The easiest way to remove the lines in the PHP files or in HTML files, aspx files cold fusion file, JSP file from the Dreamweaver. Likewise, we can remove the static page space like of the HTML, XSLT, CSS, XML, Javascript, XML and other as follows:
Open the file
Click CTRL + F
Select “Current document” in “Find in” (You can also select the folder if you have multiple files)
Search in “Source code”
Tick “Use regular expression”
Type “[rn]{2,}” (without quotes) in “Find”
Type “n” (without quotes) in “Replace”
Press “Replace All”
We can also replace the multiple line breaks through coding the coding is as below:
<?php
$base = array("f:/www/docs/files/");
while (!empty($base)) {
$next = array_pop($base);
foreach (glob($next . '*.php') as $item) {
if (!is_dir($item)) {
file_put_contents($item, preg_replace(array("#^s*r?n+#s", "#s*r?n+$#s", "#s*r?n+#s"), array("", "", "rn"), file_get_contents($item)));
} else {
$base[] = $item . '/';
}
}
}
echo "Removing extra lines is done";
?>
These are the two methods by which we can remove the extra lines.
This is final year report example on E-shopping, E-commerce with affiliation which details about the page title, declaration of the report, Acknowledgement, table of contents, and executive summary.
Final Year Report on E-shopping
named Rupjaygri Shop
By:
Rupak Nepali
P.U. Reg. No: #####, Roll. No: #####
Jayman Tamang
P.U. Reg. No: #####, Roll. No: ####
Grishma Shah
P.U. Reg. No: #####, Roll. No: ####
Final Year Project Report
Submitted To:
Nobel College
Faculty of management
Pokhara University
In partial fulfillment of the requirements for the degree of
Bachelor of Computer Information System (BCIS)
Kathmandu
November 2010
—————————————————————————–
Pokhara University
Faculty of Management
Nobel College
DECLARATION
We hereby declare that the work reported in this project work on E-shopping named Rupjaygri Shop submitted to Nobel College, Pokhara University is our original work done in the form of partial requirement for the degree of Bachelor of Computer Information System (BCIS) under the supervision of Mr. Surendra Shrestha Principal, Nobel College, and Mr. Dipesh Shrestha, Coordinator, Nobel College, Mr Sanjay Lama Project-Coordinator and Mr. Nimesh Shrestha Lecturer, Nobel College.
Grishma Sharma JaymanTamang Rupak Nepali
——————————————————–
Faculty of Management Studies
PokharaUniversity
RECOMMENDATION
This is to certify that the final year report:
Submitted by:
Rupak Nepali
Jayman Tamang
Grishma Sharma
Entitled
E-Shopping named Rupjaygri Shop has been prepared as approved by this college. This internship report is forwarded for examination.
——————————— ——————-
Principal Coordinator/Lecturer
Nobel College
Date: June 14, 2010
——————————————————————————
Acknowledgment
This report has been prepared for the Final Year Project on topic E-shopping named Rupjaygri Shop to implement the theory in the real field with the purpose of fulfilling the requirements of the course of BCIS (Bachelor of Computer Information System).
The aim of this project is to make familiar to the practical aspect and uses of theoretical knowledge and clarifying the career goals, so we have successfully completed the project and compiled this report as the summary and the conclusion that we have drawn from the project.
We would like to express our sincere gratitude to our Project Coordinator Mr. Sanjay Lama who had given his valuable time and given us chance to learn something despite having his busy schedule, Principal Mr. Surendra Shrestha and Coordinator Mr. Dipesh Shrestha for their great guidelines.
Lastly, we would like to thank Mr. Nimesh Shrestha who had provided us with the guidance and his easiest MVC framework and for his encouragement, patience and expert advice and also for supplying so much invaluable information and finally special thanks go to my friends and family who have supported us throughout our project.
——————————————————–
Table of Contents
SN
Contents
Page No
a.
Title Page
i
b.
Declaration
ii
c.
Recommendation
iii
d
Acknowledgment
iv
e.
Table of Contents
v
f.
List of Figures
vii
g.
Executive Summary
ix
h.
Chapters
Introduction 1.1. Background of Study 1.2. Objectives of the Study 1.3. Limitations of the Study 1.4. Selection Methods of Data Collection Report Body 2.1. Introduction of the D.P Sign 2.2. Corporate Goal of the D.P Sign 2.3. Mission Statement of the D.P Sign 2.4. D.P Sign™s Spirit is infused into every component
2.5. Services 2.5.1. Web-Based Application Design and Development 2.5.2. Flex printing and other printing services 2.5.3. Custom Software Solutions 2.5.4. Embedded Software Solutions 2.5.5. Online Earning Training
2.6. Engagement Models 2.6.1. Fixed Price Turnkey Model 2.6.2. Per Resource Model 2.6.3. Offshore Model
2.7. Delivery Model 2.8. Process and Standards 2.9. Domain Profile 2.10. Competitive Advantage of DP Sign 2.11. Physical Infrastructure 2.12. Organizational Hierarchy Chart 2.13. The number of employees 2.14. Introduction of Departments We have worked at 2.15. Major Clients 2.16. Business Volume 2.17. Products Offered by DP Sign 2.18. Time Frame of Internship Analysis
3.1. Strategic Business Units 3.1.1 Web Development Department Analysis 3.1.2 Online Earning Department Analysis 3.1.3 PEST Analysis 3.1.4 SWOT Analysis
4 Recommendations 5 Summary and Conclusion 6 Program Workplace Relationship
1 1 1 1 2 3 3 4 4 4 5
5 5 5 5 5 6 6
6 6 7 7
11 13 14 15 16 16 20 20 21 22 23 23 23
24 25 26 28 29
30
i.
Bibliography
j.
Appendices
List of Figures
SN
Name of Figure
Page No.
Fig:2.1
Organization Structure
13
Fig:2.2
The business volume of DP Sign
19
Fig:2.3
Timeframe representation in Gantt chart
22
List of Tables
SN
Name of Table
Page No.
Tab:2.1
System unit and its Software
11
Tab:2.2
List of technology with the platform
Tab:2.3
Number of employees
Tab:2.4
Collection of Pay Per Click sites
Tab:2.5
List of major clients
Tab:2.6
Printing product of DP Sign
Tab:2.7
Web services providing by DP Sign
ABBREVIATION USED
DP Sign
Digital Printed Sign
CRM
Customer Relation Management
IT
Information Technology
QA
Quality Assurance
CMS
Content Management System
SWOT
Strength, Weakness, Opportunity, and Threats
PEST
Political, Economical, Social and Technological
RFQ
Request For Quotation
RFP
Request For Proposal
GIS
Geographic Information System
PMBOK
Project Management Body of Knowledge
PMI
Project Management Institute
CMMI
Capability Maturity Model Integration
ISO
International Organization for Standardization
ODC
Offshore Development Center
IP
Internet Protocol
CVS
Current Version Software
TFS
Team Foundation Server
EXECUTIVE SUMMARY
The main objective of this report is to recapitulate our Final Year Project on E-shopping named Rupjaygri Shop and to be familiar with the practical aspect of the theoretical knowledge gained in a classroom. This report is the part of the final year project, required by Pokhara University in partial fulfillment for the requirement of BCIS program.
We (Rupak Nepali, Jayman Tamang, and Grishma Sharma) feel that Nepal is progressing in the ICT field thus the import and export of this country are mounting with the help of e-commerce and e-businesses. Thus, there is a need for shopping software so that people can broaden their business worldwide.
In this post, we are defining ActiveX Classes, Category Common classes, Database Classes, Client-Side Classes, SDI and MDI Applications, Document/View Architecture, Message Maps and provide some self-check questions.
ActiveX Classes
MFC provides classes that simplify the process of adding ActiveX capabilities to your applications and significantly reduce development time. The ActiveX classes work with the other application framework classes to provide easy access to the ActiveX API. Using the ActiveX classes, you can:
Create ActiveX controls and ActiveX control containers.
Use Automation to control one program with another.
Create compound documents, which enable users to create and edit documents containing various types of data, including text, graphics, spreadsheets, and sound. These various data objects can be created by different applications.
Create OLE objects that can be embedded in compound documents.
Use drag-and-drop to copy data between applications.
Note This course does not cover creating ActiveX components. For information about how to create and modify ActiveX components using MFC, see Mastering MFC Development Using Visual C++ 5, listed in the Library.
To see an illustration that shows the ActiveX and OLE classes within the MFC object hierarchy, click this icon.
ActiveX classes can be divided into the categories shown in the following table.
Category Common classes
ActiveX control classes COleControlModule, COleControl, CConnectionPoint, CPictureHolder, CFontHolder, COlePropertyPage, CPropExchange, CMonikerFile, CAsyncMonikerFile, CDataPathProperty, CCachedDataPathProperty, COleCmdUI, COleSafeArray Active Document classes CDocObjectServer, CDocObjectServerItem ActiveX-related classes COleObjectFactory, COleMessageFilter, COleStreamFile, CRectTracker Automation classes COleDispatchDriver, COleDispatchException Container classes COleDocument, COleLinkingDoc, CDocItem, COleClientItem OLE server classes COleServerDoc OLE drag-and-drop and data transfer classes COleDropSource, COleDataSource, COleDropTarget, COleDataObject OLE common dialog classes COleDialog, COleInsertDialog, COlePasteSpecialDialog, COleLinksDialog, COleChangeIconDialog, COleConvertDialog, COlePropertiesDialog, COleUpdateDialog, COleChangeSourceDialog, COleBusyDialog
Database Classes
Accessing data and connecting to databases are two of the most common Windows environment programming tasks. MFC provides classes that enable operations on databases through Open Database Connectivity (ODBC) and the data access objects (DAO). To see an illustration that shows the database classes within the MFC object hierarchy, click this icon.
Note This course does not cover creating database applications. For information about how to create database applications using MFC, see Mastering MFC Development Using Visual C++ 5 listed in the Library.
CDatabase and CDaoDatabase A CDatabase or CDaoDatabase object represents a connection to a data source through which you can operate on the data source. A data source is a specific instance of data that is hosted by a database. CRecordset and CDaoRecordset A CRecordset or CDaoRecordset object represents a set of records selected from a data source. Known as recordsets, CRecordset and CDaoRecordset objects are available in two forms: Dyna-sets and snapshots. A Dyna-set is a dynamic recordset that stays synchronized with updates by other users. A snapshot is a static recordset that reflects the state of the database at the time the recordset is requested. CDaoRecordset also can directly represent a table in a database. ï‚®Internet Classes
Creating applications that interact with the Internet, intranets, or both, is becoming a major focus for developers. MFC includes the WinInet APIs and the Internet Server API (ISAPI), which provide classes for client-side and server-side applications, respectively. To see an illustration that shows the Internet classes within the MFC object hierarchy, click this icon.
Note This course does not cover creating Internet applications. For information about creating Internet applications using MFC, see Mastering MFC Development Using Visual C++ 5, listed in the Library.
Client-Side Classes
This table describes MFC Internet classes related to client-side applications.
Class Description
CInternetSession Creates and initializes one or more simultaneous Internet sessions. Specific application-level services can be established by using the member functions GetHttpConnection, GetFtpConnection, and GetGopherConnection. CHttpConnection Manages an application’s connection to an HTTP server. CFtpConnection Manages an application’s FTP connection and provides for member functions that enable you to create applications that explore remote directories, retrieve files, and otherwise manage remote file systems. CGopherConnection Manages an application’s Gopher connection and enables the application to search for and retrieve various types of documents. CFileFind This class, the base class for CFtpFileFind and CGopherFileFind, supports searching, locating, and returning information about found files. All these classes support wildcard searches.
Server-Side Classes
This table describes MFC Internet classes related to server-side applications.
