2          ANALYSIS OF ACHIEVEMENTS BY MAJOR ACTIVITIES

2.1       Activities Carried Out in FY 2062/63

2.1.1        Prevention of malnutrition

2.1.2        Protection and promotion of breastfeeding/complementary feeding (Infant and Young Child Feeding – IYCF)

• Developed and approved National Strategy for Infant and Young Child Feeding (an integral part of the comprehensive National Nutrition Policy and Strategy);
• Celebrated Breastfeeding Week (August 1-7) in all districts with rallies, talk programmes, adolescent orientation and School health program etc;
• Conducted one day orientation to HWs (including doctors, nurses and paramedics) in four teaching hospitals in Kathmandu valley;
• Conducted survey on availability of breast milk substitutes at the local market of Kathmandu;
• Developed promotional messages for exclusive breastfeeding through mass media and distributed of booklets on breastfeeding for health workers;
• Conducted ToT and participant training on IYCF Counselling to HWs;
• Conducted two-day IYCF orientation to all Nutrition Focal Persons and Health Education Technicians in five regions;
• Developed a low cost fortified blended complementary food for social marketing campaign and its promotional materials designed and tested.

2.1.3              Growth monitoring for screening and prevention of PEM

• Conducted regular growth monitoring at  Hospital, PHC, Health Posts, Sub Health Posts and Outreach clinics;
• Distributed growth monitoring and counselling card;
• Completed evaluation study of growth monitoring activities in selected health facilities of 4 districts in CDR in July 2004;
• A booklet on measurement of mid-upper arm circumference (MUAC) was developed and distributed to all FCHVs throughout Nepal;
• Mid-upper arm circumference (MUAC) measuring tapes (Shakir Tape) distributed to FCHVs.
• Salter scales distributed to D(P)HOs;
• Conducted orientation about proper method of growth monitoring practices and counselling activities to health workers including FCHVs in Syanja and Parbat districts;

2.1.4    Control of IDD

• Finalised Iodised Salt Regulation and its implementing Guideline;
• Conducted regular supervision and monitoring of iodized salt conducted at STC’s warehouses;
  • Iodized Salt Social Marketing Campaign V continued in Rupandehi, Kapilvastu, Nawalparasi, Dhanusha, Siraha and Dang districts;
  • IDD month celebrated throughout the country in the month of February for intensification of promotional activities;
  • Surveillance on consumption of iodized salt along with Vitamin A was continued by conducting a mini survey. FCHV registers used for Intensification of Antenatal Iron Supplementation Program (IAISP) was also used for this purpose;
  • Second edition of €œA booklet on Iodine Deficiency Disorders for health workers and program managers€ was published;
  • National scale survey for tracking the process towards prevention of iodine deficiency disorders in Nepal completed;
  • Renewed Indian Grant in IDD control program;
  • Published IDD calendar for community level for promotional activities.

2.1.5    Control of Vitamin A deficiency disorder

• Continued mass biannual distribution of high-dose vitamin A capsules to children between 6 to 59 months throughout the country;
• Continued nutrition education activities through media, community-level health workers and agriculture extension workers;
• Conducted mini-surveys to assess the outreach supplementation programme;
• Continued postpartum vitamin A supplementation through health institutions and FCHVs;
• Continued pilot intervention for treatment of night-blind pregnant women with low dose vitamin A capsules in three districts;
• Continued case treatment with vitamin A through health facilities;
• Initiated community-based nutrition reactivation training to HWs with emphasis on Vitamin A in selected districts;
• Conducted a workshop to revise IEC materials on nutrition, especially on Vitamin A;

2.1.6        Control of iron deficiency anaemia (IDA)

• Continued distribution of iron and folate tablets to pregnant and lactating women through Hospital, PHCC, HPs, SHPs ORCs, and FCHVs;
• Scaled up Intensification of Maternal And Neonatal Micronutrient Program (IMNMP) in 13 new districts (Rupendehi, Sarlahi, Rautahat, Jumla, Dailekh, Bardia, Doti, Baitadi, Kanchanpur, Kailali, Surkhet, Salyan, and Pyuthan);
• Continued production of wheat flour fortified with iron, folic acid and vitamin A few mills on voluntary basis;
• Received commitment of KfW to provide financial assistance to procure 40 million iron tablets for the fiscal year 2062/63;
• Initiated advocacy on use of low cost iron tablets to pregnant and postnatal women attending Maternity Hospital in Kathmandu;
• Conducted surveillance on consumption of iron along with Vitamin A mini survey continued during October and April rounds;

2.1.7    Deworming

• Continued regular biannual deworming of children aged 1-5 years along with vitamin A capsule distribution;
• Continued deworming of pregnant women as per the Policy and protocol;
• Included reporting of deworming of pregnant women in HMIS;
• Explore school Deworming program.

2.1.8    Miscellaneous

Developed National School Health and Nutrition Strategy.

 

1.4       Strategies

The following general strategies have been pursued to address the nutritional situation in Nepal:

• Promote, facilitate and utilise community participation and involvement in all nutrition activities;
• Develop understanding and effective co-ordination among various concerned Sections, Divisions and Centres within the Department of Health Services;
• Maintain and strengthen co-ordination among other agencies involved in nutrition activities, i.e., the Ministries of Agriculture, Education, Local Development and the National Planning Commission, as well as with international development partners, NGOs, INGOs and private sector;
• Decentralise authority to the region, district, Health Post, Sub Health Post and community for needs assessment, planning, implementation, and monitoring;
• Conduct national advocacy and social mobilisation campaigns;
• Integrate/incorporate activities (such as Expanded Programme on Immunisation, Integrated Management of Childhood Illness, Maternal and Child Health and Family Planning programmes etc.) into nutrition plans;
• Develop a systematic approach for monitoring and evaluation of all nutrition program activities;
• Celebrate Nutrition week (Poush 10-16) to raise awareness about the importance of Nutrition;
• Implement School Health and Nutrition Program as per National Strategy; and

Specific strategies are as follows:

