paper, Newsprint papers, revised manual of HMIS
tools, Laptops
• Resource Persons: DHOr, Statistician
• Facilitators: Team members
• Participants: 18 participants from district hospital, Sub health posts
(Bhedetar, Chungmang and Faksib)
124 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
7.6 Plan of Action
Table 57: Plan of Action of MAP
Activities Date
Prioritization of problem 11/02/068
Discussion with DHOr and Statistician to finalize the subject for MAP 11/02/068
Planning for the MAP 12/02/068
Implementation 13/02/068
Evaluation 13/02/068
Figure 1: Phases of MAP
125 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
7.7 Activities
According to our planning we had conducted a workshop with health workers of district
hospital and few other peripheral institutions in co-ordination with statistician Purna
Shekhar Shrestha.
• Welcome speech and objective clarification: by our team member.
• Introduction: the workshop was started with the introduction from the participants
and ourselves
• Issues of discussion: by our team member.
• Information about revised Integrated HMIS tools: by Purna Shekhar Shrestha
• Raising of issues related to HMIS tools, problems and constraints in recording and
reporting: by Participants
• Discussions for possible solutions: by Purna Shekhar Shrestha and team members
• Compiling the common views raised in the presentation
7.8 Results
• Direction was given from DHOr to record properly and to report timely.
• Constraints and possible solution regarding recording and reporting were sorted out.
• Major misunderstandings were clarified from the group discussion.
• Commitment of DHO, statistician and all participants for timely reporting,
improving reporting status and properly recording.
7.9 Evaluation of Mini Action Project
• Active participation of resource persons & participants.
• Positive feedback from DHOr and statistician
• Commitment to conduct monthly review meetings from incharge of Sub-health
posts.
126 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
7.10 Sustainability of MAP
Sustainability of the MAP was assured through commitment from DHOr for the
allocation of the sufficient budget for the monthly review meetings and for the proper
monitoring of the progress.
CHAPTER VIII
FIVE YEAR PLAN
127 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
CHAPTER VIII
FIVE YEAR PLAN ON SAFE MOTHERHOOD
8.1 Introduction
The goal of the National Safe Motherhood Programme is to reduce maternal and neonatal
mortalities by addressing factors related to various morbidities, death and disability
caused by complications of pregnancy and childbirth. Global evidence shows that all
pregnancies are at risk, and complications during pregnancy, delivery and the postnatal
period are difficult to predict.
Within the health sector, safe motherhood has been a national priority programme for the
last decades, and is highlighted in all major health related policies and plans. The
Eleventh Plan, the Second Long Term Health Plan and the NSMLTP (2002- 2017) all
highlight the need to improve the maternal health. The Millennium Development Goals
(MDG) specifies a two thirds reduction in the under-five mortality rate and 75 percent
reduction in the maternal mortality ratio by the year 2015. The NHSP-IP draws on the
Millennium Development Goals, with the stated purpose of improving the health status of
the Nepalese population through utilization of essential health care services (EHCS),
specifying maternal mortality and infant and child mortality reduction among other
essential health care indicators. Since safe motherhood and newborn health are not purely
health issues, they warrant a multi-sectoral approach, and the role of other sectors is
particularly important in enhancing access and promoting equity.
This plan on Safe Motherhood outlines strategic directions and defines the major inputs,
outputs and general areas of activity, with a specific set of activities and detailed costing.
8.2 Rationale
The rationale for developing five year plan in Safe Motherhood was as follows:
• First ANC visit as percentage of expected pregnancy is 62.4% which is lower than
that of national average.
• Only 17.58% deliveries are conducted by HW & SBAs.
128 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
• Still large proportion (42%) of deliveries is conducted at homes.
• It is the most priority programme of Nepal Government.
• It is also matter of equity and social justice.
• Safe Motherhood is a matter of concern of DPHO.
8.3 Process of Developing the Plan
Developing a comprehensive five year plan was one of the objectives of our field visit.
After the analysis of health service statistics of Dhankuta district, we prioritized Safe
Motherhood for developing five year plan.
Improving maternal health and survival is a complex issue. However, a vision was
needed in terms of where Dhankuta needs to reach in the near future. Therefore realizing
this; we initiated an effort with expertise and involvement of DHOr, program supervisor
in SM and in guidance of other program supervisors to develop a SM plan for the period
2010-15. This plan is mainly based on the above-mentioned facts, however it is a more
comprehensive document since it draws from the National Safe Motherhood Plan (2002-
2017) as well. This plan gives a vision of where Dhankuta should be in the next 5 years.
Preparations for the plan began with several meeting with program officer on SM and
participatory discussions were conducted at May 25-27 2011 to come up with a plan for
safe motherhood. During the discussions we reviewed the current strategies discussed
achievements, problems and drawbacks and lessons for the future, which were the key
elements for consideration while formulating the various levels of objectives and
indicators.
129 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
8.4 Plan Format
The Log Frame Matrix has been used to lay out the various level outputs and activities.
The matrix consists of four columns. The first column shows the hierarchy of objectives,
the second column of the matrix identifies the indicators in the base line and sets time
bound targets. It also identifies how the progress is to be measured through means of
verification in the third column. More importantly it outlines the assumptions and the
risks, which help program implementers to identify the constraints beforehand. However
the plan is not without its limitations. The neonatal component has not been addressed
although improving neonatal health and survival is one of the important components of
safe motherhood.