Class Description
CHttpServer Use this class to create and manage a server extension DLL, also known as an Internet server application (ISA). ISAs are used to extend an Internet server’s capabilities. CHttpServerContext Used by CHttpServer to encapsulate the instance of a single client-side request. CHttpFilter Use this class to create a DLL to filter incoming and outgoing client data. CHttpFilterContext Used by CHttpFilter to encapsulate the instance of a single notification for a single client. CHtmlStream Encapsulates an HTML data buffer to be used by a CHttpServer to respond to the client.
Global Afx Functions
MFC provides some functions that are not members of classes. These are global functions whose names begin with Afx. Class member functions can only be called in the context of the class to which they belong, but Afx functions are available to all classes and functions in an application. The following table lists some commonly used Afx functions and describes the tasks they perform.
Function Description
AfxAbort() Unconditionally terminates an application. AfxMessageBox() Displays a Windows message box. AfxGetApp() Returns a pointer to the project’s CWinApp object. AfxGetAppName() Returns a pointer to a string containing the application name. AfxGetMainWnd() Returns a pointer to the main frame window. AfxGetInstanceHandle() Returns a handle (HINSTANCE) to the current instance of the application.
Documents, Views, and the Application Framework
MFC provides an application framework on which you can build applications for Windows. The framework provides a set of starter files for an application and supplies standard user-interface features that you can implement in your application. You provide the rest of the code, specifically those things needed for your application. Your work with the framework is based largely on a few major MFC classes and several Visual C++ tools. Some of the classes encapsulate the Win32 API. Other classes encapsulate application objects such as documents, views, and the application itself. Still, others encapsulate ActiveX, database, and Internet features. This section presents an overview of the application framework, the major objects that make up your application and how they are created, and a brief look at how messages are handled in the MFC environment. This section includes the following topics:
Document/View Architecture
The MFC document/view architecture provides a single, consistent way of coordinating application data, referred to as a document, and views of that data. A document is a data object with which the user interacts in an editing session. A view is a window object through which the user interacts with the document. This topic provides a broad overview of document/view architecture. For detailed information, see Chapter 4: Creating MFC Applications.
Document/view architecture is important because applications that use documents and views derive the greatest benefit from the application framework. You can write MFC applications without using documents and views; however, to get the most out of the framework and take advantage of advanced MFC features, you must use document/view architecture. For more information about non-document/view architecture, see Writing Applications in Non-Document/View in Chapter 4: Creating MFC Applications.
To see an illustration that shows how a single set of data can be viewed or displayed in more than one way by a document/view application, click this icon.
As shown in the previous illustration, Microsoft Graph is a good example of an application that separates the data from the interface. The user can select a set of values from the data in a spreadsheet view, and then display the same information as a bar chart or a three-dimensional bar chart. If the user changes values or changes the range of data that is selected in the spreadsheet view, the chart view is updated. The application can also present two views of the same type; changes made in one view would also appear in the other. To see a demonstration that shows how the Microsoft Excel application uses document/view architecture, click this icon.
SDI and MDI Applications
MFC makes it easy to work with both single document interface (SDI) and multiple document interface (MDI) applications. SDI applications allow only one document frame window at a time. MDI applications allow multiple document frame windows to be open in the same instance of an application. An MDI application has a window within which the user can open multiple MDI child windows that are themselves frame windows, each containing a separate document. In some applications, the child windows can be of different types, such as chart-windows and spreadsheet windows. In that case, the menu bar can change as MDI child windows of different types are activated.
Note Under Windows 95, applications will increasingly be SDI as the operating system moves toward a “document-centered” view. This course teaches you how to create SDI applications using MFC. For information about how to create MDI applications, see Mastering MFC Development Using Visual C++ 5 listed in the Library.
Objects in an SDI Application
Document/view architecture provides the framework for documents and views in the base classes CDocument and CView. The CWinApp, CFrameWnd, and CDocTemplate classes work in conjunction with CDocument and CView to ensure that all the pieces of the application fit together. You will learn more about how to implement these classes in an application in later chapters. The following table lists the application objects and related classes in an SDI application and describes the major tasks each object performs. Object Description
Document Your document class (derived from CDocument) specifies your application’s data.
View Your view class (derived from CView) is the user’s window to the data. The view class specifies how the user sees your document’s data and interacts with it.
Frame window Views are displayed inside document frame windows using the CFrameWnd class. In an SDI application, the document frame window is also the mainframe window for the application.
Document template A document template orchestrates the creation of documents, views, and frame windows. A particular document-template class (derived from CDocTemplate) creates and manages all open documents of one type. Use class CSingleDocTemplate for SDI applications.
Application Your application class (derived from CWinApp) controls all of the objects above and specifies the application’s behavior such as initialization and cleanup.
In an SDI application, each document template creates and manages one document. The user views and manipulates a document through a view contained inside a frame window. The application objects cooperatively respond to user actions, bound together by commands and other messages. The following illustration shows the relationship between the document/view objects in a running SDI application.
Non-Document/View Architecture
Although most of the discussion about Visual C++ and MFC functionality assumes the use of the document/view architecture, this is not a requirement. The benefits associated with document/view architecture also carry with them potentially significant performance and size costs. In some cases, document/view may not be the right choice for your application. For example, applications that compress files may need only a dialog box that requests file names and displays a progress bar. The mainframe window and a view are not needed; document/view architecture would provide little, if any, benefit in this instance. For another example, consider an application that provides a single database recordset to a simple database browser. The document/view architecture could be used, but it may be more effective for the view (the browser) to hold the recordset directly. Remember that an MFC application consists of a number of objects that you can combine in many ways to create a program solution. Some possible combinations in a non-document/view application include:
A CWinApp object and a modal dialog box. In such applications, the dialog box is responsible for storing and displaying data.
A CWinApp object, the mainframe (CFrameWnd) window, and a view. In such applications, the view usually is located where any data is stored and displayed.
Regardless of the combination you choose, the non-document/view application usually begins with the override of the CWinApp:: InitInstance function. At this point, the main window, either a dialog box or other window, is created.
Messages
Communication between the operating system, applications, and application components is conducted through various types of messages. For example, when creating an instance of an application, the operating system sends a series of messages to the application, which then responds appropriately to initialize itself. Keyboard and mouse activity causes the operating system to generate messages and send them to the proper application. User-interface components, such as command buttons and list boxes, generate messages to their parent windows. There are many types of messages; two of the most important are standard Windows messages and command messages. The MFC architecture supports Windows messages through the CWnd class and its derived classes, such as CView and CFrameWnd. MFC supports command messages through any of the classes derived from the CCmdTarget class. A command message originates from a menu item, command button, or accelerator key. In Chapter 6: Handling Messages, you will learn how to handle Windows and command messages in MFC applications.
Message Maps
Before you start writing MFC applications, it is important to understand how MFC maps messages to the functions that will handle the messages. The application framework implements the message map data structure, which provides the link between the message ID and the function that will handle the message. Each entry consists of a message-specific macro. Standard Windows messages all have predefined macros containing an implicit ID and handler name. Command message macros contain an explicit ID and handler name. Below is an example of a message map for the CMyView class with two entries. Note that the base class is included to allow the framework to continue searching for a given handler if one does not exist within this class. Every standard Windows message has a macro of the form ON_WM_xxx, where xxx is the name of the message. A simple convention is used to generate the handler function name. The name of the function starts with “On.” This is followed by the name of the message with the “WM_” removed and only the first letter of each word capitalized. In the following example, the handler name would be OnCreate: BEGIN_MESSAGE_MAP(CMyView, CView) ON_WM_CREATE() ON_COMMAND(ID_APPLY_SEQUENCE, OnApplySequence) END_MESSAGE_MAP()
You can add a message map entry by using ClassWizard or the WizardBar in Developer Studio. Alternatively, you can add the entry manually.
Self-Check Questions
Which one of the following statements is true about MFC’s relationship to the Win32 API? A. The current version of MFC does not wrap any of the Windows operating system extensions. B. MFC represents a high-level encapsulation of the Windows API. C. A program can easily mix MFC- and API-level calls. D. MFC completely encapsulates the Windows API, freeing the developer from all SDK dependency.
Which one of the following is not a potential benefit of MFC? A. MFC reduces complexity by providing a higher-level abstraction of Windows. B. MFC simplifies database programming through the DAO and ODBC classes. C. A developer needs less knowledge and skill to program with MFC than with the Windows SDK. D. MFC displays many of the stronger features of the C++ language, including support for object-oriented techniques, stronger type checking, exception handling, and so on.
Which one of the following is a primary function of the application class? A. It starts the application€™s message loop. B. It forms the primary window for the application. C. It acts as a binder for the frame, view, and document objects and a set of GUI resources in an application. D. It contains member functions to enumerate through all the views in an application.
Which one of the following is not considered to be one of the main classes that comprise the application framework? A. CObject B. CWinApp C. CView D. CFrameWnd
The Microsoft Foundation Class (MFC) Library and Visual C++ provide an environment that you can use to easily create a wide variety of applications. This chapter discusses the various class types and primary architectures that are used in most applications.
Objectives
After completing this chapter, you will be able to:
List the major categories of MFC classes and the primary classes derived from each category.
Describe the relationship of the foundation class CObject to the other MFC classes.
Explain the key features CObject contributes to the classes derived from it.
Define the main base classes used in a typical MFC application.
Describe the document/view architecture and how this architecture applies to MFC.
Describe the benefits and costs of document/view, non-document/view, and dialog-based application architectures.
Describe how MFC maps messages to functions.
Introduction to MFC
The MFC Library is a collection of C++ classes and an application framework designed primarily for creating Microsoft Windows-based applications. This collection of classes extends the C++ language to include most of the basic structural elements used to create Windows programs. The application framework defines the structure of an application and handles many routine tasks for the application.
This section describes the relationship between MFC and Windows technology and explains some key advantages that MFC and Visual C++ offer developers.
This section includes the following topics:
MFC and the Win32 API
The MFC Library is built on top of the Win32 application programming interface (API). This API is a set of functions exposed by the operating system for use by applications. Through MFC, base classes are exposed that represent common objects in the Windows operating system, such as windows and menus.
MFC does not encapsulate or wrap, the entire API, just the main structural components and components that are commonly used. Because MFC is written in C++, MFC developers can easily use the Win32 API to make native calls to the operating system.
To see an illustration that shows the relationship between MFC, the Windows Base Operating Services, and the Windows Operating System Extensions, click this icon.
MFC version 1.0 was little more than a thin wrapper for the Win32 API. However, each subsequent version of MFC provides significantly more features and functionality. MFC incorporates many names and constructions familiar to developers who have used the Microsoft Windows Software Development Kit (SDK). For example, MFC provides a member function named CWnd::InvalidateRect that corresponds to the Win32 function InvalidateRec.
Wrapper Classes for Operating System Extensions
MFC encapsulates important Microsoft Windows operating system extensions, including COM, ActiveX, ODBC, and Windows Internet APIs. The encapsulation is not complete. However, combining MFC and native API usage is usually simple.
Benefits of Using Visual C++
Visual C++ provides a productive visual development environment that gives you the tools you need to create a wide variety of applications, from client/server solutions to high-performance multimedia applications.
Visual C++ supports the latest in Windows operating system-based technology, including the Windows 95 operating system. Visual C++ offers full support for the common controls in the Windows 95 and Windows NT operating systems, as well as support for the Windows 95 Explorer shell. Most of the new Windows 95-based common controls are fully supported by Visual C++, and you can access them through MFC and the Win32 API.
Some other features that make Visual C++ an excellent choice for developing solutions are:
Code reusability.
Application wizards for MFC applications, DLLs, ActiveX controls, Active Template Library (ATL) projects, ATL Component Object Model (COM) objects, and ISAPI extensions.
The integrated development environment of the Developer Studio.
Components and Controls Gallery, a place to store and access reusable components and controls.
Support for the MFC Library.
Portability and cross-platform support.