1.4.1    Infant and Young Child Feeding (IYCF)

• Create awareness regarding the importance of growth monitoring and timely introduction of complementary foods through Mothers Groups, radio, TV news and poster/pamphlets, and counsel mothers on growth-patterns and proper child caring practices;
• Provide growth-monitoring services at Outreach Clinics, Sub Health Posts, Health Posts and PHCC;
• Integrate breast-feeding training with growth monitoring promotion and link breastfeeding promotion with child care programmes;
• Increase awareness among medical professionals through advocacy efforts, such as by including sessions on breastfeeding on seminars/workshops held by various associations;
• Establish mother€™s groups support to protect existing good practices regarding breast-feeding at the community level;
• Celebrate Breastfeeding Week (August 1-7) as an advocacy for the protection and promotion of breastfeeding;
• Encourage social marketing of low cost fortified blended complementary food targeting infants and young children 6-23 months of age.

1.4.2        Control of IDD

• Strengthen the implementation of Iodized Salt Act, 2055 for regulation and monitoring of iodized salt trade to ensure that all edible salt is iodized;
• Increase the accessibility and market share of iodized packet salt with €˜two-child€™ logo;
• Create awareness about the importance of use of iodized salt for the control of iodine deficiency disorders;
• Explore the possibility of progress evaluation system in IDD control program on a rotational basis in all 5 development regions;
• Expand iodized salt social marketing campaign in EDR & CDR.

1.4.3    Control of Vitamin A Deficiency (VAD)

• Distribute high-dose vitamin A capsules to children between 6 and 59 months biannually through FCHVs;
• Advocate for increased home production, consumption and preservation of Vitamin A rich foods at the community level;
• Explore the fortification of suitable foods (such as sugar and cooking oil) with Vitamin A;
• Strengthen the usage of Vitamin A Treatment protocol;
• Supplementation of Vitamin A capsule (200000 IU) to postpartum mothers through healthcare facilities and community volunteers;
• Treatment of night-blind pregnant women with low dose Vitamin A capsule (25,000 IU) through healthcare facilities (in Sunsari, Chitwan and Parsa districts only);

1.4.4    Control of Iron Deficiency Anaemia (IDA) and Postnatal  

• Increase the coverage and compliance of iron/ folate supplementation for pregnant women;
• Reduce the burden of parasitic infestations (helminths, malaria and Kalazar);
• Identify and implement food fortification to increase the dietary iron intake focusing on commercial as well as small-scale community based fortification initiatives;
• Promote dietary diversification to improve the quality of food consumed with an emphasis on bio-available iron;
• Promote maternal care practices and services to improve health and nutritional status of mother and babies;
• Identify and implement  the effective modalities to address iron deficiency in young children, adolescents and non-pregnant women of reproductive age; 

1.4.5    Deworming

• Distribute de-worming tablet to all children aged 1-5 years along with vitamin A capsule distribution;
• De-worming of pregnant women through health facilities with single dose tablet (Albendazole 400 mg) starting from 2^nd trimester (4 months) of the pregnancy;

Follow up the comprehensive deworming work plan.

 

In this section of our Internship report, we are writing objectives of the Nutrition Program and Targets of Nutrition and list out main indicators, its numerator, and denominator

1.1 Objectives of the Nutrition Program

In order to improve the overall nutritional status of children and pregnant women, the national nutrition program has set the following objectives:

1.1.1  Control of Protein Energy Malnutrition

To reduce protein-energy malnutrition in children under three years of age through a multi-sectoral approach;

1.1.2  Control of Iodine Deficiency Disorders

To eliminate iodine deficiencies disorders by the year 2010;

1.1.3  Control of Vitamin A Deficiency Disorders

To eliminate vitamin A deficiency by the year 2010;

1.1.4  Control of Anaemia

To reduce the prevalence of anemia (including iron deficiency) by one third by the year 2010;

1.1.5 Low Birth Weight

To reduce the incidence of low birth-weight to 19 percent of all births by the year 2007;

1.1.6  Protection and Promotion of Breastfeeding

To promote exclusive breastfeeding until the age of six completed months. Thereafter, introduce complementary foods along with breast milk until the child completes 2 years or more.

1.2 Targets

1.2.1 Reduce severe and moderate malnutrition among children under three years of age at 40 percent by the year 2007;

1.2.2  Reduce iron deficiency anemia in pregnant women to 58 percent by the year 2007;

1.2.3  Reduce subclinical vitamin A deficiency among children under five years of age to 19 percent by preventive measures by the year 2007;

1.2.4  Reduce nutritional blindness caused by vitamin A deficiency among pregnant women to 3 percent by the year 20071.3 Indicators

Main Indicators	Numerator and Denominator
1 Growth-monitoring coverage	Number of visits  x 100
Number of targeted visits
2 The 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 Vitamin A mass distribution  coverage	Number of children (6-59 months) who received vitamin A capsules  x 100
Target Population (6-59 months)
4  Postpartum Vitamin A coverage	Number of Postpartum women supplemented with vitamin A capsule  x 100
Total number of Expected pregnancies
5 Iron distribution coverage (women)	Number of pregnant women who receive at least some iron tablets x 100
Target population (expected pregnancies)
6 Deworming coverage	Number of children (1-5 years) receiving deworming tablets twice a year  x 100
Number of children of 1-5 years
7  Iodised salt coverage	Number of Households using adequately iodized salt (³15 ppm) x 100
Number of Households Surveyed
8 Urinary iodine excretion (UIE)	³ 100 microgram iodine per liter of urine (Median)

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 Calculated as follows: 1/3 x target population x 6 visits + 2/3 target pop. x 4 visits, where the target population is all children 0-36 months of age. This target cannot be monitored with HMIS data at the central level, but a sample survey of Nutrition Registers will provide this information.  Note: In FY 2061/62, the target for visits was to be 85 percent of children 0-36 months of age.

The target was 85 percent of expected pregnancy in FY 2061/62.