8.5 Goals and Objectives
8.5.1 Overall Goal
The overall goal of the plan is to improve maternal health and survival of women in
Dhankuta district.
8.5.2 Objectives
• To increase the percentage of women seeking ANC visits
• To increase the deliveries attended by SBAs
• To increase the percentage of institutional deliveries
• To increase the percentage of women completing PNC visit (1 visit)
• To provide training to all health workers regarding SM
• To increase the no. of institutions providing safe abortion services
• To increase the percentage of women receiving emergency obstetric care
130 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
8.6 Targets
By the year 2011,
• To increase the percentage of women seeking ANC (1st
• To increase the percentage of women seeking ANC (4 visits) from 56.75%.
(among first visits) to 80%
Visit) from 62.47% to
85%.
• To increase the deliveries attended by SBAs from 11.4% to 40%
• To increase the institutional deliveries from 57.86% to 80%.
• To increase the percentage of women completing PNC Visit (1 visit) from
44.89% to 65%
• To provide training to cent percent health workers working in SM
• To provide safe abortion services through all PHCCs
131 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
8.7 Safe Motherhood Plan in Logical Framework Approach
Table 58: Safe Motherhood plan in log-frame approach
Narrative Summary Objectively Verifiable Indicators Means of Verification Assumptions/ Risks
1 GOAL
Improved maternal
health and survival
• Increase in percentage of women
seeking ANC visits
• Increase in no. of delivery attended
by SBAs
• Increase in institutional delivery
• Increase in percentage of women
completing PNC visit (1 visit)
• No. of training received by health
workers regarding SM
• Increase in no. of institutions
providing safe abortion services
• Percentage of women receiving
emergency obstetric care
• Annual Report; DHO,
Dhankuta
• Annual Report; DOHS
• Monthly monitoring and annual
performance review worksheet
• Records and reports from HIs
• Overall environment
(social, political &
economic) is stable
• Political situation
remains stable and
peaceful
132 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
2 PURPOSE
Sustained increase in
utilization of quality
maternal health
services
• Increase in percentage of women
seeking ANC (1st
2012- 65%
Visit) from
62.47% in 2011 to 85% in 2016
2013-70%
2014-75%
2015-80%
2016-85%
• Increase in % of women seeking
ANC (4 visits) from 56.75%.
(among first visits) in 2011 to 80%
in 2016
2012- 60%
2013-65%
2014-70%
2015-75%
2016-80%
• Increase in percentage of delivery
by SBAs from 11.4% in 2011 to
40% in 2016
2012- 15%
• Regular HMIS reports from
peripheral HIs
• Records and report from
District Hospital
• Annual Report; DHO,
Dhankuta
• Annual Report, DOHS
Monthly Monitoring Sheets;
DHO
• The private hospitals
and birthing centers
increases
• Political situation
remains stable and
peaceful
• DDC & VDCs are
functional
• Overall environment
(social, political &
economic) is stable
133 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
2013- 20%
2014- 26%
2015- 33%
2016- 40%
• Increase in percentage of deliveries
at health institutions from 57.86%
in 2011 to 80% in 2016
• Increase in percentage of women
completing PNC Visit (1 visit)
from 44.89% in 2011 to 65% in
2016
2012-47%
2013-52%
2014-56%
2015-60%
2016-65%
• Training to cent percent health
workers working in SM
• All PHCCs provide safe abortion
services by 2016
134 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
3 OUTPUTS
• Enhanced and
equitable provision of
quality SM services
-focused ANC
-delivery by SBAs
-new born care
-PNC
-CAC/PAC
-referral services
• 1st
• 4
ANC coverage achieved to 85%
by 2016 th
• All HPs providing normal delivery
services & newborn care.
ANC coverage among first
visits achieved to 80% by 2016
• Increased number of SBAs
available for safe delivery
• Women receiving PNC (1visit)
increased to 65% by 2016
• Provision of BEOC including
newborn care and CAC at all
PHCCs by 2016
• Adequate provision for referral of
all complicated obstetric cases to
higher institutions by 2016
• Sustainability of CAC/ PAC
services in the District Hospital.
• Administrative records (DHO,
Dhankuta)
• Periodic supervision report
• Annual Report; DHO
• Annual Report; DOHS
• Study/ Survey reports
• Monthly monitoring sheets
• Referral sheets
• Continuing national
commitment and
resources for SM as a
priority
• Commitment and
resources for capacity
building of peripheral
institutions in health
management
• Development of safer
and effective way of
working in critical
areas
• NESOG continues to
support on SBA
training
135 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
4 INPUTS
• Budget
Improve sustainable
financing system for
SM services
• Increased share for SMNH in
district annual budget
• District Budget
• Records from account section,
DHO
• Audit Reports
• Timely release and
disbursement of
budget
• Human Resources • District hospital, all PHCCs and
HPs fully staffed by SBAs (with
skill mix, both number and type)
• Increase in number of technical
and administrative human
resources required for SM
• Training to all staffs responsible
for Safe Motherhood Program
• Human resource records from
administration section, DHO
• Records from training section,
DHO
• HURIC data
• Records on human
resources are available
• Physical
Infrastructures, assets
and procurement
-Adequate physical
resources for SM
services an year
round availability of
SM related drugs and
supplies
• Number of health posts with fully
equipped birthing centers
• All PHCCs with fully equipped
BEOC facilities sustained
• Fully equipped CEOC facility at
district hospital enhanced
• Annual report, DOHS
• Annual Report, DHO
• LMIS report, DHO
• Study/ Survey reports by
different institutions
(professional and educational)
• Level of resources
remain the same as
planned
136 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
• Year-round availability of SM
drugs and commodities (SDKs,
EOC kits, Iron tablets, Vit-A
capsules, etc.)