Availability in Chinese, English, German, French, Italian, Korean, Japanese, and Spanish.
Support for the latest C++ features.
Benefits of Using MFC
The Microsoft Foundation Class (MFC) Library enables you to build on the work of expert Windows developers. MFC shortens development time, makes the code more portable, provides support without reducing programming freedom and flexibility, and provides easy access to hard-to-program user-interface elements and technologies such as ActiveX, OLE, and Internet programming. Furthermore, MFC simplifies database programming through data access objects (DAO) and Open Database Connectivity (ODBC) and simplifies network programming through Windows Sockets. MFC makes it easy to program such features as property sheets (tab dialog boxes), print preview and floating, customizable toolbars.
By using MFC, you can add many features to your applications in an easy, object-oriented way. In MFC version 3.0, you could add ToolTips to your application by adding only three lines of code. With MFC 4.0, a similar amount of code enables ActiveX controls in your application. Now with MFC version 4.2, Visual C++ 5.0, the Gallery, and the wizards, you can add the Active Template Library (ATL) components, Internet classes, and synchronization for multithreaded programs.
MFC offers the experienced C++ developer many advantages when developing full-featured Windows applications, front-end database applications, ActiveX controls and components, and Internet applications, such as:
An application framework on which you can build a Windows application
Compatibility with previous MFC versions and the new C++ classes
The largest base of reusable C++ source code in the industry
Integration with Visual C++
Flexible, fast database access methods using DAO or ODBC
Support for ActiveX and Internet technologies
Support for popular data-binding technologies
Support for Windows messaging API
Support for multithreading
The MFC Class Hierarchy
The first step on the road to becoming an MFC developer is becoming familiar with the classes. This section gives you an overview of the kind of infrastructure MFC provides, including the classes and class hierarchy.
MFC provides nearly 250 classes designed to serve a wide range of programming needs. The first step in programming with MFC is to become familiar with these classes and learn how they are related to one another in the MFC hierarchy. Some classes are used directly, while others serve as base classes for the classes that you create.
When learning about the MFC classes, it is helpful to organize them into the following categories, which are the topics included in this section:
CObject-Derived Classes
Application Architecture Classes
User-Interface Classes
General-Purpose Classes
ActiveX Classes
Database Classes
Internet Classes
Global Afx Functions
These categories of MFC classes are not mutually exclusive. The majority of MFC classes are derived, either directly or indirectly, from CObject.
CObject-Derived Classes
CObject is the base class for most of MFC and provides the foundation for serialization (loading and saving data to a file), run-time class information, diagnostic and debugging support (validations and dumps), and compatibility with collection classes.
CObject Hierarchy
To see an illustration that shows the relationship of CObject to the other classes in the MFC class hierarchy, click this icon.
The classes in MFC that are derived from CObject provide most of the structure and functionality of an MFC application. The following table lists some of the most important classes and describes the tasks they perform.
Category
Base class
Description
Command targets CCmdTarget For classes that are capable of handling the user’s requests.
Applications CWinApp Represents the core of the application.
Documents CDocument Contains an application’s data set.
Windows CWnd For graphical user interface (GUI) objects that are capable of handling general Windows messages.
Frames CFrameWnd For an application’s primary window frame.
Views CView Displays data and interacts with the document object.
In addition, there are many CObject-derived classes for other aspects of a Win32-based application, such as menus, graphics, file services, and so on.
Support for CObject-Derived Classes
CObject provides three basic types of support to classes that inherit from it, as shown in this table.
Type of support Description
Serialization In this context, serialization is the process of writing or reading an object to or from a persistent storage medium, such as a disk file.
Run-time class information Because it is derived from CRuntimeClass, objects derived from CObject contain information about their origins that are accessible at runtime. This run-time type-checking feature gives functions the ability to react based on the type of object that is acted on.
Diagnostic output To aid in the development of an MFC application, CObject provides a number of diagnostic or debug output functions. Overriding these functions provides information about the execution of your program that is especially useful when program behavior is not as expected.
Classes Not Derived from CObject
MFC also contains a set of classes that are not derived from CObject. These classes are useful in situations where the overhead associated with CObject and run-time type identification are unnecessary. These classes fall into three general categories, as shown in the following table.
Category Examples
General utility classes for general programming CString, CTime, CTimeSpan, CRect, CPoint, CSize
MFC support classes to assist the architecture CArchive, CDumpContext, CRuntimeClass, CFileStatus, CMemoryState
Templatized versions of the collection classes that take a user-defined pointer CTypedPointerArray
Application Architecture Classes
The application architecture classes represent the basic architectural elements of an application and include CWinApp, which represents the application itself. To see an illustration that shows the architecture classes in the MFC object hierarchy, click this icon.
Some of the architectural classes include CWinApp, CDocument, CCmdTarget, and CWinThread. These classes are the first to be instantiated when the application starts, and they have significant responsibility.
The following table describes these four classes in more detail.
Class name Description
CWinApp This class represents the application itself. All MFC applications derive a class from CWinApp.Depending on the type of framework chosen, the application object is responsible for:
Initializing the application.
Building the document template structures. Providing the message loop with retrieved messages from the message queue and dispatching these messages to the appropriate location. Cleaning up the application on exit.
CDocument This is the base class for documents in applications that use document/view architecture. A document is simply an abstract representation of a program’s data. A major architectural task for the developer is to determine how data is to be stored in the document, and how and to what extent the document will provide access to that data.
CCmdTarget This is the foundation class for message map architecture in MFC. The capabilities that a class inherits from CCmdTarget enable it to serve as a target for a special class of messages, known as command messages. These messages are generated when the user chooses a command from a menu.
CWinThread This class encapsulates the threading capabilities of the operating system. Member functions enable MFC applications to create and manipulate threads.
User-Interface Classes
Typically, the user-interface classes encompass the elements of a Windows-based application that are visible to the user. These include windows, dialog boxes, menus, and controls. The user-interface classes also encapsulate the Windows device context and graphics device interface (GDI) drawing objects.
To see an illustration that shows the user-interface classes within the MFC object hierarchy, click this icon.
Some of the user-interface classes include CWnd, CView, CGdiObject, and CMenu.
CWnd
CWnd is the base class for all MFC windows and defines the basic functionality of a window and a window’s default response to most messages. CWnd is sometimes used directly to derive classes, but more often, classes are derived from the other built-in classes that are derived from CWnd. The following table shows some of the classes that are derived from CWnd.
Class and Description
CFrameWnd Models the behavior of a single document interface (SDI) frame window.
CControlBar Serves as the base class for toolbars, status bars, and other controls.
CDialog Encapsulates the functionality of dialog boxes.
CButton, CListBox, CScrollBar, and so forth Corresponds to controls such as buttons, list boxes, and scroll bars.
CView
Most applications provide the user with one or more views of the underlying data. For example, Microsoft Excel provides a worksheet view and a graphic view of the same data. The CView class, derived from CWnd, is the base class that provides visible representation in a document/view application.
CGdiObject
The graphics device interface (GDI) portion of Windows is designed to provide applications with a device-independent and feature-rich set of drawing capabilities. The GDI contains a number of “objects” that are used to display output, such as brushes, pens, and fonts. CGdiObject is a wrapper class that provides MFC applications with the ability to create and use these objects.
CMenu
Menus are one of the main methods by which users interact with applications. An application’s menu items not only give the user the ability to invoke an action, but they also provide information to the user about the state of the application and what options are currently available.
The CMenu class provides an object-oriented interface to menus. Through the CMenu class interface, the application can dynamically control its menus at run time.
® General-Purpose Classes
MFC includes a number of general-purpose classes that do not encapsulate the Win32 API. These classes represent simple data types such as points and rectangles and more complex data types such as strings.
To see an illustration that shows the general-purpose classes within the MFC CObject hierarchy, click this icon.
The following table lists some commonly used general-purposes classes and describes the tasks they perform.
Class and Task
CFile File I/O
CString Managing string variables
CException Exception handling
CByteArray, CIntArray, CStringArray, CStringList, CObList Working with data structures such as arrays and linked lists
We are detailing about Anatomy of a Windows-Based Application, Elements of a Windows-Based Application, Resource type Description, how a Window Processes Message, and show you the illustration of Anatomy of a windows-based application.
Anatomy of a Windows-Based Application
Knowing the elements that make up a Windows-based application and how windows communicate information between the application and the user is important to writing effective MFC applications.
In this section, you will learn about the essential components of a Windows-based application and get a brief introduction to how messages are processed in the Windows environment.
This section includes the following topics:
Elements of a Windows-Based Application
The basic elements that make up a Windows-based application include code, user interface resources, and library modules invoked by the application through dynamic linking.
The primary content of any application is executable code. Windows-based applications have two required functions. One, called WinMain, provides an entry point for the operating system. The second function, a window procedure, is needed to handle messages from the operating system.
User Interface Resources
Many application-defined elements of an application’s graphical user interface (GUI), such as menus and dialog boxes, are stored as templates and references in a special read-only section of the corresponding executable or DLL file. When required, Windows reads from this resource section and constructs the GUI element dynamically.
Note that while resources are primarily used to store information about the GUI elements of an application, any read-only information could be placed in the resource section. The advantage is that resources are shipped as part of the executable file, minimizing the need for additional files to be shipped with an application.
The following table lists the common Win32 resources.
Resource typeDescription
Accelerator Stores the keystrokes and their command associations. Bitmap Contains a graphical image in Windows-compatible format.
Dialog box Details the controls, layouts, and attributes for dialog boxes.
Icon Stores special sets of bitmaps for icons.
Menu Details the text and layout for menus and their items.
String table Stores character strings and an associated ID value.
Toolbar Details toolbar layouts and contains references to the special bitmaps that are used to draw the button faces.
Version information Maintains program status information, such as program name, author, copyright data, version number, and so on.
Cursor Contains the special bitmap that is used to draw the cursor.
Library Modules
Microsoft Windows, along with most modern operating systems, supports dynamic linking, a method for invoking library modules at run time. A library module is a binary file that contains the executable library routines. A library module that can be loaded in this manner is called a dynamic-link library, or DLL.
How an Application Is Started?
For a Windows-based application to get up and running, several events must occur first. When a user starts an application, the following events occur in sequence:
The operating system creates a new process and an initial thread.
The application code is loaded into memory.
Dynamic-link libraries also are loaded into memory, if your application uses them.
Space for items, such as data and stacks, is allocated from physical memory and mapped into the virtual address space.
The application begins execution.
How a Window Processes Message?
Most Windows users are familiar with the term window and the visual elements that characterize applications. From a developer’s standpoint, windows take on a new meaning. In a Windows-based application, windows are the primary method of communicating information from the application to the user. Similarly, the user uses the window to communicate with the application, thus achieving the desired behavior to accomplish a task.
The following steps explain how a Windows-based application prepares itself to receive messages that are sent to it by the system queue.
When a Windows-based application is started, the operating system connects with the application at a predefined entry point. This entry point is defined in the WinMain function, a required function in all Windows-based applications.
The application then creates one or more windows. Each window contains a window procedure that is responsible for determining what the window displays and how the window responds to user input.
A section of code called a message loop retrieves messages from the message queue and gives them back to Windows to send to the appropriate window procedure. This gives the application a chance to preprocess messages before they are sent to a window.
The code to implement each of the steps in this process is presented in a sample application and described in detail in Analyzing a Simple Windows-Based Application later in this chapter.
The following illustration shows how messages passed from the system queue are processed by the application.
We are going to understand Windows Architecture, Threads and Multitasking, Threads, Messages, and Message Queues, How does the Virtual Memory System work?
Chapter 1: Windows Fundamentals and Architecture
When you develop Windows-based applications, you can choose from a wide variety of programming environments depending on the requirements of your application. Many developers are choosing the C++ language for developing Windows-based applications because it is object-oriented in nature and provides a simplified approach to dealing with the complexity of Windows and the wide range of application programming interface (API) functions. Using C++, combined with a class library, further simplifies the development process by grouping the API functions into logical units and encapsulating the basic behavior of windows and other objects in reusable classes.