Here we are showing you some of the nutrition reports from Nepal, malnutrition and how it is a serious obstacle to child survival and overall goal.

1 BACKGROUND

Malnutrition remains a serious obstacle to child survival, growth, and development in Nepal. The most common forms are protein-energy malnutrition (PEM) and micronutrient deficiency states (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.

There is wide variation in the state of malnutrition throughout Nepal, both ecologically and regionally. Stunting is more common in the mountain areas than in the Terai, but underweight and wasting are more common in the Terai area than in the mountain areas.  There are many causes of PEM.  An important cause of PEM in Nepal is low birth weight.  Low birth weight also leads to an intergenerational cycle of malnutrition.

Iodine deficiency disorder was another most endemic problem in Nepal, especially in the western mountains and mid-hills during the 1970s. To overcome this public health problem, Government of Nepal, Ministry of Health and Population adopted a policy in 1973 to fortify all edible common salt with iodine under the ‘Universal Salt Iodization (USI) Program’. Later in 1998, the Ministry of Health and Population issued a ‘two-child logo’ for quality certification of iodized packet salt with 50 ppm iodine at the production level.

Since fiscal year (2060/61), Child Health Division decided to celebrate February as the month to create general awareness about the use of iodized salt by conducting different activities with the help of different partner agencies like UNICEF, WHO and Salt Trading Corporation Ltd. This advocacy campaign is expected to further contribute to the prevention of Iodine Deficiency Disorders (IDD).

In order to assure proper usage and storage of iodized salt at the household level, the Child Health Division is also co-ordinating with the Curriculum Development Centre under the Ministry of Education to update the current curriculum on iodine.

Micronutrient Initiative (MI), in 2005 conducted the survey to track the progress towards elimination of IDD in Nepal. Two main indicators of the IDD- urinary iodine excretion and salt iodine at the household level were assessed in the survey. The survey also explored the knowledge, attitude and behavior patterns of consumers towards procurement and consumption of iodized salt in the country. This  survey has revealed improved iodine status in Nepal as the median Urinary Iodine Excretion (UIE) among school-aged children increased from 144 micrograms/liter in 1998 to 188 microgram/liter in 2005, both of the levels being over the minimum level designated by WHO to indicate the adequacy of iodine intake i.e. 100 microgram/liter. Nepal has however yet to achieve the goal of Universal Salt Iodization, which requires that at least 90% of households should be consuming adequately iodized salt.

Vitamin A deficiency still remains to be a public health problem among school-aged children and women. Rates of night blindness increase with age in both children and women. Furthermore, rates are higher in rural areas. Among preschool children, no cases of night blindness are reported in urban areas. The highest rate of night blindness is seen in the eastern and central Terai.

Low dose vitamin A program has been piloted in Sunsari, Parsa and Chitawan to treat night blind pregnant women with 25000 IU vitamin A capsule, 4 weekly doses.

The prevalence of worm infestation in Nepal is very high. Worm infestation in children leads to decreased resistance to infection, induces malnutrition, and also, leads to anemia and also impairs cognitive function in children.

The deworming impact survey conducted in 2003/04 noted that children below the age of 2 years also are severely affected by worm infestation. Because of this and in accordance with recent WHO recommendation, the MoHP in 2004 lowered the age limit for deworming from one year to five years of age.  Therefore deworming of one to five years of age into the National biannual vitamin A supplementation is implemented in the entire country.

Similarly, de-worming of all pregnant women with a single dose of albendazole tablet after the first trimester of pregnancy in order to prevent anemia in them is being routinely practiced through all health facilities in Nepal.

Anemia caused by iron deficiency is a major public health problem in Nepal affecting all segments of the population. The prevalence of anemia was higher in preschool children (78 percent) than in pregnant women (75 percent). Moreover, astonishingly high rate of 90 percent was found in infants 6-11 months old (NMSS, 1998).

Recognizing the severe consequences of iron deficiency anemia, and its effects on health, learning capacity, productivity, and maternal and neonatal survival, Ministry of Health and Population has approved a five year Anemia Control Plan of action developed by Child Health Division, DoHS.

Iron supplementation during pregnancy has been a key health initiative in Nepal since 1980. According to the government policy, all pregnant women are supplied with an iron tablet containing 60 mg. of elemental iron, free of cost. It is provided to all pregnant women since the beginning of the second trimester of pregnancy and continued up to 45 days postpartum (225 days in total).

In order to increase coverage and compliance of iron tablets among pregnant and postnatal mothers, the Nutrition Section of the Child Health Division has been implementing the Intensification of Maternal and Neonatal Micronutrient Program (IMNMP)™ since 206061. IMNMP is operated through the existing health facilities as well as through community-based outlets like FCHVs. IMNMP is an integrated approach as it includes the promotion of antenatal check-ups, deworming during pregnancy, consumption of adequately iodized salt, postpartum vitamin A supplementation, promotion of nutritious foods and rest during pregnancy.

Phase one of IMNMP was launched in five priority districts in 2003 with support from MI. Nepali Technical Assistance Group (NTAG) was entrusted with the task of providing initial training and logistics support. Evaluation of the program has revealed a significant increase in coverage and compliance of iron tablet supplementation among pregnant and postpartum women. As for example, coverage among third trimester pregnant women rose from 47 percent at baseline at 2003 to 85 percent in 2005. Similarly, compliance increased from 28 percent at baseline to 73 percent by the end of the second year.

These achievements have resulted in the phase-wise expansion of this program to 22 districts by July 2006. The MI, UNICEF and other organizations are replicating the program in additional districts in the year 2006/2007. The DoHS has planned nationwide program implementation by on 2009-10.

Food fortification with iron is a low-cost intervention for providing iron-rich nutrients to a larger population without changing their food consumption patterns. In Nepal, the most appropriate fortification vehicle to reduce iron deficiency anemia is wheat flour.  Fortification is now underway at few flour mills.

