This Annual Report presents the annual performance of the major programmes carried out through the network of health facilities of the Department of Health Services during the fiscal year 2062/63 (2005/2006). The report mainly focuses on the implementation status of activities carried out by programme divisions and centers against the set targets. Major programme activities are analyzed and attempts are made to highlight the trends in services coverage over the preceding two fiscal years. This report also identifies issues, problems, and constraints, and suggests actions for improvement, to be taken by the related health institutions. The information and statistics used in this report are based on the information collected by the Health Management Information System (HMIS) section of the Management Division, Department of Health Services from health institutions across the country.
Basic health services during FY 2062/63 were provided by 89 hospitals, 186 Primary Health Care Centers (PHCCs), 698 Health Posts (HPs) and 3,129 Sub Health Posts (SHPs). Primary health care was also provided by 14,512 Primary Health Care Outreach Clinic (PHC/ORC) sites. These services were further supported by 48,352 Female Community Health Volunteers (FCHVs).
During the current fiscal year, despite the disturbances in the country, most of the indicators suggest an improvement in overall health service coverage particularly in immunization, the severity of CDD, ARI, Iron distribution to pregnant women, family planning and safe motherhood. Though the regular immunization programme (EPI) and safe motherhood programme activities have shown improvements there remain some issues in other programmes that require attention such as preventing outbreaks of some communicable diseases, quality surveillance and quality of care to service consumers to have a tangible effect.
The Child Health programme includes the following:
- Expanded Programme of Immunisation (EPI) including Hepatitis B vaccination
- Supplemental immunization programs
- Community-Based Integrated Management of Childhood Illnesses (CB-IMCI)
- Control of Diarrhoeal Diseases (CDD)
- Acute Respiratory Infection (ARI)
- Nutrition Programme
EXPANDED PROGRAMME ON IMMUNISATION (EPI)
The national coverage of all antigens in the regular EPI programme has improved. DPT3, Polio3 and Measles coverage has increased by more than 8.0 percent compared to the last fiscal year. Hepatitis 3 coverage has gone to 89.1 percent. TT2 to pregnant women has increased by more than 6.0 percent. School Immunization programme has been initiated. Last yearâ€™s measles campaign had a significant positive impact in terms of a reduction in measles outbreaks, measles cases and more importantly, a reduction in deaths.
Intensified National Immunisation Days (NIDs) were conducted as in previous years. These activities made substantial contributions toward the goal of maintaining Nepal polio-free.
The proportion of malnourished children decreased to 8.6 from 10.5 in the last fiscal year and growth monitoring coverage and the average number of growth monitoring visit has also increased. Vitamin A capsules were distributed to 100.0 percent targeted 6 to 59 months children. More pregnant women received iron tablets during this fiscal year compared to the previous fiscal year. However, the reliability of reporting in terms of duplication and compliance need to be assessed to ensure the quality of service.
COMMUNITY-BASED INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS (CB-IMCI)
During this fiscal year, the CB-IMCI programme was expanded to eight more districts making the total of thirty-three. The CB-IMCI programme has shown positive results in the management of childhood illnesses in comparison to districts where the programme is not implemented. The incidence of ARI and pneumonia detection is higher in the districts where the CB-IMCI programme is implemented compared to non-CB IMCI districts. However, the severity of pneumonia is lower in the districts where the CB-IMCI programme is implemented in comparison to the districts where the CB-IMCI programme is not implemented.
CONTROL OF DIARRHOEAL DISEASE (CDD)
A substantial progress has been achieved in control of Diarrhoeal diseases among the Nepalese children. The proportion of severe dehydration cases and case fatality rate has decreased to 1.4 and 0.11 percent during the FY 2062/63. Almost nine out of ten diarrhoeal cases were treated with oral rehydration solution (ORS), while treatment with IV fluid had decreased from 2.9 percent to 1.9 percent in FY 2062/63.