This course focuses on the Microsoft Foundation Class (MFC) Library, the class library created by Microsoft to be used in combination with Visual C++, the Microsoft version of C++. You can use these tools together to develop Windows-based C++ applications.
MFC extends the object-oriented programming model used in Windows-based applications. Since MFC is based on the Windows programming model, you need a basic understanding of Windows architecture before learning how to use the classes in your applications. If you’re coming to MFC from a traditional Windows programming background, such as C and the Windows SDK, you’re already familiar with these concepts. If you’re new to Windows programming, then this chapter is for you.
This chapter provides an overview of the Windows programming architecture and briefly takes you behind the scenes to see how Windows-based applications work.
Objectives
At the end of this chapter, you will be able to:
Define processes, threads, and multitasking.
Describe the structure of memory management.
Explain the purpose of messages and the concept of event-driven programming.
Describe the minimum components of a simple Windows-based application.
Explain how an application is initialized and windows are created.
Understanding Windows Architecture
Before you begin writing MFC applications, you should understand several key architectural features of Windows-based applications and the Windows operating system.
This section explains the run-time structure of Windows-based applications. Here you will learn about the differences between applications, processes, and threads of execution. You will also learn about how the Windows operating system manages processes and threads in order to maximize performance.
This section includes the following topics:
Processes
The term “process” and the more common term “application” are sometimes used interchangeably. However, in the Windows environment, there is a distinction between a process and an application.
An application is a static sequence of instructions that make up an executable file. A process is usually defined as an instance of a running application. A process has its own private address space, contains at least one thread, and owns certain resources, such as files, allocated memory, and pipes.
A process consists of:
An executable program
A private address space in memory
System resources, such as files, pipes, communications ports, and semaphores
At least one thread, where a thread is a path of execution
The Virtual Memory System
In an operating system where multiple processes are allowed, each process must be protected against corruption by other processes in memory. The Windows operating system is designed to provide this protection.
There are two types of memory in the Windows operating system:
Physical memory
Consists of the amount of physical RAM.
Virtual memory
Consists of 4 gigabytes (GB) of addresses, or 232Â bytes of addressable memory that is available to your application. This is not 4 GB of actual physical memory. Each application is given 2 GB of addresses while the operating system reserves 2 GB for its own use.
Note In Windows NT, an application may have up to 3 GB of addresses for its own use.
How does the Virtual Memory System work?
When an application is started, the following process occurs:
The operating system creates a new process. Each process is assigned 2 GB of virtual addresses (not memory) for its own use.
The virtual memory manager maps the application code into a location in the application’s virtual addresses, and loads currently needed code into physical memory. (The virtual address has no relationship to the location of the application code in physical memory.)
If your application uses any dynamic-link libraries, the DLLs are mapped into the process’s virtual address space and loaded into physical memory when needed.
Space for items such as data and stacks is allocated from physical memory and mapped into the virtual address space.
The application begins execution by using the addresses in its virtual address space, and the virtual memory manager maps each memory access to a physical location.
The application never directly accesses physical memory. The virtual memory manager controls all access to physical memory through requests for access by using virtual addresses.
To see an animation that explains how virtual memory and physical memory work, click this icon. Benefits of Using a Virtual Memory System
A virtual memory system helps both to ensure robust application execution and to simplify memory management.
As mentioned earlier, one concern about running an application in a multitasking environment is protecting that application’s execution from intrusion by other applications. Forcing applications to use virtual memory allows the operating system to provide strict physical memory partitioning between applications. If an application requests private memory space, the operating system will provide a map between that application and physical memory.
Virtual memory also allows applications to view memory as a flat, 2 GB of memory space without having to contend with the physical memory management architecture that is used by the operating system.
Threads and Multitasking
While a process can be thought of as a task that the operating system must perform, such as running a spreadsheet application, a thread represents one of the possibly many tasks needed to accomplish the job. For example, controlling the user interface, printing, and calculating the spreadsheet may be tasks of the spreadsheet application that are assigned to individual threads. A thread runs in the address space of its process and uses the resources allocated to its process.
A process can have a single thread, or it can be “multithreaded”. A multithreaded process is useful when a task requires considerable time to process. The task can run within one thread, while another task runs within a separate thread. The threads can be scheduled for execution independently on the processor, which allows both operations to appear to occur at the same time. The benefit to the user is that work can continue while the first thread completes its task. Another benefit is that on a multiprocessor system running Windows NT, two or more threads can run concurrently, one on each processor.
Multitasking is the ability of an operating system to give the appearance of the simultaneous running of multiple threads. The operating system achieves multitasking by allowing each thread to be active for a relatively short amount of time (tens of milliseconds) and then switching to the next scheduled thread. This process, called “context switching”, is done by:
Running a thread until the thread’s time slot is exhausted or until the thread must wait for a resource to become available.
Saving the thread’s context.
Loading another thread’s context.
Repeating this sequence as long as there are threads waiting to execute.
To see an illustration of context switching in a multitasking operating system, click this icon.
Threads, Messages, and Message Queues
Each thread of execution has its own virtual input queue for processing messages from hardware, from other processes, or from the operating system. These queues operate asynchronously — that is, when one process posts a message to another thread’s queue, the posting function returns without having to wait for the other thread to process the message. The thread that has received the message can access and process the message when it is ready.
Of special interest is the handling of keyboard and mouse events. A special system thread, known as the raw input thread (RIT), receives all key and mouse events. Whenever the RIT receives hardware events from the processor, its sole function is to place them on the virtual input queue of the appropriate thread. Thus, under normal circumstances, no application thread need wait for its hardware events.
To see an animation that shows how messages are handled by the system message queue, click this icon.
Event-Driven Programming
Central to understanding how Windows-based applications work is the concept of event-driven programming. To hear an expert in the field describe event-driven programming, click this icon.
The best way to understand event-driven programming is to contrast it with the procedural programming of MS-DOS. Under MS-DOS, users enter command-line parameters in order to control how an application runs. Under Windows, users start the application first, and then Windows waits until users express their choices by selecting items within a graphical user interface (GUI). A Windows-based application thus starts and then waits until the user clicks a button or selects a menu item before anything happens. This is known as event-driven programming.
This is the collection of the common questions of Digital Economy that we mostly get in the exam of Bachelor of Computer Information system.
a) What is knowledge management? Explain the framework for developing a knowledge management program. (8) b) Define e-Governance. Explain the levels of e-Governance Maturity Model. (7)
State the use of the business model. Explain the issues to be addressed by a business model and their respective components. (15)
Write short notes on any two: (2*5=10) roots of knowledge management features of e-Commerce technology layers of internet economy
a) What is Secure Electronic Transfer. Explain the steps involved in the SET transaction. (8) b) What is the value chain? Explain Porter’s Generic value chain. (7)
What is understood by value proposition? Explain in details the attributes that characterize value proposition. (15)
Write short notes on any two: (2*5=10) a) Broadband b) Features of SET c) Digital convergence
(Questions for reference only)
BCIS Digital Economy
a) Explain how knowledge has become the fourth factor of production.
b) Explain e-Governance as a means of governance reform and outline its scope
a) What is meant value chain? How can IT contribute to improving value chain efficiency?
b) Explain the term CRM and explain why firms invest in CRM
a) Explain e-Governance maturity model b) What is open source movement? Explain how developing countries stand to benefit from it
c) Explain the term broadband and list down 3 major broadband technologies.
b) What do you understand by the term ‘knowledge economy’ and what are its key enabling elements?
a) What is e-commerce? List out its typologies (types) and distinguish between e-commerce and e-business?
b) What is your opinion are the limitations for the growth of B2C e-Commerce in Nepal?
a) What is meant by Knowledge Management?
Explain the significance of Knowledge management in organizations
b) What is VoIP? Explain benefits and challenges of VoIP and discuss in favor or against of legalizing VoIP
7. Write short notes on (any two):
a)Venture capital
b)Open Source
c)Digital convergence
d) Supply chain
BCIS: Digital Economy
a) Explain how knowledge has become the fourth factor of production. b) Explain e-Governance as a means of governance reform and outline its scope c) What is meant by value chain? How does e-commerce contribute to improving value chain efficiency? d) Explain the term value proposition with examples e) Explain e-Governance maturity model
What is the open-source movement? Explain how developing countries stand to benefit from it
What is understood by e-readiness? List out some of the indicators used in e-readiness assessments and its significance in IT policy formulation
What do you understand by the term ‘knowledge economy’ and what are its key enabling elements?
What is e-commerce? List out its topologies and distinguish between e-commerce and e-business?
What is your opinion are the limitations for the growth of B2C e-Commerce in Nepal?
What is BPO? Explain BPO with examples and outline international trends in BPO with special reference to India
What is VoIP? Explain benefits and challenges of VoIP and discuss in favor or against of legalizing VoIP
Write short notes on (any two):
Venture capital
Open Source
Digital convergence
Unified Messaging System
Explain what is meant by e-Governance and list key elements of e-Governance maturity model (EGMM)
Scope of e-Governance
What are the limitations for the growth of B2C e-Commerce?
What is BPO? Explain BPO with examples and outline international trends in BPO with special reference to India
What is VoIP? Explain benefits and challenges of VoIP and discuss in favor or against of legalizing VoIP
Explain what is meant by e-Governance and list key elements of e-Governance maturity model (EGMM)
What is the difference between VoIP and IP telephony?
Write short notes on two of the following a)Unified Messaging System b) Value chain c) Supply chain
What do you understand by the term ERP? Explain the benefits that ERP systems offer to the organization as well as challenges in ERP implementations
Explain the term CRM and explain why firms invest in CRM?
Explain how internet bandwidth will become a crucial issue in the days to come for the development of the ICT sector in the country
Explain the term broadband and list down 3 major broadband technologies.
What is understood by e-readiness? Explain in detail the significance of e-readiness assessment surveys in IT policy formulation.
Explain the major features of Nepal’s IT policy and strategies.
Explain what value proposition in your opinion could the IT park in Banepa offer to potentials IT firms wishing to locate their operations in the park.
a. Define Knowledge Management and Knowledge Economy. Explain the four pillars of the Knowledge Economy.
Explain the benefits of e-Governance and outline its scope.
Define e-commerce and explain the features if e-commerce technology.
What, in your opinion, are the factors, limiting the growth of B2C in Nepal.
Explain the elements of e-business model that a firm can pursue in order to operate successfully in the Internet era.
What is understood by the value chain and explain how firms can gain competitive advantage through the value chain.
Define Broadband along with its benefits and explain its role in the economic development of a nation.
Define ERP and explain why firms undertake ERP. Outline some of its limitations.
Define CRM. Give reasons as to why firms today should invest in CRM.
Define the value proposition. What according to you is the value proposition offered by IT Park in Banepa to IT professional and IT firms in Nepal?
Discuss some of the policies and strategies outlined in IT Policy of Nepal.
Recognizing diarrhea diseases as one of the major public health problems among children under five in Nepal, the National Control of Diarrhea Diseases Program (NCDDP) has been accorded high priority status by GON and is an integral part of Primary Health Care.
Improvement in diarrhea case management has been used as a primary strategy for the reduction of mortality due to diarrhea among children under five years of age. Standard diarrhea case management are provided in the health institutions by establishing Oral Rehydration Therapy (ORT) corners in all Hospitals, Primary Health Care Centers, Health Posts and Sub Health Posts throughout the country. All health facilities and community health volunteers serve as the primary health service providers in the treatment of Diarrhea with Oral Rehydration Solutions (ORS) which is free of cost.