• Free health schemes implemented
as stated
• Co-ordination and
Public Private
Partnership
• Number of SM services related
contracts
• Annual health plans developed by
DDC that cover SM
• Records from DHO
• DDC plan
• Conducive policy
environment for
partnership with
I/NGO, CBOs and
private sectors
• DHO remains
committed to concept
of public private
partnerships
137 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
8.8 Major Activities
Table 59: Major activities in safe motherhood plan
Major Activities Assumptions
1 ANC Services
• Regular ANC services (examination: BP, Weight & FHR), birth
preparedness and complication readiness, TT immunization,
Iron supplementation, deworming, malaria prophylaxis) by all
peripheral institutions.
• Make existing PHC Outreach Clinics functional
• Conduct mothers’ Group meetings by FCHVs on a regular basis
• Health education and counseling for birth preparedness and
complication readiness
• Provide support for transport
• Pregnant women will have active
participation in ANC services.
• There is a policy that directs the DHO to
provide such services free
2 Safe Delivery Services
• Improving physical infrastructures for safe delivery (birthing
centre)
• Adequate supply of physical resources for safe delivery services
(SBK, EOC kits, etc.)
• Promotion of institutional deliveries
• Continuity of incentive schemes for institutional deliveries
• Orientation to mother groups
• Pregnant mothers go to the health facilities
for delivery & SBA are available in the
health facilities.
• The provisions of incentives for
institutional delivery are sustained and
continued.
• No bands and strikes
138 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
• Strengthening and expansion of safe delivery services to all
HPs, PHCCs, in a phased manner
• Decision making power relies on women
3 PNC Services
• Regular services available at all HIs for physical examination of
mother and newborns (to detect complications, provide
treatment and referral)
• Promotion of exclusive breast-feeding
• Regular immunization services to newborn
• Postnatal, FP counseling to all mothers utilizing PNC services
• Postnatal Vit A. and iron supplementation
• Institutional deliveries are increased
• Mother’s group is aware of safe
motherhood activities
• Mobilization of FCHVs is ensured
4 Training
• SBA training for HWs
• Orientation to all staffs of all peripheral HIs on RH and SM.
• Training on recording and reporting
• Orientation to mothers groups regarding SM practices
• Identify gaps in the existing BEOC in-service curriculum and
adapt in-service SBA training
• Develop generic (27 core skills) competency based SBA
training package
• Train doctors on C/S
• NESOG continues to support on SBA &
CAC/PAC training
• Availability of budget & resource persons
• Co-ordination & co-operation of DPHO
with RHTC and NHTC
• Curriculum development
139 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
5 EOC services
• Providing BEOC services through all PHCCs
• Sustaining and strengthening CEOC services available at the
district hospital on a 24 hour basis
• EOC kits made available to all health facilities
• Improving the functioning of referral system by developing
simple referral protocols, orientating HWs and ensuring 24 hrs.
availability of services
• Developing and implementing need based planning and
monitoring system and a phased expansion on B/CEOC sites in
the district hospital and PHCCs
• Health facilities have enough space and
trained human resources for BEOC will
retain in HIs.
6 Safe Abortion
• Strengthening CAC/PAC services in district hospital and Maire
Stopes center
• Develop CAC/PAC services to all PHCCs
• Encourage private/NGO sectors to expand CAC services in line
with CAC policy
• Decision making power relies on women
7 Behaviour Change Communication (BCC)
• Promote SM related healthy behaviours, including birth
preparedness by conducting BCC activities and using right
based approaches
• Conflicts does not limit the mobility and
gathering of people at district level and
below
140 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
• Develop and implement research based communication
interventions to reach disadvantaged and vulnerable groups
• Update and implement integrated SMNH communication
strategy, including standardizing messages and making them
available at all level
• Awareness campaign on SM
• Establishment and maintenance of IEC corners at all HIs
• Co-ordinated effort to implement BCC
activities
• Communities are willing to participate in
SM BCC program
8 Information Management
• Develop strategy to incorporate key SM information within an
integrated matrix (disaggregated by ethnicity, caste and wealth)
• Orientation and training on effective recording and reporting
using HMIS tool
• Design and implement research for generating additional
information that is not incorporated in HMIS
• Increase access to SM information at all levels (community to
district)
• Comprehensive HMIS is feasible
• Regular review to respond for change in
HMIS regarding SM needs
• Load shedding is reduced so that
motivation to enter computer data is not
lost.