Realizing a need for a comprehensive document on nutrition policy and strategy for generating support and effective implementation of the program, A National Nutrition Policy and Strategy was compiled and approved in a single document form in FY 2061/62. During the development of this document, several new areas like household food security, improved dietary habit, life cycle-related diseases, school health and nutrition, nutrition in exceptionally difficult circumstances and analyzing, monitoring and evaluation of nutrition situation for future activity were also identified.

School-aged children, especially in the government-run schools are also one of the vulnerable groups to suffer from PEM problems. This leads to an undernutrition situation in them and thus they suffer from PEM, vitamin ‘A’ deficiency and iron deficiency anemia. To address these issue, a ‘National School Health and Nutrition Strategy’ has also been approved by MoHP as an integral part of the comprehensive National Nutrition Policy and Strategy.

Overall goal:

Achieving nutritional well being of all people in Nepal so that they can maintain a healthy life and contribute to the socio-economic development of the country in collaboration with relevant sectors.

Achieving nutritional well being of all people in Nepal so that they can maintain a healthy life and contribute to the socio-economic development of the country in collaboration with relevant sectors.

EPI program is to reduce child morbidity, mortality, and disability associated with vaccine-preventable diseases, MMS as MiniMicroSpheres with Delivery of Services, its Indicators, analysis, and report of achievements.

Expanded Programme on Immunisation

Background:

The National Immunisation Programme (NIP) is a high priority program (P1) of the Government of Nepal.  Immunization is considered as one of the most cost-effective health interventions.  Effective implementation of the Immunization program is considered to contribute directly to the reduction of infant, child morbidity and mortality and ultimately will contribute to achieving millennium development goal.

Vaccine-preventable diseases (VPDs) are routinely reported through the HMIS and outbreak response complemented by active integrated surveillance of AFP with the support of Immunization Preventable Diseases/WHO. This includes surveillance of Measles, NT and Japanese Encephalitis.

The National immunization program covers all the 75 districts of the country. It is striving hard to have uniform high coverage in all the districts and sustain it (i.e. at least 90 percent for BCG, OPV3, DPT-Hepatitis B3, and measles vaccine in children under one year of age and 80 percent for TT2+ in pregnant women).  There are still pockets of low coverage VDCs and districts. Due to weak immunization structure coverage is low in most of the municipalities.

1.1 GOAL

The overall goal of the EPI program is to reduce child morbidity, mortality, and disability associated with vaccine-preventable diseases.

1.2 Objectives

1.2.1  Achieve and sustain immunization coverage of >90 percent in National level with >80 percent in all districts and below for all antigens.

1.2.2 Maintain a polio-free status.

1.2.3 Eliminate maternal and neonatal tetanus by 2005 and sustain the status.

1.2.4 Reduce measles mortality by 50 percent from 2003 levels and sustain the achievement.

1.2.5 Integrate the surveillance of additional VPDs into the existing surveillance system.

1.2.6 Strengthen and sustain the vaccine and logistics management system.

1.2.7 Introduce new and underused vaccines into the National Immunization Program on the basis of disease burden.

1.3 Targets

1.3.1  All infants (under one year – 12 months) for BCG, DPT-HepB, OPV, and Measles vaccines

1.3.2  All pregnant women for TT2+ vaccine

1.3.3  All 1, 2 and 3-grade students for School Immunization Programme.

The table below provides a schedule for immunizations at different ages.

Immunization Schedule

Immunization Schedule
Type of Vaccine	Number of Doses	Recommended Age
BCG	1	At birth or on the first contact
OPV	3	6, 10, and 14 weeks of age
DPT – Hep B	3	6, 10, and 14 weeks of age
Measles	1	9 months of age
TT	2	Pregnant women
JE	1	Under discussion

NIP under Child Health Division has a lead role in all immunization-related activities at the National level including coordinated actions with other Divisions of the DoHS and all other partners. The Regional Health Directorate (RHD) acts as a facilitator between the Central and the District levels.  It is the responsibility of the D(P)HO to ensure that a successful immunization program is implemented at the district level.  Primary Health Centers (PHCs), Health Posts (HPs), and Sub-Health Posts (SHPs) implement immunization programs in their Village Development Committees (VDCs)

Delivery of Services

NIP delivers the Immunization services through Routine and Supplemental Immunization Programs

1. Routine Immunization

The National Immunization Program delivers routine immunization through fixed health facilities, outreach programs, and mobile teams.

• Fixed facilities: Immunization services are provided at hospitals, primary healthcare centers, health posts, and sub-health posts.  Some health facilities equipped with refrigerators provide immunizations daily and some provide weekly.
• Outreach services: Provide access to the people who have difficulty in reaching health facilities due to long distance to travel, three to five immunization sessions a month are conducted at several locations in each VDC. The frequency of outreach services is based on village setting, population density, and seasonal variations. These sessions account for more than 90 percent of immunization coverage.
• Mobile teams:  Geographical conditions such as lack of roads and bridges hamper immunization in remote areas. Due to vacant or frequent absenteeism of health worker in remote areas, there is poor access of target population to routine immunization. These areas are identified and appropriate strategy are developed during micro-planning.  To address these issues, at least four visits to identified hard-to-reach areas by vaccinators are mandatory through mobile teams to immunize targeted population.

Though the immunization service is mainly delivered through government health network, there is an increasing trend of immunization service delivery through the private sector. This is due to the realization of Public-Private Partnership in Health Sector Reform Strategies of government. In the private sector, immunization services are delivered through private clinics, hospitals, nursing homes as well as NGOs. Government supplies all vaccines and immunization related logistics to these private institutions free of cost. All vaccine under the National Immunization Program are given free of cost or there is no cost-sharing / recovery.