1.1 OBJECTIVES
The main objective of the National Control of Diarrhea Diseases Program (NCDDP) is to reduce mortality due to diarrhea and dehydration (from the estimated 30,000 deaths per year in the past) to a minimum, and to reduce morbidity from 3.3 episodes per child per year to a minimum.
1.2 TARGETS
1.2.1 To reduce the under-five mortality rate due to diarrhea by 50 percent by 2005/2006;
1.2.2 To reduce the under-five morbidity rate due to diarrhea by 20 percent by 2005/2006;
1.2.3 To increase the accessibility of Oral Rehydration Solution (ORS) to 100 percent of the population by 2005/2006;
1.2.4 To raise public awareness about the correct preparation and use of Oral Rehydration Solution in the treatment of diarrhea, and increase use of ORS by 20 percent by 2005/2006; and
1.2.5 To increase the proportion of caretakers that provides ORT for children with diarrhea to 40 percent by 2005/2006.
1.3 Indicators
Main Indicators
Numerator and Denominator
1. Morbidity rate due to diarrhea
Total diarrhea new cases in specified time x 1000
Target population (under-fives)
2. Mortality rate due to diarrhea
Total number of diarrhea-related deaths x 1000
Target population (under-fives)
3. Case fatality rate from diarrhea
Total diarrhea deaths per year x 1000
Total diarrhea new cases in same period
1.4 STRATEGIES
General Strategies
4.1 Establish functioning ORT Corners and replenish ORT Corner sets in each health facility in order to educate mothers/caretakers, to demonstrate proper ORS preparation, and to treat children suffering from diarrhea;
4.2 Increase access to Oral Rehydration Solution packets through FCHVs, SHPs, HPs, PHCCs, hospitals and commercial outlets;
4.3 Raise public awareness;
4.4 Promote specific preventive measures through communication and information activities;
4.5 Involve Community Health Workers including the volunteers (VHWs, MCHWs and FCHVs), District Development Committee (DDC) and VDC members, local NGOs and local decision-makers;
4.6 Apply an integrated child health package including the CDD, EPI, Nutrition, Acute Respiratory Infection (ARI) and Malaria programs; and
4.7 Emphasize program management at all health facilities.
Strategies for Tenth Five Year Plan
4.8 Train all levels of health workers including VHWs/MCHWs/FCHVs/community leaders;
4.9 Orient community opinion leaders, VDC members, faith healers;
4.10 Supply Oral Rehydration Solution to all health institutions;
4.11 Supply Oral Rehydration Solution to all FCHVs;
4.12 Develop health education materials (including development and printing of IEC materials) to be used by mothers, FCHVs, and through channels of radio and TV communication;
4.13 Promote supervision and monitoring at all levels; and
4.14 Promote “Knowledge, Attitude and Practice” (KAP) on CDD among health workers, mothers and FCHVs
2 ANALYSIS OF ACHIEVEMENTS BY MAJOR ACTIVITIES
2.1 ACTIVITIES CARRIED OUT IN FY 2062/63 (2005/2006)
2.1.1 Planning
District-level planning and orientation was conducted for District Health Officers (DHOs), Public Health Officers (PHOs), and other health personnel including DDC members and local decision makers in Sankhuwasabha, Sindhuli, Udayapur, Gorkha, Parbat, Kapilvastu, Surkhet and Jumla districts.
2.1.2 Supply of ORS
2,500,000 sachets ORS purchased and distributed to the districts.
2.1.3 Communication and Training Materials
Revised and finalized training materials and printed through WHO and GoN.
2.1.4 Transportation
Supply of IEC materials regarding CDD to districts as requested.
2.1.5 Monitoring and Supervision
Supervision from center and region to districts accomplished
Supervision from district to PHCC, HP/SHP as per schedule done
2.1.6 Epidemic Control
Financial support to all districts provided where epidemic occurred
2.2 TARGETS vs. ACHIEVEMENT, FY 2062/63 (2005/2006)
S.
No.
Activities
Unit
Targets
Achievement
Targets vs.
Achievement (percent)
1.
Purchase of ORS
Pkts.
2,500,000
2,500,000
100
2.
Printing of IMCI Register
Pcs.
1,500
1,500
100
3.
Printing of Mothers’ Card
Sheets
10,000
10,000
100
4.
Printing of CB-IMCI Training Materials
Pcs.
2,800
2,800
100
5.
CB-IMCI Drugs
freq
1
1
100
6.
Counselling Service (CB-IMCI Program for 10 Districts)
freq
2
2
100
7.
Treatment of <5 Diarrhea Cases
Cases
628,573
739,915
100
Source: HMIS/MD & IMCI Section/CHD, DoHS
As can be seen from the above table, all CDD targets were achieved satisfactorily during FY 2062/63. The overall achievement was 100 percent.
Table 2c.1 ORS Supply, Three-Year Comparison, FY 2060/61 to 2062/63
Year
Targets
Achievement
Achievement percent
2060/61 2003/2004
2,000,000
2,000,000
100%
2061/62 2004/2005
2,000,000
2,000,000
100%
2062/63 2005/2006
2,500,000
2,500,000
100%
Source: IMCI Section/CHD, DoHS
Table 2c.1 shows the trend of Oral Rehydration Solution supply to the districts from FY 2060/61 to 2062/63. The CDD program provided ten packets of ORS to each FCHV according to the CDD National Policy. Those ten packets were replenished whenever FCHVs used all on treatment of diarrhea in under-five children. During the FY 2060/61, 2061/62 and 2062/63 the target vs. achievement was 100 percent. Figure 2c.3 and Table 2c.1 for FY 2062/63 is based on the report received from the Finance Section, DoHS.
2.3 ANALYSIS OF SERVICE STATISTICS
Table 2c.2 below shows the decreasing trend in the number of diarrhea visits for the last two years compared to FY 2060/61. In FY 2062/63, the total number of diarrhea visits decreased remarkably in comparison to FY 2060/61 and 2061/62. Diarrhea deaths in FY 2062/63 have decreased by 66.4% in comparison to FY 2061/62 and 57.7% to 2060/61. The national reported incidence of diarrhea per 1,000 among children under five years also decreased in FY 2062/63 in comparison to FY 2060/61 and 2061/62. The reported incidence of diarrhea at the regional level also decreased in all the development regions. At national level, the case fatality rate has decreased significantly (0.11/1,000) in the FY 2062/63 compared to FY 2060/61 and 2061/62. The reason for this decreasing trend in the visits for diarrhea, deaths and incidence and case fatality rate may be due to rapid expansion of CB-IMCI Program.
Table 2c.2 Incidence of Diarrhea, by Region, FY 2060/61 to 2062/63
Indicators
Year
Region
National
EDR
CDR
WDR
MWDR
FWDR
Total <5 Populationfor CDD/ARI
2062/63
796,079
1,202,989
725,133
524,860
384,625
3,633,687
Total diarrheaVisits
2060/612061/622062/63
2003/04
2004/05
2005/06
234,206
230,320
221,757
253,588
249,003
229,268
121,327
128,644
113,459
103,451
106,297
104,234
74,522
71,072
71,197
787,094
785,336
739,915
Total diarrheaDeaths
2060/612061/622062/63
2003/04
2004/05
2005/06
23
24
11
50
56
20
26
20
3
63
107
39
32
37
9
194
244
82
Incidence ofdiarrhea /1,000<5 yrs. Popn.
2060/612061/622062/63
2003/04
2004/05
2005/06
302
294
279
216
209
191
171
179
156
202
205
199
199
187
185
222
219
204
Case Fatality Rate/ 1,000<5 yrs. Popn.
2060/612061/622062/63
2003/04
2004/05
2005/06
0.1
0.1
0.05
0.2
0.2
0.09
0.2
0.2
0.03
0.6
1.0
0.37
0.4
0.5
0.13
0.2
0.3
0.11
Source: HMIS/MD, DoHS
Figure 2c.4 shows the three-year trend of reported diarrhea incidence per 1,000 under-five children. At the national level during FY 2062/63, incidence of diarrhea decreased slightly, (204 per 1,000) compared to FY 2060/61 and 2061/62. At regional level also diarrhea incidence has decreased in all regions in FY 2062/63 in comparison to FY 2060/61 and 2061/62.
Figure 2c.5 shows the three-year trend of reported diarrhea deaths. In FY 2062/63 the total number of diarrhea deaths decreased by 66.4% in comparison to FY 2061/62 and by 57.7% compared to FY 2060/61. Similarly, at regional level also the diarrhea deaths decreased by more than 50 percent in comparison to FY 2060/61 and 2061/62. Amongst the five development regions the highest number of diarrhea deaths occurred in the MWDR (39) followed by CDR (20) and the lowest number occurred in the WDR (3) in FY 2062/63.
Table 2c.3 Classification of Dehydration, by Region, FY 2060/61 to 2062/63
Indicators
Year
Region
National
EDR
CDR
WDR
MWDR
FWDR
Total cases
2060/612061/622062/63
2003/04
2004/05
2005/06
234,206
230,320
221,757
253,588
249,003
229,268
121,327
128,644
113,459
103,451
106,297
104,234
74,522
71,072
71,197
787,094
785,336
739,915
No Dehydration Cases
2060/61
2003/04
110,764
47.3%
146,966
58.0%
80,141
66.1%
63,918
61.8%
47,726
64.0%
449,515
57.1%
2061/62
2004/05
114,888
49.9%
155,256
62.4%
88,256
68.6%
66,137
62.2%
46,449
65.4%
470,986
60.0%
2062/63
2005/06
127,884
57.7%
154,586
67.4%
81,938
72.2%
68,062
65.3%
48,660
68.3%
481,130
65.0%
Some Dehydration Cases
2060/61
2003/04
118,086
50.4%
100,715
39.7%
38,760
31.9%
34,921
33.8%
24,812
33.3%
317,294
40.3%
2061/62
2004/05
111,610
48.5%
89,176
35.8%
38,038
29.6%
35,144
33.1%
22,876
32.2%
296,844
37.8%
2062/63
2005/06
91,701
41.4%
72,407
31.6%
30,199
26.6%
33,113
31.8%
21,297
29.9%
248,717
33.6%
Severe Dehydration Cases
2060/61
2003/04
5,356
2.3%
5,907
2.3%
2,426
2.0%
4,612
4.5%
1,984
2.7%
20,285
2.6%
2061/62
2004/05
3,822
1.7%
4,571
1.8%
2,350
1.8%
5,016
4.7%
1,747
2.5%
17,506
2.2%
2062/63
2005/06
2,172
1.0%
2,275
1.0%
1,322
1.2%
3,059
2.9%
1,240
1.7%
10,068
1.4%
Source: HMIS/MD, DoHS
Table 2c.3 shows the classification of dehydration by region over the last three years. CDD reactivation, CBAC, and IMCI programs had positive impact on the skill and knowledge of health workers, enabling them to better identify various categories of classifications and treat them appropriately. Because of their better skill and knowledge, more cases are gradually being classified as ‘No Dehydration’ and less cases as ‘Some Dehydration’. Also because of increased awareness among caretakers, cases of diarrhea in children are brought to health facilities at an earlier stage. At the national level cases of ‘Severe Dehydration’ has gradually declined (2.6 percent, 2.2 percent and 1.4 percent) during the three fiscal years. This decline in severe dehydration is observed in all regions in comparison to FY 2060/61 and 2061/62.