9 Physical Assets and Procurement
• Develop an inventory of SM services, facilities, equipment and
instrument
• Establish data based for drug and commodities
• Political instability does not affect
implementation activities
• Situation allows monitoring of physical
141 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
• Strengthen the quarterly LMIS reporting system for
consumption of SM related drugs and other commodities
• Timely and adequate supply of SM related logistics
• Develop mechanism for replenishment of RH kits (e.g. use
money raised from deliveries for SM drugs and supplies)
• Ensure proper use of RH kits
facilities construction
• Fund commitment remains at least the
same
• Government is committed to establish
transparent procurement mechanism
10 Supporting Activities
• Regular review meetings with all related HIs
• Develop mechanism for reward and punishment
• Coordination between DHO, hospital and RTC for management
issues
• Good co-operation from all HIs
• Fair evaluation for reward and punishment
• Roles and responsibilities of PHO,
hospitals, RTC clearly defined and applied
for smooth functioning
11 Human Resource Management
• Identify requirements (placement in District Hospitals and PHCs
with BEOC but without doctors)
• Advocate for and implement a system whereby the EOC
competent staff (midwife, doctor) are retained
142 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
8.9. Targets for Safe Motherhood Programme
Table 60: Targets for safe motherhood programme
Activities Target Unit 2012 2013 2014 2015 2016
1 First ANC visit 28713 Person 5634 5699 5747 5799 5834
Fourth ANC visit 20124 Person 3381 3704 4023 4349 4667
Health Institution Delivery 14248 Person 2028 2408 2816 3262 3734
Post Natal Visit 14248 Person 2028 2408 2816 3262 3734
2 Logistics Supply
Supply of essential drugs and vaccines 15 Times 3 3 3 3 3
Supply of SDKs 5 Times 2 - 1 - 1
Supply of EOC kits 5 Times 2 - 1 - 1
Supply of IEC materials 5 Times 1 1 1 1 1
Supply of forms and registers 5 Times 1 1 1 1 1
3 Trainings and Orientations
SBA training to MOs, SN & ANM 36 Person 12 - 12 - 12
Gender sensitivity training to HA/ HW 75 Person 25 - 25 - 25
Orientation to FCHVs, VHWs & MCHWs 400 Person 150 - 130 - 120
Training on recording and reporting 300 Person 120 - 100 - 80
4 Infrastructures
Construction & maintenance of BEOC and
birthing centers
7 Health centers 3 2 - 2 -
Repair & Maintenance 18 Health Centers 8 - 5 - 5
143 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
5 Awareness campaigns using BCC 6 Times 3 - 2 - 1
6 Meetings
DRHCC meeting 15 Times 3 3 3 3 3
Review meeting of C/BEOC centre & birthing
centers
10 Times 2 2 2 2 2
FCHV review meeting 5 Times 1 1 1 1 1
7 Incentive Schemes
Incentives for four ANC visits 20124 Person 3381 3704 4023 4349 4667
Incentives for institutional delivery 14248 Person 2028 2408 2816 3262 3734
144 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
8.10 Budget Plan
Table 61: Budget plan for safe motherhood programme
Activities Unit 2012 2013 2014 2015 2016 Total
Target Budget Target Budget Target Budget Target Budget Target Budget
1 First ANC visit Person 5634 5699 5747 5799 5834
Fourth ANC Visit Person 3381 3704 4023 4349 4667
Health Institution
Delivery
Person 2028 2408 2816 3262 3734
Postnatal visit Person 2028 2408 2816 3262 3734
2 Logistics Supply
Supply of essential
drugs and vaccines
Times 3 75000 3 84000 3 87000 3 90000 3 93000 429000
Supply of SDKs Times 2 50000 - 1 28000 - 1 30000 108000
Supply of EOC
kits
Times 2 40000 - 1 23000 - 1 25000 88000
Supply of IEC
materials
Times 1 15000 1 16500 1 18000 1 19500 1 21000 90000
Supply of forms
and registers
Times 1 10000 1 13000 1 15000 1 18000 1 20000 76000
145 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
3 Trainings and
Orientations
SBA training to
MOs, SN & ANM
Person 12 72000 - 12 72000 - 12 72000 216000
Gender sensitivity
training to HA/
HW
Person 25 50000 - 25 50000 - 25 50000 150000
Orientation to
FCHVs, VHWs &
MCHWs
Person 150 52500 - 130 45500 - 120 42000 140000
Training on
recording and
reporting
Person 120 60000 - 100 50000 - 80 40000 150000
4 Infrastructures
Construction of
BEOC and
birthing centers
Health
Centers
3 900000 2 600000 - 2 600000 - 2100000
Repair &
Maintenance
Health
Centers
8 400000 - 5 250000 - 5 250000 900000
5 Awareness
campaigns using
BCC
Events 3 15000 - 2 10000 - 1 5000 30000
146 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
6 Meetings
DRHCC meeting Times 3 13500 3 13500 3 13500 3 13500 3 13500 67500
Review meeting
of C/BEOC centre
& birthing centers
Times 2 100000 2 115000 2 125000 2 140000 2 148000 628000
FCHV review
meeting
Times 1 141750 1 151200 1 157500 1 163800 1 173250 787500
7 Incentive
Schemes
Incentives for four
ANC visits
Person 3381 1352400 3704 1481600 4023 1609200 4349 1739600 4667 1866800 8049600
Incentives for
institutional
delivery
Person 2028 2028000 2408 2408000 2816 2816000 3262 3262000 3734 3734000 14248000
Grand Total 5375150 4882800 5369700 6046400 6583550 28257600
CHAPTER IX
OTHER ACTIVITIES
147 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
CHAPTER IX
OTHER ACTIVITIES
9.1 District Presentations
9.1.1 First District Presentation
9.1.1.1 Date, Time and Venue
• Date: 2068/02/12
• Time: 1:15 P.M. - 3:20 P.M.