1.4 Indicators

The indicators used for National Immunization program monitoring are as follows:

Main Indicators	Numerator and Denominator
1  Immunization coverage	Number of children under one year of age immunized with a specific dose of antigen
Total estimated number of children under one year of age
2 Immunization coverage for TT2+ vaccine	Number of pregnant women immunized with TT2+
Total estimated number of pregnant women
3 DPT-Hep-B drop-out rates   (DPT-HepB1 vs. DPT-HepB3)	Number of children received DPT-HepB1 – Number of children received DPT-HepB3
Number of children received DPT-HepB1
5 Measles drop-out rates (BCG vs. Measles vaccine)	Number of children received BCG – Number of children received Measles vaccine
Number of children received BCG
6  Vaccine Wastage Rate	Number of vaccine doses received – Number of vaccine doses used
Number of vaccine doses received
7 Immunization Session	Number of Immunization Session conducted in a year
Number of total immunization session planed in a year
8  AFP Surveillance	At least 2 AFP cases in 100,000 population per year
9. NT Surveillance	No or less than one NT case in 1,000 live birth per year per district

For the purpose of monitoring of the EPI activities wastage rate and morbidity due to vaccine-preventable diseases is also taken into consideration.

1.5  Strategies

The strategies to achieve the above objectives are:

1.5.1  Provide immunization services through all health facility, EPI outreach sessions; Mobile Clinics

1.5.2 Conduct supplemental immunization activities for:

– Polio eradication

– Measles and JE control

1.5.3 Expansion of School Immunization Program to sustain MNT elimination

1.5.4 Strengthen monitoring system of Immunization Program:

• VDCs wise data analysis, categorization, and prioritization for action at districts level
• Use of immunization monitoring chart
• Review of Immunization Program at a different level and feedback

1.5.5 Conduct districts level Micro-planning

1.5.6  Strengthen and expand integrated surveillance of VPDs built on AFP Surveillance (AFP, Measles, Neonatal Tetanus and Japanese encephalitis) and initiation of the study of the disease burden of other vaccine-preventable diseases like Hib and Rubella.

1.5.7 Control outbreak of VPDs through appropriate interventions;

1.5.8 Increase and promote public awareness and demand through social mobilization for immunization services and IEC/BCC interventions.

1.5.9  Strengthening of cold chain capacity in all 75 districts and ensure their functioning

1.5.10  Training to Health Workers (Mid Level Manager and Cold Chain Assistant)

1.5.11  Strengthening and expansion of AEFI surveillance

1.5.12  Strengthen supportive supervision

2  ANALYSIS OF ACHIEVEMENTS BY MAJOR ACTIVITIES

2.1       Major Activities Carried Out in FY 2062/63 (2005/2006)

The following were the major activities carried out during FY 2062/63

2.1.1       Conduction of immunization services through three to five outreach immunization sessions per Village Development Committee (VDC) per month;

2.1.2       Continuation of immunization services through health facility-based clinics located at the hospitals, PHCCs, HPs and SHPs;

2.1.3       Provided training on immunization for various levels of health workers (Mid Level Manager and Cold Chain Assistant training).

2.1.4       Expanded and continued integrated VPDs Surveillance (AFP, Measles, and NT) including JE Surveillance.

2.1.5       Initiated Hib diseases burden study

2.1.6       Conducted Responsive Mopping-up activity in 5 Terai districts of Nepal

2.1.7       Conducted Sub-National Immunization Days (SNID) for Polio Eradication Initiatives in 21 high-risk districts of Nepal (bordering with India).

2.1.8       Established Polio static booths (131 booths) on bordering districts with Bihar and UP of India in response to the supplementary immunization activities.

2.1.9       Completed districts micro-planning in 20 districts

2.1.10   Conducted performance review of immunization program at a different level

2.1.11   Developed a multi-year plan of action (2007-2011)

2.1.12   Implemented of School Immunization Activities in 8 districts

2.1.13   Developed and print Immunization Atlas of Nepal.

2.1.14   Revised, Printed and Distributed Immunization Monitoring Chart

2.1.15   Completed JE Vaccination Campaign in 6 hyperendemic districts

2.1.16   Districts NIP performance was verified through Data Quality Self Assessment in 10 districts

2.2       TARGET vs. ACHIEVEMENT, FY 2062/63 (2005/2006)

During FY 2062/63, the EPI target was to cover 90 percent of under-one-year children. However, the achievement shows that the BCG coverage was 96.1 percent, DPT3 93.0 percent, OPV3 91.9 percent and Measles 87.5 percent.  Overall coverage for all the vaccines increased in this FY compared to previous fiscal year 2061/62.

SN	Activities	Unit	Targets	Achievement	Target vs. Achievement (percent)
1	BCG vaccination	Infants	742,164	713,086	96.1
2	DPT1 vaccination	Infants	742,164	690,496	93.0
3	DPT2 vaccination	Infants	742,164	681,006	91.8
4	DPT3 vaccination	Infants	742,164	690,298	93.0
5	Hepatitis B I vaccination	Infants	742,164	655,774	88.4
6	Hepatitis B II vaccination	Infants	742,164	653,122	88.0
7	Hepatitis B III vaccination	Infants	742,164	661,584	89.1
8	Polio1 vaccination	Infants	742,164	684,053	92.2
9	Polio2 vaccination	Infants	742,164	675,059	91.0
10	Polio3 vaccination	Infants	742,164	682,401	91.9
11	Measles vaccination	Infants	742,164	649,390	87.5
12	TT2 vaccination	Pregnant women	941,890	482,841	51.3
13	Polio Responsive Mopping-up activity €“ I Round	Under 5 yrs Children	475,617	471,460	99.1
14	Polio Responsive Mopping-up activity €“ II Round	Under 5 yrs Children	475,617	476,586	100.2
15	Polio Responsive Mopping-up activity €“ III Round	Under 5 yrs Children	475,617	482,922	101.5
16	Polio SNID in 15 Districts €“ I Round	Under 5 yrs Children	1,796,760	1,756,422	97.8
17	Polio SNID in 15 Districts €“ II Round	Under 5 yrs Children	1,796,760	1,770,453	98.5
18	Polio SNID in 6 Districts €“ I Round	Under 5 yrs Children	597,683	554,452	92.8
19	Polio SNID in 6 Districts €“ II Round	Under 5 yrs Children	597,683	546,951	91.5

Source: HMIS/MD and EPI/CHD, DoHS

Analysis of the reports from all 75 districts of the country for FY 2062/63 shows that overall coverage level for BCG vaccination is 96.1 percent, measles vaccination is 87.5 percent, DPT3 93.0 percent, OPV3 91.9 percent and Tetanus Toxoid (TT2) is 51.3 percent.  However, coverage for all antigens are not uniform among the districts and within the VDCs of the districts, some of the districts achieving more than 100 percent coverage, and others are far behind.