Table 2c.4 Treatment of Diarrhea Diseases, by Region, FY 2060/61 to 2062/63
Indicators
Year
Region
National
EDR
CDR
WDR
MWDR
FWDR
Total cases
2060/612061/622062/63
2003/04
2004/05
2005/06
234,206
230,320
221,757
253,588
249,003
229,268
121,327
128,644
113,459
103,451
106,297
104,234
74,522
71,072
71,197
787,094
785,336
739,915
Treated withORS
2060/612061/622062/63
2003/04
2004/05
2005/06
192,352
188,410
176,215
233,303
230,052
212,912
114,664
121,641
107,050
88,973
89,188
89,267
67,968
64,540
63,727
697,260
693,831
649,171
88.6%
88.3%
87.7%
Treated withIV fluid
2060/612061/622062/63
2003/04
2004/05
2005/06
5,637
4,266
2,599
6,309
5,645
3,404
3,863
4,017
2,527
5,810
6,185
4,306
2,812
2,730
1,449
24,431
22,843
14,285
3.1%
2.9%
1.9%
Source: HMIS/MD, DoHS
Table 2c.4 shows that, at the national level over the three fiscal years, treatment by IV fluid is gradually decreasing, whereas the percentage of ORS treatment in all three fiscal years remained almost the same. In FY 2062/63 1.4 % of cases were diagnosed as severe dehydration where as 1.9% were treated by IV Fluid. But this has been gradually improving over the years.
Figure 2c.6 shows a consistent seasonal variation in total diarrhea visits over the last three years. Increases in diarrhea incidence starts from the month of Falgun and continues till Jestha, and then starts declining gradually. This sort of seasonal variation was observed during the last three fiscal years.
2.4 Recommendations
Based on field experience, the following strategies are to be improved and should be continued for a successful and effective implementation of program.
A) Strategies to be modified
IMCI approach
Extension of community-based IMCI to FCHV and VDCs
Decentralized planning to promote district-level commitment and a feeling of program ownership and responsibility for effective program implementation
Central level facilitators should be made available for each district-level training as well as for community-level program monitoring
Focus on program management without neglecting case management
B) Strategies to be improved
Training allowances for VHWs, MCHWs, and FCHVs to be revised according to the level of status and allocated in central-level budget planning
FCHVs to be supervised/recognized by all levels to maintain high motivation
Motivation and follow-up mechanisms to be developed for VDCs to support FCHVs
3 PROBLEMS/CONSTRAINTS AND ACTIONS TO BE TAKEN
S. No.
Problems/constraints
Action to be taken
Responsibilities
Deadline
3.1
Inadequate ORS in some districts
Increase budget for ORS for some districts.
CHD
As soon as possible
3.2
Inadequate budget for epidemics of diarrhea.
Strict management and discipline over proper use of epidemic budget and increase budget.
DHO/RHD and CHD
As soon as possible
4 TARGETS FOR FY 2063/64 (2006/2007)
S. No.
Activities
Unit
Annual Targets
Budget Rs.’000
1
ORS purchase
Pkts.
2,500,000
11,000
2
Treatment of <5 diarrhea cases
Cases
628,573
1,177
Source: IMCI Section/CHD, DoHS
Note: For detailed, district-specific data and analysis on this program/project, please refer to the annexes in this document.
Community Based Integrated Management of Childhood Illness (CB-IMCI)
1 BACKGROUND
In 1997, the CDD/ARI Section of the Child Health Division implemented the Integrated Management of Childhood Illness (IMCI), an integrated package of child-survival Program in Mahottari District as a pilot. It addresses five major killer diseases (diarrhea, pneumonia, malnutrition, measles, and malaria) in a holistic way. Based on the recommendations made in FY 2055/56, Program personnel and EDPs representatives decided to include a community component, enabling mobilization of community health workers (VHWs and MCHWs) and FCHVs to provide CDD, ARI, nutrition and Immunization services to the communities. As a result, the (CBAC) Program merged into IMCI in 1999 and is now called Community Based IMCI (CB-IMCI).
In the beginning CB-IMCI Program was implemented in Nawalparasi, Bardiya, and Kanchanpur districts in FY 2056/57 and gradually expanded to 25 districts of the country by the end of FY 2061/62 in a phased manner. In FY 2062/63 CB-IMCI was further expanded to 8 more districts (Udayapur, Sankhuwasava, Sindhuli, Gorkha, Parbat, Kapilvastu, Jumla and Surkhet) making the total of 33 districts. Out of the 33 districts, CB-IMCI is functional in HF and Community level in 22 districts and where as in 11 districts it is functional at HF level only.
Status of IMCI Training (FY 2062/63)
Districts
Doctor
Supervisors & others from DHO/ Hospital
PHI
Sr.AHW/
AHW
HA
Staff
Nurse
ANM
NGO &
others
Total
Surkhet
1
7
–
62
6
9
28
7
120
Kapilvastu
2
16
–
88
4
4
21
1
136
Gorkha
1
9
–
52
4
3
15
–
84
Udayapur
3
6
–
57
1
4
28
–
99
Sindhuli
1
14
–
58
8
2
10
1
94
Jumla
2
4
–
41
2
2
7
–
58
Parbat
5
1
2
53
3
2
13
5
84
Sankhuwasava
2
–
2
42
5
3
19
8
81
Total
17
57
4
453
33
29
141
22
756
During the FY 2062/63, 756 persons of various categories from eight districts were provided IMCI training. Sixty percent of those were Sr. AHW/AHW followed by ANMs and other categories. The categories of staff trained in IMCI is given in the above table.
Community level training
SN
Activities
Number of Participants
Total
Parbat
Sankhuwasabha
Jumla
Surkhet
1.
FCHV 1st phase
494
311
527
876
2,208
2.
VDC/HFOMC
557
373
234
515
1,679
3.
Mothers€™ Group Orientation
9,702
3,913
4,806
10,655
29,076
4.
FCHV 2nd Phase Training
474
300
506
–
1,280
5.
Traditional Healers Orientation
197
103
111
–
411
Community level Training on IMCI by type of activities in four districts is given in the above table. More than 29,000 of mothers group have participated in the orientation Program. FCHV were provided training in two phases. Visualizing the important role played by the traditional healers, more than 400 traditional healers were also participated in the training program. For details see the above table.
Mothers’ Group Orientation
SN
Activity
Number of Participants
Total
Parbat
Sankhuwasabha
Jumla
Surkhet
1.
Total # of Mothers attended
9,702
3,913
4,806
10,655
29,076
2.
Total <5 cases examined
3,198
1,182
1,950
4,436
10,766
3.
Total # of pneumonia cases treated
179
95
272
415
961
4.
Total severe cases Referred to HF
21
13
119
79
232
5.
Total ARI cases provided Home therapy
2,998
1,074
1,559
3,942
9,573
Source: IMCI Section
Impact of CB-IMCI Program
The figure 2c.1 shows the effectiveness of CB IMCI Program by comparing 3 key indicators of Diarrhea between 25 CB-IMCI districts and 50 non-CB-IMCI districts. The incidence of Diarrhea detection in 25 CB-IMCI districts is lower than those of 50 non-CB-IMCI districts. In the CB-IMCI districts out of total registered Diarrhea cases (373,888) only 1.4% are severe dehydration where as in non-CB-IMCI districts out of total registered cases (411,448) 3.0% are severe dehydration. This could be due to increased accessibility, availability of services as well as ORS packets at any time in the community, timely referral by FCHV and increased health facility use rate by the mothers/caretakers of <5 children.
Similarly, figure 2c.2 shows an impact of CB-IMCI Program by comparing 3 key indicators of ARI between 25 CB-IMCI districts and 50 non-CB-IMCI districts. The incidence and pneumonia detection in 25 CB-IMCI districts is higher than those of 50 non-CB-IMCI districts. In the CBIMCI districts out of total registered ARI cases (760,409) only 1.1% are severe where as in non-IMCI districts out of total registered ARI cases (530,223) 3.5% cases are severe. This could be due to increased accessibility, availability of services at any time in the community, timely referral by FCHVs and increased health facility use rate by the mothers/caretakers of <5 children.
Community-Based ARI and CDD (CBAC)
CDD reactivation was one of the most prominent Programs executed by the Child Health Division. It was designed to help health workers gain professional knowledge, skills, and attitudes regarding WHO standards for case management of diarrhea and acute respiratory diseases.
In FY 2055/56, it was renamed as the Community-based ARI and CDD (CBAC) Program, and combined two other child survival Programs-Nutrition and Immunization. The CBAC Program was implemented in FY 2055/56 in five districts: Siraha, Rautahat, Bara, Rasuwa and Bajura. It was expanded to 6 more districts in FY 2056/57. Out of 11 CBAC districts, 5 have already been converted to CB-IMCI districts and 3 more districts will be taken up this year.
The Program includes the following three main strategies of CDD, ARI, Nutrition and Immunization Programs: (1) recognition of the danger signs of diseases related to CDD, ARI, Nutrition and Immunization; (2) timely referral to nearby health facilities; and (3) improved community support for CDD, ARI, Nutrition and Immunization through group participation and Program management. Support and assistance from communities are encouraged through:
a) Introduction to the Combined Child Health Package which includes instructional materials as well as supplies for CDD, ARI, Nutrition and EPI;
b) Emphasis on CDD/ARI Program Management along with case management activities;
c) Organization of district and VDC orientation Programs to encourage community involvement and active participation; and
d) Specialized training for all community based health workers and volunteers (VHWs, MCHWs, and FCHVs) to reduce morbidity and mortality due to diarrhea diseases, acute respiratory infections, malnutrition, and vaccine-preventable diseases.
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.
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 2nd trimester (4 months) of the pregnancy;
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)
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
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
1.5.3 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,
The Department of Health Services is one of three departments under the Ministry of Health and Population and have a different level of Institutional framework. Millennium development goals aim to bring peace, security, and development to all people.
The institutional framework of the department of health services
The overall purpose of the Department of Health Services is to deliver preventive, promotive and curative health services throughout the country. The Department of Health Services is one of three departments under the Ministry of Health and Population. As seen in Figure the organizational structure of the MoHP outlines how different levels of the health system related to form a network under the DoHS.
According to the institutional framework of the DoHS and MoHP, the Sub Health Post (SHP) from an institutional perspective, is the first contact point for basic health services. However, in reality, the SHP is the referral center of the volunteer cadres like TBAs and FCHVs as well as a venue for community-based activities such as PHC outreach clinics and EPI clinics. Each level above the SHP is a referral point in a network from SHP to HP to PHCC, and to the district, zonal and regional hospitals, and finally to specialty tertiary care centers in Kathmandu. This referral hierarchy has been designed to ensure that the majority of the population receive public health and minor treatment in places accessible to them and at a price they can afford. Inversely, the system works as a supporting mechanism for lower levels by providing logistical, financial, supervisory, and technical support from the center to the periphery. Organizational Structure of the Department of Health Services
Acronyms
MD
Management Division
NTC
National Tuberculosis Centre
FHD
Family Health Division
NCASC
National Centre for AIDS and STD Control
CHD
Child Health Division
NPHL
National Public Health Laboratory
EDCD
Epidemiology and Disease Control Division
FCHV
Female Community Health Volunteer
LMD
Logistics Management Division
TBA
Traditional Birth Attendant
LCD
Leprosy Control Division
PHC/ORC
Primary Health Care Outreach Clinic
NHTC
National Health Training Centre
EPI
Expanded Programme on Immunisation
NHEICC
National Health Education, Information and Communication Centre
Millennium Development Goals (MDGs)
At the millennium summit of September 2000, the member states of the United Nations adopted the Millennium Declaration, which aims to bring peace, security, and development to all people. The Millennium Development Goals (MDGs), drawn from the Millennium Declaration, are a groundbreaking international development agenda for the 21st century to which all nations are committed. The MDGs outline major development priorities to be achieved by 2015. Numerical targets are set for each goal and are to be monitored through 48 indicators. The MDGs are:
Goal 1. Eradicate extreme poverty and hunger
Goal 2. Achieve universal primary education
Goal 3. Promote gender equality and empower women
Goal 4. Reduce child mortality
Goal 5. Improve maternal health
Goal 6. Combat HIV/AIDS, Malaria and other diseases
Goal 7. Ensure environmental sustainability
Goal 8. Develop a global partnership for development
Note: Goals no. 4, 5 & 6 are directly related to MoHP/GoN.