• Venue: District Health Office, Dhankuta
9.1.1.2 Participants
• 24 people attended the presentation
• District Health officer & other programme officers
• Statistician
• Representative from DACC
• Members from District Hospital
• Field Supervisor from VCTS
9.1.1.3 Main objectives of the programs
• To present the district profile
• To discuss about the district health system
• To present about the supporting organizations on the basis of our findings.
9.1.1.4 Subject matter we discussed
• District Profile
• Health Profile of the district
• District Health System (in system model)
• Health Programs in the districts (trend analysis of achievements)
• Findings about supporting organizations
148 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
9.1.1.5 Details of the program
• Welcome speech:- Anil Dhungana
• Objectives of the program:- Anu Gomanju
• Dissemination of the action plan:- Uttam Gautam
• Presentation of findings:
Shreetina Keshari Tuladhar
Prabesh Ghimire
Dinesh Rupakheti
Naresh Bhatta
• Feedback from:-
Senior Public Health Administrator Mr. Jhalak Sharma Poudel
(DHOr, Dhankuta)
Prof. Chitra Kumar Gurung (Institute of Medicine)
• Thanks giving:- Rabina Kumari Rajak
9.1.2 Final presentation
9.1.2.1 Date, Time and Venue
• Date: 2068/02/18
• Time: 11:30 A.M. – 12:15 P.M.
• Venue: Seminar Hall, DHO
9.1.2.2 Participants
• About 18 people participated at our final presentation
• Section officer, Program Officers (CB-IMCI, Safe motherhood, family
planning, Malaria, AIDS)
• Statistician, Store keeper, Medical Recorder (district hospital)
• Members from district hospital (Medical doctor, Staff nurse, ANM)
• Representative from DACC
149 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
9.1.2.3 Objectives
• To present the overall information about our comprehensive field practice
• To overview our activities performed during the field practice
• To present the comprehensive five year plan on Safe Motherhood
• To thank people for their support during our study and obtain feedback of
our study.
9.1.2.4 Activities:
• The programme was conducted informally with no chairmanship.
• The specific objectives of our field practice were clearly stated prior to the
beginning of the program.
• The chief activities performed during field visit were stated.
• The five year plan was briefly presented in a log-frame approach.
• We thanked everyone for their valuable co-operation, suggestions and
valuable inputs that was provides to us during the course of our study
• Feedback from:-
Ram Narayan Shrestha: Section Officer, Dhankuta
Purna Shekhar Shrestha: Statistician
Akshay Lal Yadav: Programme Officer (CB-IMCI)
Balkumari Gurung: Programme Officer (Safe Motherhood)
Toya Nath Ghimire: Programme Officer (Family Planning)
Indu Nepal Yonjan: District Aids Co-ordination Committee
150 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
9.2 Participated Programs
9.2.1 Interaction on Comprehensive Abortion Care in District Hospital
Dhankuta: Issues and Challenges
The interaction program with doctor, nurses and paramedics was held in DHO,
Dhankuta on the issues and challenges for comprehensive abortion care in
District Hospital, Dhankuta. Five members of our team participated in the
interaction program and gained valuable in-sights on the problems and issues
regarding the CAC services provided by the hospital.
• Date: 27/01/2068
• Venue: Seminar Hall, DHO
• Time: Duration: 45 minutes
• Key Persons:
Dr. Joji Baral (NESOG)
Mr. Jhalak Sharma Poudel (District Health Officer, Dhankuta)
9.2.2 International Nursing Day
All of our members participated in the Nursing Day Programme organized by
the nursing council of Dhankuta. We were benefitted by the valuable speeches
from the key stakeholders of Dhankuta district on the importance of health
services & roles of health professionals in providing all forms of care and
support to the patients and the community. We were really glad to see Chhori
Shrestha, (District Hospital, Dhankuta) being honoured for her indefatigable
contributions for 32 Years in the nursing services in Dhankuta.
• Date: 12/05/2011
• Venue: Seminar Hall, DHO
151 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
9.2.3 Orientation on Disaster Management
We also participated and interacted actively in a brief orientation programme on
Disaster Management given by Nepal Red Cross Society. We could acquire
helpful information on the public health importance of disasters, their effects
and impacts. We were also oriented briefly on the cycle of disaster
management.
9.2.4 Orientation to the members of District Population Co-ordination
Committee.
We got the opportunity to participate as an observer in the orientation of
members of District Population Co-ordination Committee on 2nd
of Jestha 2068.
We obtained the prospect to know the various population programmes due to
commence within a month time in Dhankuta district. The programme was
organized under the chairmanship of LDO Baburam Gautam and attended by
heads of most of the government line agencies operating in Dhankuta district as
well as by the heads from different educational institutions.