ACUTE RESPIRATORY INFECTION (ARI)
The incidence of ARI per 1,000 under-five children has increased from 360 to 405. The possible reason may be due to the community’s increased accessibility to ARI related health services. However, the percentage of new cases treated with antibiotics has decreased from 38.1percent to 35.2. Although, pneumonia cases have increased compared to last fiscal year, the proportion of severe pneumonia among new cases has decreased to 1.6 percent. The death rate due to pneumonia has remained constant to 0.2/1,000 over a period of three years. It is worth noting that in 25 districts where the Community Based ARI/IMCI programme has implemented the incidence of ARI and pneumonia cases was higher but the proportion of severe pneumonia cases was significantly lower than in the 50 districts where the programme is not implemented.
Family Planning is one of the major components of the Reproductive Health Programme. Over the past several years, contraceptive use has shown incremental improvements. Contraceptive methods like Depo Provera, Pills and Condoms are available nation-wide. Intra-uterine contraceptive device (IUCDs) services are made available in 67 districts and Norplant in 61 districts. Voluntary surgical contraceptive services are made available through static clinics as well as the mobile outreach program.
The Contraceptive Prevalence Rate (CPR) for modern methods shows an increasing trend, from 41.03 percent in FY 2061/62 to 42.01 percent in FY 2062/63. The preliminary finding of NDHS 2006 has shown the CPR of 48.0 percent for all method and more than 44.0 percent for the modern method. The total number of new acceptors of spacing methods has increased by about 5.0 percent from 442,371 in FY 2061/62 to 463,508 in FY 2062/63.
The total number of new acceptors of all spacing methods, except Depoprovera has increased in FY 2062/63. The new acceptors for voluntary surgical contraception (VSC) have also increased from 87,298 in FY 2061/62 to 93,413 in 2062/63 achieving 102.0 percent against the expected cases. The male participation in surgical contraception has increased by 2.0 percent over the last year. In terms of family planning current users, it has achieved 97.0 percent of the set target during the FY 2062/63. The involvement of I/NGOs in performing the voluntary surgical contraception is noteworthy in the national programme.
The safe motherhood programme has been successful in maintaining the increasing trend of service coverage. Similarly, expansion and strengthening of different safe motherhood services such as comprehensive abortion care, basic and comprehensive EOC services, maternity incentive schemes etc are being carried out in a planned manner. Post-Abortion Care services have decreased during the review period compared to FY 2061/62 due to the legalization of safe abortion. Met need for EOC services has improved. CEOC and BEOC sites have also been expanded in various districts. The Maternal Mortality Ratio based on the preliminary findings of NDHS 2006 has indicated a remarkable reduction compared to Nepal Family Health Survey Report of 1996.
FEMALE COMMUNITY HEALTH VOLUNTEER (FCHV) PROGRAMME
The role of the FCHVs is mainly focused on motivation and education of local mothers and community members for the promotion of safe motherhood, child health, family planning, and other community health services. Female Community Health Volunteers (FCHVs) contributed significantly to the distribution of oral contraceptive Pills, Condoms, and Oral Rehydration Solution (ORS) packets.
In addition to the above activities, FCHVs supported in providing Vitamin A capsules, iron supplementation and de-worming to pregnant women in intensified districts and polio immunization to children below 5 years during NID, community-based management, and treatment of ARI and other public health activities in 25 CB-IMCI districts.
PRIMARY HEALTH CARE OUTREACH CLINIC (PHC/ORC)
PHC/ORC clinics are the extension of services provided at SHP and HP in order to make these services more accessible to the community. The number of PHC/ORC clinics has decreased during the current FY due to numerous constraints. In spite of the reduction in the number of PHC/ORC, the average number of clients served per clinic has increased. The PHC/ORC clinics strategy has been revised to improve its effectiveness.
During this fiscal year, the malaria metric indicators such as ABER, API, SFR, and Pf % have increased compared to last fiscal year. More efforts are required to forecast, prevent and control major outbreaks that might occur in the coming years. GFATM support for the RBM programme provides hope for future malaria control activities.