Since GoN endorsed the Millennium Declaration, Nepal has been committed to achieving the MDGs. As the primary medium-term strategy and implementation plan for achieving the MDGs, the country’s Tenth Plan (Poverty Reduction Strategy Paper 2002/2003 2006/2007) has incorporated the MDGs into its strategic framework, and has highlighted the importance of improving the monitoring mechanism.
Targets: The targets based on the above goals of MDGs are as follows:
Target 1. Halve between 1990 and 2015, the proportion of people whose income is less than one dollar a day;
Target 2. Halve between 1990 and 2015, the proportion of people who suffer from hunger;
Target 3. Ensure that, by 2015, children everywhere, boys and girls alive, will be able to complete primary schooling;
Target 4. Eliminate gender disparity in primary and secondary education, preferably by 2005, and at all levels of education no later than 2015;
Target 5. Reduce by two-thirds between 1990 and 2015 the under 5 mortality rate;
Target 6. Reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio;
Target 7. Have halted by 2015 and begun to reverse the spread of HIV/AIDS;
Target 8. To have halted by 2015 and begun to reverse the incidence of malaria and other diseases;
Target 9. Integrate the principles of sustainable development into country policies and programs and reverse the loss of environmental resources;
Target 10. Halve by 2015, the population without sustainable access to safe drinking water and basic sanitation;
Target 11. This target is related to develop a global partnership for development;
Target 12. Develop further an open, rule-based, predictable, non-discriminatory trading and financial system, includes a commitment to good governance, development, and poverty reduction-both nationally and internationally;
Target 13. Address the special needs of the LDCs, includes: tariff and quota-free access for LDC exports; enhanced program of debt relief for HIPC; and cancellation of official bilateral debt; and more generous ODA for countries committed to poverty reduction;
Target 14. Address the special needs of landlocked developing countries and small island developing states;
Target 15. Deal in a comprehensive manner with the debt problems of developing countries through national and international measures in order to make debt sustainable in the long term;
Target 16. In cooperation with developing countries, develop and implement strategies for decent and productive work for youth;
Target 17. In cooperation with pharmaceutical companies, provide access to affordable essential drugs in developing countries;
Target 18. In cooperation with the private sector, make available the benefits of new techniques, especially information and communications.
Among all the above targets, the targets and their respective indicators which are directly related to MoHP are as follows:
Relates to
Indicators
In 1990
In 2005
In 2015
Target 5
Infant Mortality Rate
108
–
34
Under five years mortality rate
162
–
54
Proportion of one year olds immunized against Measles
42
–
90
Target 6
Maternal Mortality Ratio
850 or 515
–
213 or 134
Percentage of deliveries attended by health care providers (Doctors/Nurses/Auxiliary Nurse Midwives)
7
–
60
Target 7
HIV Prevalence among (15-49) years of age (in %)
NA
0.5
–
Contraceptive Prevalence rate including condom (in %)
24
NA
–
Target 8
Prevalence rate associated with malaria (no. of cases per 10,000 people at risk)
115
–
–
Proportion of population in malaria risk areas using effective malaria prevention measures
NA
–
–
Slide Positivity Rate (SPR)
5.1
–
–
Prevalence associated with Tuberculosis
460
–
–
Death rates associated with Tuberculosis
43
–
The proportion of Tuberculosis cases detected
NA
–
The proportion of Tuberculosis cases cured under DOTS
Nepal Health Sector Program (NHSP) is a sector wide program focused on performance results and health policy reforms implemented under a Sector Wide Approach (SWAp) with an agreed set of program performance indicators and policy reform milestones for the program duration. The policy reform milestones are outlined in the Nepal Health Sector Program Implementation Plan (NHSP-IP). Of the eight NHSP outputs, three are defined for strengthening the health service delivery:
Delivery of essential health care services,
Decentralized management of service and
Public private partnership.
The remaining five outputs are designed for improvement in institutional capacity and management in the areas of:
Sector management,
Health financing and financial management including alternative financing,
Physical asset management and procurement,
Human resource management,
Health management information system and quality assurance.
5.2 PURPOSE OF NEPAL HEALTH SECTOR PROGRAM
This program seeks to address disparities in the system and improve the health of the Nepali population, especially the poor and vulnerable. NHSP marks a new approach in Nepal which aims at the delivery of basic services to poor and rural populations and the aid resources will increasingly support a sector program, rather than isolated projects. The program design was led by the efforts of Nepali themselves and is built under a sound sector strategy. Hence, the Health Sector Strategy with its Nepal Health Sector Program Implementation Plan is a building block of sector wide rationalization aimed towards aid harmonization, strong performance and reform focus.
5.3 PROGRAM OBJECTIVES
The objective of NHSP is to improve health outcomes by expanding access to and increasing the use of Essential Health Care Services (EHCS), especially for the poor with a nationwide coverage.
5.4 NHSP STRATEGIC PROGRAM ACTIVITIES
NHSP strategic program activities are broadly organized in two components that consolidate the eight areas of work in the NHSP-IP: a) Strengthened Service Delivery through the expansion of essential health care services, greater local authority over and responsibility for service provision, and public-private partnerships; b) Institutional Capacity and Management Development through improved health sector management; sustainable health financing and financial management; human resource development; physical asset management and procurement; and health management information system and quality assurance.
5.5 SUMMARY OF ACHIEVEMENTS DURING FY 2062/63 (2005/2006): PROGRAM PERFORMANCE MEASUREMENT STATUS
As defined in the NHSP four key programmatic indicators were agreed to assess annual achievement in program performance: (a) contraceptive prevalence rate (CPR) (b) skilled attendance at birth (c) immunization rates and (d) population€™s knowledge about at least one method of preventing HIV/AIDS. Nepal Demographic and Health Survey (NDHS), 2006 has published a preliminary report showing a remarkable improvement over the period 2001 as a base line on the above indicators.
According to reports from the MoHP, DoHS, Management Division, Health Management Information Section (HMIS) between 2004/2005 and 2005/2006, CPR increased from 41.3% to 42.1 and delivery by trained health workers from 20.2% to 23.4%. The routine immunization coverage increased from 80% to 93% for DPT3 and from 79% to 88% for measles. As per the NDHS 2006, the knowledge of at least one method of preventing HIV/AIDS has also improved considerably.
The overarching national objective of the Tenth Plan is to reduce the magnitude of poverty among the Nepali people substantially and sustainable by developing and mobilizing the healthy human resources.
4.2 OBJECTIVES
In order to provide capable and effective type of curative, preventive, promotional and rehabilitative health services and to make the reproductive health and family planning services available to reduce the growing population, the health service sector will have the following objectives:
4.2.1 Apart from improving the quality of health services, increase the access of the poor and disadvantaged people of the rural and remote areas to these services.
4.2.2 Besides the management of the growing population, access of reproductive health and family planning services will be extended to the rural areas extensively in consideration of maternal health service.
4.3 QUANTITATIVE GOALS
The goals of the health service sector are given in the following table:
SN
Health Indicators
Status as of FY 2002
Target of 10th plan
General Growth
Alternative growth
1
Availability of Essential Health Care Service (in %)
70
90
88
2
Availability of the stipulated essential medicines in the specific institutions (%)
80
90
89
3
Provide essential health services with all health workers required (%)
60
80
78
4
Percent of women receiving prenatal service for four times
14.3
18
17
5
Women of 15-44 age group receiving TT vaccines (%)
45.3
50
49
6
Birth attendance by the trained health workers (%)
13
18
17
7
Contraceptive Prevalence Rate (in %)
39
47
46
8
Use of Condoms for safe sex (14-15 yrs) (%)
–
35
35
9
Total Fertility Rate (women of 15-49 yrs)
4.1
3.5
3.6
10
Crude Birth Rate (per 1000)
34
30
30
11
Maternal Mortality Ratio (per 100,000 live birth)
415
300
315
12
Newly born infant mortality rate (Neo-Natal Mortality Rate) per 1,000 live births
39
32
33
13
Infant Mortality per 1,000 live births
64
45
47
14
Child Mortality (<5 yrs.) per 1,000 live births
91
72
74
15
Crude mortality Rate
10
7
7
16
Life Expectancy at birth (years)
61.9
65
64
Source: Tenth Plan (2059-2064) National Planning Commission
4.4 STRATEGIES
The following strategies have been developed:
4.4.1 Investment to provide essential health service to the poor and the backward communities will be increased gradually.
4.4.2 Ayurveda, naturopathy services and traditional healing systems (like homeopathy, Unani) will be developed as the supplementary health service. In order to conserve and promote these services, these remedial systems will be developed by the use and promotion of local medicinal herbs and by enhancing skills and expertise in the use of these.
4.4.3 Health services will be gradually decentralised in line with the Local Self-Governance Act, 1998 and the office-bearers of Local Health Administration and Management Committees will be involved in orientation programmes to enhance their working capability.
4.4.4 So as to raise the availability of and access to essential health services, main contributors to health problems such as safe motherhood, reproductive health, child health, nutrition, tuberculosis, kala-azar (typhus), malaria, Japanese encephalitis and other communicable diseases need to be addressed in order to enhance health services in rural and remote areas through special programs.
4.4.5 All government, non-government and private health institutions at the local level providing basic health services and at the central level providing specialist services will be effectively managed and strengthened by means of two-way communication system.
4.4.6 With the aim of improving the quality of health services provided in partnership by the government, private and non-government sectors, the human, financial and physical resources will be managed effectively.
4.4.7 The reproductive health program has an important role to play in the effective management of population. Family planning services will be made more extensive and effective based on the increasing informed choices. Moreover, it will help reduce maternal and child mortality as well.
4.5 POLICIES AND WORK PLANS
In order to fulfill the objectives of keeping the population growth within the desired rates, reducing the disease burden, and providing the people in general and the poor, women and children with the quality health services, the following policies are listed out.
Extension of essential health services
Ayurveda, naturopathy, Unani and other traditional health services management and decentralized health service
Special health service to control communicable and non- communicable diseases
Disseminating system
Partnership/participation of the government, non-government and private sectors
Reproductive health service
4.5.1 Basis of the Programs:
In line with the recommendations made by the Public Expenditure Review Commission and the policy of involving local elected bodies in the management of physical infrastructure and financial resources of the health institutions operating at the rural level, the health posts and primary health care centers will be handed over to the local elected bodies in the Tenth Plan.
Communicable diseases, malnutrition and the motherhood-related diseases are found to be the causes of 68 percent of all diseases and 50 percent of total mortality in Nepal. In order to implement such programs relating to control of contagious diseases, nutrition, reproductive health and family planning with due priority, it is necessary that in the days to come, the government and private institutions be listed and the places and norms of the services (including specialist-oriented services) be specified.
There is substantial disparity in the conditions of health services between the urban and the rural areas. An independent National Micro-economic Health Commission will be set up within the accepted structure of the national program of poverty eradication to conduct the health sector program in a coordinated manner.
The health service program are prioritized in the Tenth Plan on the following basis:
Burden of diseases,
Implementing capacity,
Equity,
Programs targeted to the poor, the oppressed and those deprived of opportunities,
Programs contributing to poverty eradication,
Availability of resources
There are 3 categories of programs P1, P2 and P3 based on descending order of priority.