CHAPTER X
LEARNINGS AND
RECOMMENDATIONS
152 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
CHAPTER X
CONCLUSIONS AND RECOMMENDATIONS
10.1 Conclusions
Comprehensive field practice on management of district health system is actually a
learning process. Hence, it was really proved to be a platform for us to bring all the
theoretical aspects of our learning into actual field situation.
Through the close look to the overall district health managerial patterns and the
service system, by remaining there at the district itself, we could able to comprehend
how District Health System really works.
Some of the conclusions that we could cumulate during our field practice are as
follows:
• District health profile
Keeping quality record/ proper recording is a great job.
Just compilation of data doesn’t give any meaning. It’s review, analysis and
discussion and use at the local level is the most.
• Critical Review
Breaking problems into various critical points and striking on most
appropriate point is the way of bringing change.
Same problem can be studied through different perspectives, and finding
their solution in the existing condition of the district setting is important.
• Epidemiological study
Health workers should follow the standard operational definition of diseases
for diagnosing a problem.
Gender based differences on health seeking behaviour and service utilization
pattern widely exists so it needs to be addressed by empowerment.
153 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
• Mini action project
Without the motivation and participation of district health supervisors and
peripheral health workers, no programme becomes success.
• Five year plan
Geographical patterns and other difficulties in the districts and VDCs must
be considered while preparing operational plans.
For realistic and implementable plan, district supervisors and peripheral
health workers must be involved actively.
• Group dynamics and others
For the success of any project, the mathematics of teamwork is –“Sum the
ideas, minus the differences, multiply the unity and divide the
responsibilities”.
No task is difficult when there is unity among diverse ideas, experiences and
leanings of the group members.
Learning to adapt in every situations- may it be different or difficult
situation, by maintaining team spirit inspite of individual variations to
accomplish a predetermined goal.
Learning to offer help to a team or take help from a team for a team in the
spirit of team approach.
154 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
10.2 Recommendations
• To DHO Dhankuta
The vacant posts in DHO should be fulfilled for efficient and effective
functioning of the DHO.
Health information and resource center should be established in DPHO.
Ambulance services should be made available at both PHCCs
Continuous supervision should be done irrespective of geographical
constraints and accessibility.
• To Campus
The schedule for the field was not at appropriate time because it was the end-
time of financial year. Hence, DHOr including all program supervisors were
busy completing their activities that were to be completed within that fiscal
year.
Orientation classes were done but all those were proven theoretical in actual
field settings. Hence, the orientation classes should be made more
comprehensive and practical.
The schedule for supervisory visits should be arranged timely.
Appropriate guidelines should be provided for report writing so as to
maintain uniformity.
BIBLIOGRAPHY
151 A Report on Comprehensive Field Practice on Management of District Health System, Dhankuta
BIBLIOGRAPHY
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Provinces. Geneva: World Health Organization; 1995.
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4. DDC. An Introduction to Dhankuta District. Dhankuta: 2065; District
Development Committee
5. Department of Health Services. Annual Report 2065/66. Kathmandu: 2066.
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Toolkit for District Health Managers. Pakistan: Ministry of Health, Government
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Management. Geneva: World Health Organization; 1989.
ANNEX
ANNEX I
LIST OF INDICATORS
Immunization Main Indicators Numerator and Denominator 1 Immunization coverage Number of children under one year of age immunised
with specific dose of antigen x 100 Total estimated number of children under one year of age
2 Immunization coverage for TT2+ vaccine
Number of pregnant women immunized with TT2+ x 100 Total estimated number of pregnant women
3 Measles drop-out rates (BCG vs. Measles
vaccine)
Number of children received BCG - Number of children received measles vaccine x 100 Number of children received BCG
4 Vaccine Wastage Rate Number of vaccine doses received - Number of vaccine doses used x 100 Number of vaccine doses received
Nutrition
1 Growth-monitoring coverage
Number of visits x 100 Number of targeted visits
2 Proportion of malnourished children (weight for age)
Number of children (0-36 months) under low growth curve for 1st visit x 100 Number of children (0-36 months) new cases
3 Postpartum Vitamin A coverage
Number of Postpartum women supplemented with vitamin A capsule x 100 Total number of Expected pregnancies
4 Deworming coverage Number of children (1-5 years) receiving deworming tablets twice a year x 100 Number of children of 1-5 years
Control of diarrhoeal disease 1. Morbidity rate due to diarrhoea Total diarrhoeal new cases in specified time x 1000
Target population (under-fives) 2. Mortality rate due to diarrhoea Total number of diarrhoea-related deaths x 1000
Target population (under-fives)
ARI
1 Under-five child mortality due to ARI-related causes
Total deaths due to ARI in one year x 1000 Total <5 yr. population in the same year
2 Annual incidence of ARI among under-five children
Total no. of ARI cases in one year x 1000 Total no. of <5 yr. population in the same year
3 Annual incidence of pneumonia among under-fives
No. of pneumonia cases in a specified year x 1000 Total no. of <5 yr. population in same year
Family Planning
1 Contraceptive Prevalence Rate (CPR)
Number of current users of modern FP methods x 100 Married Women of Reproductive Age (MWRA)
2 Method-specific new acceptors as a percent of MWRA
Number of method specific New Acceptors x 100 Married Women of Reproductive Age (MWRA)
Safe Motherhood
1 ANC service coverage No. of ANC first visits x 100 Expected no. of pregnancies 2 Percentage of 4 ANC visit No. of 4 time ANC visit x 100 No. of 1st ANC visits 3 Delivery service coverage by
health Total no. of delivery services provided by health workers x 100
Workers Total no. of expected pregnancies 4 Postnatal service coverage Total no. of first postnatal visits x 100 Total no. of expected pregnancies 5 Maternal mortality ratio Total maternal deaths x 100,000 Total live births
Malaria
1 Annual Blood Examination Rate
Total no of slides examined x 100
(ABER) Total population at risk of malaria 2 Slide Positivity Rate (SPR) Total no of positive slides x 100 Total slides examined
Tuberculosis
1. Treatment outcomes Cure rates Completion rates Failure ratess Death rates
The number of new smear- positive cases having that outcome * 100 The number of new smear- positive cases registered in that quarter
2. Smear conversion rate at 2 (3) months for new smear- positive cases, relapses, and failure cases
The number of smear- positive cases (new, relapse or failure cases) which are smear- negative at 2(3) months of treatment x 100 The number of smear- positive cases (new, relapse, or failure cases) registered during the quarter
3. Case detection ratio of new pulmonary smear- positive cases
The number of new smear- positive cases registered during a year x 100 The number of new smear- positive cases estimated to occur during the year in that population.