2.3       ANALYSIS OF SERVICE STATISTICS

The table 2a.1 and figure 2a.1 present the annual immunization coverage of BCG, DPT, OPV, and measles vaccine in Nepal from FY 2060/61 to 2062/63.  The figures are expressed in percentage of the targeted population for each fiscal year.  It has been observed that the coverage of all antigens increased in FY 2062/63 compared to FY 2061/62.

Table 2a.1       Annual Immunisation Coverage in Nepal, FY 2060/61 to 2062/63

Year	BCG	DPT3	OPV3	Measles
2060/61            2003/2004	96.3%	90.3%	90.2%	85.4%
2061/62            2004/2005	92.4%	80.0%	83.0%	79.3%
2062/63          2005/2006	96.1%	93.0%	91.9%	87.5%

Source: HMIS/MD, DoHS

Based on DPT3 coverage and DPT1 vs. DPT3 dropout rates, categorizations of the districts as per their performance are shown in the District Categorized table.  Districts under category 4, 3 and 2 respectively are the most concerned for NIP to address their access and utilization problem. Activities carried out to address the problems were to revise immunization session through micro-planning, to trace missed children for successive doses, to mobilize FCHVs and involve community leaders. Districts under category 1 were continuously monitored for sustaining their achievements.

Table 2a.2       Immunisation Coverage (Percent), by Region, FY 2060/61 to 2062/63

Indicators	Year	Region	National   Total
EDR	CDR	WDR	MWDR	FWDR
BCG (<1 year)   Coverage	2060/61      2003/04	97.3	106.1	88.5	92.9	85.0	96.3
2061/62      2004/05	94.3	102.5	86.1	86.3	79.7	92.4
2062/63      2005/06	97.3	103.5	87.6	96.9	86.7	96.1
DPT3 (<1 year)   Coverage	2060/61      2003/04	94.0	97.5	85.5	85.3	77.5	90.3
2061/62      2004/05	82.6	83.2	80.9	73.8	72.8	80.0
2062/63      2005/06	95.8	98.0	84.4	96.1	84.8	93.0
Polio3 (<1 year)   Coverage	2060/61      2003/04	93.5	97.7	85.4	85.8	77.3	90.2
2061/62      2004/05	87.9	87.1	81.0	77.2	73.4	83.0
2062/63      2005/06	94.5	96.1	84.4	95.3	84.5	91.9
Measles (<1 year)   Coverage	2060/61      2003/04	87.7	89.9	81.5	84.5	76.4	85.4
2061/62      2004/05	84.4	81.2	77.4	76.3	71.2	79.3
2062/63      2005/06	89.6	91.1	80.0	91.6	81.1	87.5
TT2 Coverage   (Pregnant women)	2060/61      2003/04	45.8	44.2	40.0	36.8	39.9	42.3
2061/62      2004/05	50.9	45.0	43.1	41.0	39.1	44.9
2062/63      2004/05	56.4	49.4	49.2	52.3	48.1	51.3

Source: HMIS/MD, DoHS

Figure 2a.2 shows the trend in coverage of Measles vaccine for last 3 FYs. The coverage has increased in all the regions in FY 2062/63 with highest coverage (91.6 percent) being in MWDR and lowest (80.0 percent) in WDR. The national coverage of Measles vaccination is increased by 8.2 percent in FY 2062/63 as compared to FY 2061/62.

Figure 2a.4 shows the DPT1 vs. DPT3 dropout rate by region.  The drop out rate stands between -2.1 to 1.6 percent in FY 2062/63 with the highest rate in CDR (1.6 percent) and lowest in EDR (-2.1 percent). The national figure for the DPT1 vs DPT3 dropout rate stands at 0.0 percent in the FY 2062/63, which is a significant achievement of the NIP program of Nepal. As shown in figure 2a.3, the national coverage for TT2 vaccination in pregnant women was 44.9 percent in 2061/62. However, in FY 2062/63 the TT2 coverage increased by 6.4 percent points at the National level (51.3 percent). The percentage of pregnant women immunized with TT2 vaccine increased in all the region in the FY 2062/63.  The coverage was highest in EDR (56.4 percent) and lowest in FWDR (48.1 percent).

The Vaccine Wastage Rate (figure 2a.6) of all antigens has been observed as follows in FY 2062/63: BCG 74.8 percent, DPT 21.3 percent, Polio 24.7 percent and Measles 59.4 percent. The wastage rate of vaccines, especially BCG & Measles compared to normally accepted rate is still a challenge. Figure 2a.5 shows the BCG vs. Measles dropout rate. It has decreased from 14.2 percent in FY 2061/62 to 8.9 percent in FY 2062/63 at National level.  The highest dropout rate was observed in the CDR with 12.0 percent and lowest in MWDR 5.5 percent.  There is a trend of improvement in the dropout rate in general.

According to figure 2a.7, the lowest number of BCG vaccination was observed during the month of Chaitra.  The month-wise BCG vaccination trend is seen to be considerably better in FY 2062/63 compared to FY 2060/61 and FY 2061/62.

2.4.1    National Immunisation Days (NIDs) for Polio Eradication2.4       SUPPLEMENTARY IMMunization activities

To eradicate poliomyelitis, EPI continued to implement a program of “Intensified National Immunization Days” (INID) in two rounds from 2053/54 to FY 2060/61.  In the first year NIDs were conducted successfully in two rounds in 2053/54 (on 6 December 1996 and 17 January 1997).  Consecutively every year two rounds of NIDs were being conducted.  Besides, Sub-National Immunization Days, Pre-emptive Mopping-up and Responsive Mopping-up Activities in high-risk districts mainly districts bordering with India and Kathmandu Valley were also conducted.  Intensified National Immunisation Days were not implemented during FY 2061/62 and 2062/63.