Kala-azar is a major problem in the 12 districts of eastern and central Terai. The case fatality rate is decreased indicating an overall improvement in case management and increasing awareness among the people. The reported number of annual cases range from about eight hundred to more than thirteen hundred during the last three fiscal years. However, this does not include the cases treated either in private clinics or on the other side of the border; this clearly suggests that gross under-reporting of cases exists. The elimination of Kala-azar from endemic countries of the South East Asia region has been proposed and agreed upon. In this regard, rigorous and concrete efforts and high-level commitment from the government will be required in improving overall surveillance mechanism including mandatory reporting of disease from private healthcare sectors.
JAPANESE ENCEPHALITIS (JE)
Twenty four districts of Terai and inner Terai are affected by Japanese Encephalitis putting 12.5 million people at risk of the disease. The number of Encephalitis (including JE) ranged from 1,900 to 2,900 during the period of 2001 to 2005. But in this fiscal year, the reported cases have decreased to about 1,500 cases. The number of deaths due to Encephalitis ranged from 161 to 316 during the period from 2003 to 2005. It was decreased to 110 in the year 2006.
The NTP continues to make progress with DOTS expansion to 560 treatment centers and 2,795 sub-centers. Case finding was decreased by 5.0 percent during this FY against the target defined by WHO of maintaining at 70 percent but treatment success rate was maintained at 88 percent and sputum conversion rate was improved by 2.0 percent. A partnership between the NTP and private sector, public sector, NGOs, traditional healers, medical colleges, media, pharmacies, and communities is continuously increasing.
Nepal is one of the five countries in the world, not yet able to eliminate leprosy despite all efforts. Nevertheless, the program has been reporting a steady decline both in PR and NCDR at 1.65 and 1.96 per 10,000 populations. Out of 75, 44 districts have the PR of fewer than 1/10,000 populations. Case holding is exceptionally good with the cure rates of over 90 percent for MB and 93 percent for PB cases. Endemicity of leprosy is almost localized to Terai region accounting for more than 80 percent. The Disability rate (4.81) has increased at the national level compared to last fiscal year (3.52). This increment was observed in WDR by more than five-fold during the F.Y 2062/63.
HIV/AIDS and sexually transmitted infections (STIs) are emerging as major threats to Nepalâ€™s socio-economic and health sectors. Since the first case of AIDS was detected in 1988, Nepal has progressed from a low prevalence country to one with a concentrated epidemic in certain sub-group of the population. This indicates a threat of a generalized epidemic if comprehensive efforts are not taken immediately. Nepal has responded to the threat by developing a national strategy for HIV/AIDS prevention and has identified priority areas that need to be addressed.
NATIONAL HEALTH TRAINING
Overall 92 percent of the set targets were achieved in training activities at the central level during the FY 2062/63. At the same time, 83 percent of the district level training activities were completed. Based on the identification of necessary training needs several trainings such as Master Training of Trainers (MTOT), Training of Trainers (TOT), District Training of Trainers (DTOT), Competency-Based Skills (CBS) training to clinical trainers i.e., Doctors, Nurses and Health Assistants, Bio-medical equipment/ instrument repair and maintenance, Community drug training and Logistic training etc were conducted in this fiscal year.
HEALTH EDUCATION, INFORMATION AND COMMUNICATION
Various types of IEC/BCC activities were implemented at national, regional and district level to support demand creation and behavior change in preventive and promotive health services. The main activities were; formative and Desk review research, health education programme guidelines, materials production and distribution, the presentation of regular, weekly and periodic audio-visual programs, the dissemination of health message through the mass media, social mobilisation, advocacy workshop/seminar, folk events, observation on special days and exhibitions etc. Overall more than 90 percent of the set targets were achieved in IEC/BCC activities at the central level whereas more than 82 percent of the district level IEC/BCC set activities were performed during the FY under review.
Because of the difficult geographical terrain in the country efficient logistics management is a great challenge. Emphasis is placed on efficient management of health logistics for improving the distribution of medicines, vaccines, medical types of equipment, contraceptives, hospital types of furniture and maintenance of medical types of equipment at all level of health facilities.