4. Positivity rate for smear positive cases
The number of smear- positive cases detected during a quarter x 100 The number of TB suspects examined by smear microscopy in that quarter
Leprosy
1 Registered Prevalence Rate Total number of leprosy cases registered at the end of year x 10,000 Total Population
2 New Case Detection Rate ( NCDR)
Total number of new cases detected for leprosy x 10,000
Total population
OPD/ In-patients care
1 Percentage of OPD new Total number of OPD new visits (cases) x 100 Total population of catchment areas 2 Ten leading OPD cases on district
basis 1st ten leading OPD new cases
3 Top five leading causes of hospitalization
1st five leading cause of hospitalization
4 Death Rate among in- patients Total number of in- patient deaths x 100 Total number of in-patients admitted 5 Average length of stay Total In patients days Total no. of discharges 6 Bed occupancy rate Total inpatients stay in a hospital x 100
365 (days) x Total no. of beds available 7 Bed turnover interval 365 (days) – (Average length of stay x Throughput) Throughput
Others
Main Indicators Numerator and Denominator 1.Average no of people served by FCHV
No of people served by FCHV
Total no of FCHV 2.% of PHC/ORC clinics held by month
Total number of clinics held x 100 Total number of clinics to be held
3.No. of people served per clinic
Number of people served by clinics x 100
Total no. of clinics held
4.% of Mothers group conducted meeting
Number of Mothers Group meeting conducted x 100 Total no. of Mothers group
ANNEX II
INTERVIEW GUIDELINES FOR DHO
1. Administrative Management
A) Planning
1. How do you prepare the district health plan?
2. What is planning process of PHCC/HP/SHP?
3. Have you prepared training schedule of district annually?
4. How do you set the target and activities of different programs for different
health facilities?
B) Organization
1. What is the organizational structure of DHO?
2. What is the networking system of different organizations in the district?
C) Staffing
1. What is staffing pattern in DHO?
2. How do you determine training needs in district?
3. How do you appraise the program of your subordinates?
4. How often do you have staff meetings in your office?
D) Directing
1. What is the decision-making system of DHO?
2. Is there any reward and punishment system in DHO/PHCC/HP/SHP?
3. What types of authorities are delegated to your sub-ordinates during your
absence in office?
4. How do you circulate the information with your subordinates?
E) Communication
1. How do you communicate within and in between the office?
F) Coordination
1. How do you coordinate with PHC/HP/SHP?
2. How do you coordinate among INGOs, NGOs and GOs?
3. Could you explain about the role of management committee in different
health institutions?
4. Are you facing any problem in coordination?
G) Supervision
1. Do you have supervision schedule of PHC/HP/SHP?
2. How often do you supervise?
3. Do you have feedback system after supervision?
4. What is the process of supervision?
5. Is there any supervision of DHO from higher level authorities?
H) Recording and reporting
1. How is recording and reporting system running in PHCC/HP/SHP and
other health organizations?
2. How do you maintain and use reports made available at the district?
3. Have you faced any problem during recording and reporting?
4. Do you have any provision of refresher training for your staffs regarding
recording and reporting?
I) Budgeting
1. How do you plan a budget in the district?
2. What are the basic components of budgetary allocation?
3. How do you manage the appropriate recording process of income and
expenditure of budget?