Nepal has not detected any poliomyelitis case caused by wild poliovirus for the last four years (the year 2001 to 2004) most probably because of high NID coverage of around 100 percent (see above figures). But in the FY 2061/62, four polio cases were detected in Sarlahi and Rautahat district which were imported from India one polio case was detected in 2062/2063 in Dailekh district of Nepal. Acute Flaccid Paralysis (AFP) Surveillance, is becoming a major activity in the eradication of polio from the country. Nepal has expanded active surveillance of polio to neonatal tetanus and measles from FY 2060/61 through the AFP-surveillance site and in FY 2061/62 JE surveillance was also integrated with VPDs surveillance.

2.4.2    Measles Campaign to Control Measles in Nepal

It was estimated that every year some 150,000 children are infected with measles and some 2,700 die due to its consequences. To prevent this huge amount of deaths and measles cases, Nepal conducted a successful campaign throughout the Kingdom aiming to reduce 50 percent of child mortality due to measles complications.  The success of this campaign created history in the field of public health by immunizing about 10 million children. The Measles Campaign was conducted in a phase-wise manner and the coverage of measles through the campaign was very satisfactory in the year 2004 and 2005.  Good social mobilization, active local participation, and assistance from various partner agencies contributed to the success of NIDs, Measles campaign and MNTE activities.  The result of this campaign is very encouraging in terms of reduction of measles outbreaks and children affected. However, to sustain this status is a challenge and to overcome this situation, initiatives like increasing coverage above and around 80 percent be reached through routine immunization strategies. Hence, RED strategies have been incorporated in the multi-year plan of action 2007-2011, which clearly states the activity to strengthen routine immunization.

Table Showing Effect of Measles Campaign:

Indicators	2004	2005	2006
Measles outbreaks (Lab confirmed)	138	1
Children affected	6,050	12

Note: Data as of 05 December 2005 (through active surveillance)                                                                              Source: WHO/IPD

2.5       INTRODUCTION OF HEPATITIS B VACCINE

Introduction of Hepatitis B in the routine immunization program was done in all 75 districts by FY 2061/62.  From the FY 2062/63 DPT-HepB (Combo Vaccine) vaccine has replaced the DPT vaccine in all Districts of Nepal.

3          PROBLEMS/CONSTRAINTS AND ACTIONS TO BE TAKEN

Problems/Constraints	Action was taken	Responsibility
Denominator problem	Local Health facility will generate their denominator using local resources like FCHVs and compare with given denominator. The district will validate the denominator of each health facility	HMIS, CHD, DHO and local health facility
Some of the newly supplied freezes and unfreezes to districts and sub-center are not functioning	LMD, RMS with the assistance of CHD and partners will assess and fix the problem of freezes.	LMD/CHD
The problem for regular cold chain maintenance   No trained manpower for repairing the nonfunctioning cold chain equipment at regional/ District level No contingency plan for cold chain	The technician at center, region, and CCA of the district should be trained for general maintenance of freezes. Preventive Maintenance Plan for the regular repair of cold chain equipment is prepared Manual for the repair of €œavailable freezes” be prepared and placed to DHO. Contingency Plan for cold chain management is prepared at Central, Regional and District cold room.	CHD/ LMD/DHO
Delayed procurement of vaccine   Irregular and short supply vaccine	Vaccine forecasting and procurement should be done timely. A standard POA will be developed and adopted for timely procurement of vaccines to avert shortfall of the vaccine. All level stores should have clear vaccine requirement and distribution plan and must ensure its implementation.	LMD/CHD
Some of the VHWs are old and disable, cannot conduct the EPI session.	Districts should manage alternatives in the local context (MCHW/ VHW whoever is in place could run immunization) EPI session at health facility level should be conducted by health manpower available in HF (HFI, AHW, ANM, VHW, MCHW)	CHD/ DHO and Health facility
Immunization in municipalities is weak No sanctioned post of VHW/MCHW at Municipality. No organized immunization service delivery structure. CHD and local development ministry will find out means to develop a model of immunization services of municipalities and will adopt timely. Develop a strategy to set up urban EPI clinics A detailed micro-planning involving municipalities, district health office, and all NGOs/INGOs should be conducted Districts can better utilize vaccinators through local NGOs INGOs for local management.		MoHP/ CHD/LMD.
Coverage to hard to reach the population	IDENTIFY THE UNDERSERVED or missed children   Use maps Aim for greatest numbers of un / partially -immunized children, not just low coverage rates Prioritize Ensure micro-plans are in place and work plans are being implemented Follow up and supervision	The health facility, DHO/PHO/ CHD
There is no clear guideline to send HA, SAHW, Staff Nurse for EPI outreach clinics	As per strategic guideline, HA/ AHW / staff nurse/ANM should conduct immunization session in the absence of VHWs /MCHWs. This should be addressed during micro-planning at the local level and managed at the district level.	CHD/DoHS
Regular monitoring of immunization program using developed monitoring tools and quality information collection on immunization	Timely, report collection will be reinforced and follow up will be done on immunization coverage drop out and surveillance of VPDs EPI supervisors and health facility in-charge should monitor and supervise to verify the information and avoid inconsistency.	Health facility in-charge /District EPI Supervisors /DHO/DPHO
Injection safety in immunization   And AEFI surveillance	Collection of injection sharp will be in safety boxes and disposal will be done by burning and buried at health facility level Low-cost incinerator construction at HF level will be encouraged below districts AEFI surveillance will be expanded from 31 sentinel sites to 51 sites. The health worker will be encouraged to report each and every AEFIs and investigate major one and use the result for improvement of the program	DHOs/ RHDs/ CHD
Social mobilization, community participation, and local ownership	District level and health facility level performance, weakness and strength should be shared with community, NGOs, INGOs and plan to work together to achieve the target	DHO and Local Health facility
Quality of review at a different level and micro-planning and data quality self-assessment	Review of access and utilization of immunization services at Centre, region, district and health facility level, comparing with RCS, LQAS and DQSA findings. Micro planning at district headquarters or at the health facility level	CHD/RHD, DHO and HF management committee.
Vaccine management at a different level is poor leading to irregularity in session conduction and increase in vaccine wastage	Appropriate vaccine and logistic requirement and distribution plan at each level and ensure its implementation	DHO/LMD/CHD
BCC activities to increase demand for immunization	Community mobilization Involvement School teacher and student Use of electronic media	NHEICC/ CHD
Weak supportive supervision	Planned supervision with checklist and follow-up	All levels
Training manuals need to be revised as per the present context	Adaptation of immunization in practice in Nepali Health worker manual and cold chain manual needs to be revised	CHD