LMIS information is being used for decision-making process on health logistics management. Efforts will be directed towards networking of LMIS and inventory information among the center, regions, and districts for the development of an efficient health logistics management in the country. Processing of LMIS information piloted in five districts as per decentralization was strengthened and expanded in few more districts. LMD in collaboration with its supporting partners has completed the training on the pull system of essential drugs and now it has been implemented in 14 districts.
COMMUNITY DRUG PROGRAMME
Year round availability of essential drugs in the health facilities is one of the major challenges for the efficient management of the primary health care delivery system in the country. In order to overcome this difficulty, the government had decided to implement the Community Drug Program throughout the country in a phased manner. The CDP programme has been implemented in 44 districts of which 14 districts are fully covered, 16 districts are partially covered, DDC level orientation is completed in 5 districts and basic preparation for implementation is completed in 9 districts. CDP is emerging as a programme for the development of self-sustaining basic health care services in the country.
NATIONAL HEALTH LABORATORY SERVICES
In this fiscal year, laboratory services were established and strengthened in central as well as peripheral health institutions. Various training programmes were conducted for the different level of health staff. Now Laboratory facilities are available at 69 district hospitals and 186 PHCCs. All these laboratories require significant strengthening to provide the quality services.
Out of the 25,377 staff in the Department of Health Services over 60 percent work in rural areas. A total of 1,000 doctors and 4,199 public health staff are employed in different regions. Nursing personnel comprises 20 percent of the total health personnel. However, there is a need for the improvement in personnel records keeping and employeeâ€™s roles and responsibilities need to be clarified through functional analysis.
The health sector budget for this year was Rs. 7,55,54,31,000.00 of which Rs. 5,93,78,29,000.00 was allocated to recurrent budget and Rs. 1,61,76,02,000.00 to capital budget. The budget allocated to health programmes under the Department of Health Services was Rs 5,41,98,08,000.00 of which Rs. 4,37,52,97,000.00 (80.7 percent) was allocated to recurrent and Rs 1,04,40,09,000.00 (19.3 percent) was allocated to capital budget. The External Development Partnersâ€™ contributions comprised 47.0 percent of the total budget under DoHS. During this FY almost 6.0 of the national budget was allocated to the Ministry of Health and Population out of the total national budget.
PLANNING, PROGRAMMING, MONITORING, SUPERVISION, CO-ORDINATION AND INFORMATION MANAGEMENT
As in the previous year, Health Management Information System (HMIS) Section continued to provide trimester feedback of information on the activities undertaken by the districts to all Divisions/Centres of the DoHS, Regional Directorates, and the 75 District Health/Public Health Offices. Annual Performance Review workshops were conducted in all districts, regions and national level. Several pieces of training were conducted in programme management to improve the skills of health workers. In this fiscal year, reporting status of hospitals was improved by 1.0 percent making at 94.0 percent and maintaining the high percentage reporting from other health institutions. The annual targeted activities were almost achieved.
HEALTH SERVICE COVERAGE
As can be seen from the fact sheet high coverage of health services has been achieved by many programmes. In particular, immunization coverage has increased, CPR is gradually increasing every year; expansion and strengthening of different safe motherhood services such as comprehensive abortion care, maternity incentive scheme, basic and comprehensive EOC services are being carried out; reporting of hospital services has shown slight improvement; DOTS programme has reached to 75 districts by extending the treatment centers and sub-centers and PR and NCDR in leprosy are declining every year. Although OPD new visits were slightly increased in terms of its coverage, it was decreased by 0.3 percent compared to FY 2061/62.
SUMMARY OF PROBLEMS AND CONSTRAINTS
Each technical division and center of the Department of Health Services submitted an analysis of problems and constraints along with proposed solutions. These are presented in the specific sections. The Department of Health Services and the Ministry of Health and Population recognize the need to address these concerns. The problems and constraints identified cannot be dealt with in isolation. Analysis, planning, monitoring, and coordination are required at the macro and micro level. Ministry of Health and Population and the Department of Health Services will take appropriate actions to solve these issues where possible to improve the healthcare system so that quality care through effective management of resources is delivered.