4. Have you felt any problems in accountancy?
J) Evaluation
1. How do you evaluate the peripheral institution?
2. What method is used for the evaluation?
K) Administrative activities
1. How do you manage performance appraisal of your staffs?
2. How do you manage all administrative works in your office?
3. Do you have monthly meeting in DHO?
4. Are you facing any administrative problems?
2. Logistic Management
1. How do you demand logistic from RMS?
2. How do you supply medical / logistic to the peripheral level HI?
3. Whether the demand logistic is sufficient for the district?
4. How do you manage logistic for special situation like epidemic?
5. What audit form is used for recording and reporting?
6. When do the peripheral level HI and hospital report to district?
7. Whom do you use to look the stock level?
8. How do you place logistic in store?
9. When and how do you recheck the recording system?
10. Do you have feedback system after reporting?
11. How do you records and reports to the higher level?
12. Do you buy medicine in district?
13. What do you do to the expired drugs and few months remained to expired?
14. Do you have system of returning medicine which is not used from HI?
3. Budgeting system
1. How do you plan budgeting in the district?
2. What are the steps of budgeting allocation?
3. Can we know about the budget release and expenditure?
4. How do you manage if allocated budget is not sufficient?
5. Who do control the finance of the district?
6. How do you use the income of hospital?
ANNEX III
INTERVIEW GUIDELINES FOR PROGRAM/ SECTION
1. What is your job description?
2. What is the supervision and monitoring system?
3. When and how do you supervise your subordinates?
4. Who supervises you?
5. What is the reporting system?
6. What are the problems and constraints in the section?
7. What are the actions need to be taken to solve the problems/constraints?
Who are the responsible people?
ANNEX IV
GUIDELINE FOR GOs/ INGOs/ NGOs VISITS
1. General introduction of organization.
2. Goal and objectives of organization.
3. Areas of conducting programs.
4. Focus group of implemented programs.
5. Target, achievement and reporting system of program.
6. Coordination system with DHO, DDC and other agencies.
7. Duration of program.
8. Community involvement in programs.
9. Problems and constraints of program
ANNEX V
OBSERVATIONAL CHECKLIST FOR THE PHCC/HP/SHP VISITS
Condition Yes No
• Well constructed building • Adequate ventilation/lighting • Adequate furniture/tables • Adequate laboratory equipments. • Separate rooms for separate services. • Comfortable waiting place for the
patients. • Daily diary maintenance. • Complete registers maintenance • Condition of the stores. • Presences of dispensary rooms • Cold chain maintenance • Presence of IEC corners. • Presence of ORS corner • Proper use of safety box • Healthful environment institution • Good water supply system • Proper use of toilet • Proper waste disposal system
ANNEX VI
CHECKLIST FOR THE STORE
Condition Yes No
Infrastructure • Well constructed building • Adequate ventilation/ lighting • Cleanliness • Adequate space
Stock level maintenance
• EOP maintained • ASL level maintained • FEFO maintained • Updated records
Cold chain
• No.s of refrigerators........... • Presence of generator for power supply • Fuel Stock • Separate place to store opened and un-
opened vials Waste management
• Burning of cartoon • Separate provision for collection of
hazardous and non hazardous drugs
ANNEX VII
SECONDARY DATA REVIEW FORMATS
Dhankuta District Profile
S. no Features 1 Geography
Boundaries • East • West • North • South
Topography • Area • Region • Latitude • Longitude • Altitude (with range)
2 Socio-economic Occupations
Religions
Language
Ethnic groups
3 Political divisions Electoral Constituencies Municipalities VDCs
4 Climate
5 Natural Resources Rivers/ streams Forests
Minerals
6 Organizations NGOs INGOs Clubs
8 Communication Postal Services Newspapers/ magazines
9 Tourist areas/ Heritages
Educational Profile of Dhankuta
S no Levels Government Private Total 1 Primary 2 Lower Secondary 3 Secondary 4 Higher Secondary 5 Higher Level
Total
Health Institution Profile
S no Features 1 Primary Health Care Centre
2 Health Posts
3 Sub-Health Posts
4 EPI Clinics
5 PHC ORC
6 FCHVs
7
Human Resource Profile in Health Institutions of the District
S no Health institution Sanctioned post
Filled post
Unmanned Post
Vacant post
Fazil Post
1 DPHO 2 District Hospital 3 PHCC 4 HPs 5 SHPs
Total
Demographic Profile
S no Indicators District National 1 Population
• Male • Female • Total
2 Sex Ratio (M:F) 3 Dependency Ratio
• Child dependency • Old dependency • Total
4 Total Households 5 Average Family Size 6 Population Density 7 Fertility Status
• Crude Birth Rate (CBR) • General Fertility Rate (GFR)
8 Mortality • Crude Death Rate (CDR) • Neonatal Mortality Rate (NMR) • Infant Mortality Rate (IMR) • Under -5 Mortality Rate (U5MR)
9 Morbidity • Incidence Rate
• Disability Rate
10 Population Change • Rate of natural increase
PHOTO GALLERY
PHOTO GALLERY
Photo 1: Meeting with District Health Officer
Photo 2: Preparation for data collection
Photo 3: Review of Monthly Monitoring Sheet
Photo 4: Data collection from section officer
Photo 5: Data collection from Koshi Zonal Ayurvedic Aushadhalaya
Photo 6: Data Collection from Pakhribas Health Post
Photo 7: Observation of District Medical Store
Photo 8: Critical Review
Photo 9: Data Analysis
Photo 10: Preparation for First Presentation
Photo 11: Mini Action Project
Photo 12: Preparation of Comprehensive Five Year Plan
Photo 13: Preparation for Final Presentation
Photo 14: Final Presentation
Photo 15: College Presentation
Photo 16: Group members with DHOr and Campus Chief & BPH Co-ordinator during supervision