4          TARGETS FOR FY 2063/64 (2006/2007)

S.N.	Activities	Unit	Annual Targets
1	Routine Immunisation activities aiming for higher coverage	Children <1 year	747,567
2	TT2+ Immunisation for all pregnant women	Pregnant women	961,241

Source:  EPI/CHD, DoHS

Note:    For detailed, district-specific data and analysis on this program/project, please refer to the relevant annexes in this document.

This is an example of the Table of content for making health sector project. While writing the report how we perform the internship this is one example for the health sector in the college.

Executive Summary. ……..	1
Health Service Coverage Fact Sheet	9
Introduction and Policy Background
1a	Introduction ……	11
1b	National Policies and Plans ……….	13
Child Health
2a	Expanded Programme on Immunization ……..	26
2b	Nutrition ………	40
2c	Control of Diarrhoeal Diseases………….	54
2d	Control of Acute Respiratory Infection ………	66
Family Health
3a	Family Planning ……..	76
3b	Safe Motherhood and Newborn Health …..	92
3c	FCHV Programme …….	109
3d	Primary Health Care Outreach ………..	115
3e	Demography and RH Research…..	121
Disease Control
4a	Malaria Control ……	124
4b	Kala-azar Control……….	131
4c	Japanese Encephalitis…	135
4d	Lymphatic Filariasis……	139
4e	Tuberculosis Control…..	142
4f	Leprosy Control ….	162
4g	AIDS and STD Control.	173
Curative Services
5	Out/In-Patient Care…….	184
Supporting Programmes
6a	National Health Training ….	199
6b	Health Education, Information and Communication……..	213
6c	Logistics Management…	225
6d	Community Drug Program……………………………………………….	233
6e	Laboratory Services……	239
6f	Administrative Management……………………………………………	251
6g	Financial Management.	255
6h	Management………………	261
Development Partners
7a	Multilateral Partners……	271
7b	Bilateral Partners…………	285
7c	International Non-Governmental Organisations……………..	309
7d	National Non-Governmental Organisations…………………….	339
Other Departments
8a	Department of Drug Administration………………………………..	381
8b	Department of Ayurveda…………………………………………………	385
8c	Pashupati Homoeopathic Hospital………………………………….	391
Annexure
I	Target Populations and Health Facilities………………………….	394
II	Health Institution: Reporting Status………………………………..	396
III	Raw Data, Rates, and Ratios, by Programme, District, Ecological Zone,   Development Region and Hospital-based Data………………	401
IV	Acronyms……………………	459

Child Health Programme

2a        Expanded Programme on Immunization…………….. 26

2b        Nutrition….. 40

2c        Control of Diarrhoeal Diseases…………………………. 54

2d        Control of Acute Respiratory Infection……………… 66

Family Health Programme

3a        Family Planning……………………………………………… 76

3b        Safe Motherhood and Newborn Health……………… 92

3c        FCHV Programme………………………………………… 109

3d        Primary Health Care Outreach………………………… 115

3e        Demography and RH Research……………………….. 121

Disease Control

4a        Malaria Control…………………………………………….. 124

4b        Kala-azar Control…………………………………………. 131

4c        Japanese Encephalitis Control………………………… 135

4d        Lymphatic Filariasis………………………………………. 139

4e        Tuberculosis Control…………………………………….. 142

4f         Leprosy Control……………………………………………. 162

4g        AIDS and STD Control………………………………….. 173

5          Out/In-Patient Care (including central hospitals)… 184

Supporting Programmes

6a        National Health Training………………………………… 199

6b        Health Education, Information and Communication………………………………………………… 213

6c        Logistics Management…………………………………… 225

6d        Community Drug Programme…………………………. 233

6e        Laboratory Services………………………………………. 239

6f         Administrative Management…………………………… 251

6g        Financial Management…………………………………… 255

6h        Management………………………………………………… 261

Development Partners

7a        Multilateral Partners

UNFPA….. 271

WHO…….. 275

The World Bank…………………………………………… 279

UNICEF…. 282

7b        Bilateral Partners

USAID…… 285

GTZ/HSSP 289

KfW……… 293

DFID…….. 297

SDC/RHDP………………………………………………….. 299

NFHP…….. 302

CECI……… 306

7c        International Non-Governmental Organisations

UMN…….. 309

Save the Children US…………………………………….. 316

MSI/SPN… 322

BNMT…… 328

INRUD….. 332

CEDPA….. 334

FHI……….. 337

7d        National Non-Governmental Organisations

FPAN…….. 339

Mothers Club……………………………………………….. 353

CRS Company……………………………………………… 356

Nepal Red Cross…………………………………………… 361

NTAG……. 364

NIIP………. 367

ADRA…… 371

CARE Nepal……….. 374

Other Departments

8a        Department of Drug Administration………………… 381

8b        Department of Ayurveda……………………………….. 385

8c        Pashupati Homoeopathic Hospital…………………… 391

Annexure

I           Target Population………………………………………….. 394

II          Health Institutions: Reporting Status………………… 396

III        Raw Data, Rate, and Ratio, by Programme, District, Ecological Zone,

Development Region and Hospital-based Data….. 401

IV        Acronyms. 459