The Programs in First Priority
(P1)
The Programs in Second Priority
(P2)
The Programs in Third Priority
(P3)
Expanded vaccination and national polio vaccine
Control of Acute Respiratory Infection
Diarrhoea
Nutrition
Safe motherhood
Family planning
Reproductive Health of the adolescents
Female Community Health Volunteers and sudenis (trained traditional birth attendants)
Epidemiology and control of diseases
– Control of malaria
– Typhus (kala-azar)
– Natural disaster and management
– Vector-borne diseases and their control, research and training
– Tuberculosis
– Leprosy
– HIV/AIDS and Sexually Transmitted Diseases (STD)
– Health information, communication and education
– Supply management
– Community medicine
– Health insurance
– Information management
National Health Training
Bir Hospital
Shahid Shukraraj Tropical and Infectious Disease Hospital
Kanti Children€™s Hospital
HRH Indra Rajya Laxmi Maternity Hospital
Urban health
Ayurved services
Laboratory and other auxiliary services
Strengthening supervision, monitoring and evaluation systems
The National Health Policy was adopted in 1991 (2048 BS) to bring about improvements in the health conditions of the people of Nepal. The primary objective of the National Health Policy is to extend the primary healthcare system to the rural population so that they benefit from modern medical facilities and the services from trained healthcare providers. The National Health Policy addresses the following areas:
1.1: PREVENTIVE HEALTH SERVICES
Priority is given to programs that directly help reduce infant and child mortality. Services are to be provided in an integrated manner throughout the country through the national health systems network.
1.2: PROMOTIVE HEALTH SERVICES
The programs that enable people to live healthy lives will be given priority.
1.3: CURATIVE HEALTH SERVICES
Curative health services will be made available at all health institutions-central, regional, zonal, and district hospitals; primary health care centers (PHCCs), health posts (HPs), and sub-health posts (SHPs). Hospital expansion will be based on population density and patient loads. Mobile teams will be organized to provide specialist services to remote areas. A referral system will be developed to direct the rural population to well-equipped institutions.
1.4: BASIC PRIMARY HEALTH SERVICES
Sub Health Posts will be established in a phased manner in all Village Development Committees (VDCs). One Health Post in 205 electoral constituencies will be upgraded in a gradual manner and converted to a Primary Health Care Centre.
1.5: AYURVEDIC AND OTHER TRADITIONAL HEALTH SERVICES
The ayurvedic system will be developed and other traditional health systems (such as Unani, Homeopathy, and Naturopathy) will be encouraged.
1.6: ORGANISATION AND MANAGEMENT
Improvements will be made in the organization and management of health facilities at the central, regional and district levels. This will include the integration of the district hospitals and the public health offices into District Health Offices.
1.7: COMMUNITY PARTICIPATION IN HEALTH SERVICES
Community participation will be sought at all levels of healthcare through the participation of female community health volunteers (FCHVs), traditional birth attendants (TBAs), and leaders of various local social organizations. VDCs will provide sites for the location of SHPs.
1.8: HUMAN RESOURCES FOR HEALTH DEVELOPMENT (HRH)
Technically competent human resources will be developed for all health facilities. Training centers and academic institutions will be strengthened to produce competent human resources.
1.9: RESOURCE MOBILISATION IN HEALTH SERVICES
National and international resources will be mobilized and alternative concepts (such as health insurance, user charges, and revolving drug schemes) will be explored and affected wherever possible.
1.10: PRIVATE, NON-GOVERNMENTAL HEALTH SERVICES AND INTER-SECTORAL COORDINATION
The Ministry of Health & Population will coordinate activities with the private sector, non-governmental organizations (NGOs), and non-health sectors of GoN. The private sector and NGOs will be encouraged to provide health services to expand services and access.
1.11: DECENTRALISATION AND REGIONALISATION
Decentralization and regionalization will be strengthened; peripheral units will be made more autonomous. DHOs and DPHOs will have a prominent role in the planning and management of preventive, curative, and promotive health services from district to village levels.
1.12 BLOOD TRANSFUSION SERVICES
The Nepal Red Cross Society will be authorized to conduct all programs related to blood transfusion. The practice of buying, selling, and depositing blood will be prohibited.
1.13 DRUG SUPPLY
Improvements will be made in the supply of drugs by increasing domestic production and upgrading the quality of essential drugs through the effective implementation of the National Drug Policy.
1.14 HEALTH RESEARCH
Health research will be encouraged for helping evidence-based policy formulation and better management of health services.
2 OPERATIONAL GUIDELINES ON POLICIES AND PROGRAMS OF THE MINISTRY OF HEALTH AND POPULATION
The policies and programs of the Ministry of Health and Population and the actions and activities of its officials will be as directed by the spirit and feelings of the Jana Andolan II (Peoples€™ Revolution, 2006/2007) 2062/63.
With the prime objective of bringing about a change in the overall health of a Nepali and towards creating a healthy Nepali society, the Ministry of Health and Population will perform the following tasks:
2.1 We express our strong commitment to the worldwide recognition of “health being the basic right of people”. Our special focus will be on people of economically and socially deprived groups, sex, tribes, communities, and regions to guarantee the health of the overall Nepali people.
2.2 Our strong commitment lies in the fact that the state has a major role to deliver all kinds of health services to the people, be it preventive, promotive, or curative. Towards primary health care, the services will be provided according to the proclamation of the Alma Ata Declaration. Ayurveda and other alternative medical practices will be conserved and promoted.
2.3 The present health budget will be increased. Steps will be taken to provide more funds available to the health sector as in other social welfare sectors. In order to ensure additional funding for health services, budgetary cuts will be enforced in the budget for Royal Palace and Nepal Army. The budget allocated to the health sector will be used in an effective and efficient way and there will be no letup in administration for financial corruption and other irregularities in the health sector. System of reward and punishment will be practiced with full commitment. International donor organizations will also be encouraged to extend their cooperation according to the spirit and feelings of this Guideline.
2.4 Special initiatives will be taken to create a provider-friendly atmosphere for doctors and health workers to work in villages and rural areas. Their career development and opportunity for higher education will be ensured. A two way feedback system will be made operational.
2.5 Medical education will be made responsive to the requirement of the health sector of Nepal and a coordination mechanism will be strengthened with the Ministry of Education, the Universities, and other teaching organizations. Necessary steps will be taken to involve such teaching institutions for quality health care providers for the people.
2.6 Support will be provided through necessary policy directives and supervision of the private sector in order for them to function responsibly in society. A cooperative approach to health will be taken in a way that ensures the participation and ownership of the community.
2.7 District health system will be organized according to the concept of integrated approach and decentralization principle. To empower the people through the mechanism of health-related activities, community-based health workers will be empowered. Special initiatives will be taken to tap the inherent capabilities of these health workers and health volunteers and ensure effective use of it in their role as a bridge between the people and the health institutions.
2.8 Realizing the fact that health and development have an interdependent relation, the Ministry will make a concerted effort for effective intersectional coordination.
2.9 The population policy of Nepal will be strongly steered towards the aim of reducing poverty and hunger.
2.10 The Ministry of Health and Population will take immediate steps to provide health security to the families of those seriously injured and those who obtained martyrdom during the Jana Andolan II.
3 SECOND LONG TERM HEALTH PLAN, 1997-2017
The Ministry of Health and Population of the Government of Nepal has developed a 20-year Second Long-Term Health Plan (SLTHP) for FY 2054-2074 (1997-2017). The aim of the SLTHP is to guide health sector development for the overall improvement of the health of the population, particularly those whose health needs are often not met.
The SLTHP addresses disparities in healthcare, taking into account gender sensitivity and equitable community access to quality healthcare services. The aims of the SLTHP are to provide a guiding framework to develop successive periodic and annual health plans that improve the health status of the population; to develop appropriate strategies, programs, and action plans that reflect national health priorities that are affordable and consistent with available resources; and to ensure co-ordination among public, private and NGO sectors and development partners.
The SLTHP envisions a healthcare system with consideration of equity and access and quality services in both rural and urban areas. The system would encompass the principles of sustainability, community participation, decentralization, gender sensitivity, effective and efficient management, and public-private partnerships.
3.1 Objectives
The objectives of the SLTHP are as follows:
To improve the health status of the population of the most vulnerable groups, particularly those whose health needs often are not met – women and children, the rural population, the poor, the underprivileged and the marginalized population;
To extend to all districts cost-effective public health measures and essential curative services for the appropriate treatment of common diseases and injuries;
To provide technically competent and socially responsible health personnel in appropriate numbers for quality healthcare throughout the country, particularly in under-served areas;
To improve the management and organization of the public health sector and to increase the efficiency and effectiveness of the healthcare system;
To develop appropriate roles for NGOs, and the public and private sectors in providing health services; and
To improve inter-and intra-sectoral coordination and to provide the necessary support for effective decentralization of health care services with full community participation.
3.2 Targets
The targets of the SLTHP are as follows:
To reduce the infant mortality rate to 34.4 per thousand live births;
To reduce the under-five mortality rate to 62.5 per thousand live births;
To reduce the total fertility rate to 3.05;
To increase life expectancy to 68.7 years;
To reduce the crude birth rate to 26.6 per thousand population;
To reduce the crude death rate to 6 per thousand population;
To reduce the maternal mortality ratio to 250 per hundred thousand live births;
To increase the contraceptive prevalence rate to 58.2 percent;
To increase the percentage of deliveries attended by trained personnel to 95%;
To increase the percentage of pregnant women attending a minimum of four antenatal visits to 80%;
To reduce the percentage of iron-deficiency anemia among pregnant women to 15%;
To increase the percentage of women of childbearing age (15-44) who receive tetanus toxoid (TT2) to 90%;
To decrease the percentage of newborns weighing less than 2500 grams to 12%;
To have essential healthcare services (EHCS) available to 90% of the population living within 30 minutes€™ travel time to health facility;
To have essential drugs available around the year at 100% of facilities;
To equip 100% of facilities with full staff to deliver essential health care services; and
To increase total health expenditures to 10% of total government expenditures.
3.3 DELIVERY OF ESSENTIAL HEALTHCARE SERVICES
3.3.1 Essential Health Care Services for the Modern System of Medicine:
The Second Long Term Health Plan indicated that priority will be given to health promotion and prevention activities based on Primary Health Care principles. It identified Essential Health Care Services (EHCS) that address the most essential health needs of the population and that are highly cost-effective. EHCS are priority public health measures and are essential clinical and curative services for the appropriate treatment of common diseases. The EHCS for Ayurveda and other traditional systems of medicine are defined separately.
Main Interventions*
Health Problems Addressed
Appropriate treatment of common diseases and injuries
Common Diseases and Injuries
Reproductive health
Maternal and Peri-natal health problems including other RH issues
The expanded program on immunisation (EPI) and Hepatitis B Vaccine
Diphtheria, Pertusis, TB, Measles, Polio, Neonatal Tetanus, Hepatitis B
Condom promotion and distribution
STD/HIV, Hepatitis B, Cervical Cancer
Leprosy control
Leprosy
Tuberculosis control
Tuberculosis
Integrated Management of Childhood Illness (IMCI)
Diarrhoeal Disease, Acute Respiratory Infection (ARI), Protein Energy Malnutrition (PEM), Measles and Malaria
Nutritional supplementation, enrichment, nutrition education and rehabilitation
PEM, Iodine Deficiency Disorders, Vitamin A Deficiency, Anaemia, Cardiovascular Disease Prevention, Diabetes, Rickets, Perinantal Mortality, Maternal Morbidity, Diarrhoeal Disease, ARI
Prevention and control of blindness
Cataracts, Glaucoma, Pterygium, Refractive Error, and other Preventable Eye Infections
This is the Annual Report of the Department of Health Services for the fiscal year 2062/63, and it is the 12th consecutive report of its kind. This is also the fourth report of the tenth Five Year Plan period of the Government of Nepal (GoN). This document not only focuses on the performance of the fiscal year 2062/63 but also covers the following areas, which will be the basis for the analysis of performance in the coming years.
Program-specific policy statements, including goals, strategies, targets, and major activities;
Program-specific indicators for the monitoring of program performance on a regular basis; and
Problems/constraints and actions to be taken in order to improve performance in the coming years.
Preparation of this report followed the Regional Annual Performance Review Workshops conducted in all five regions which culminated in the National Annual Performance Review Workshop. These review meetings were attended by the Regional Directorates, all technical/support divisions, centers, and representatives from external development partners and NGO/INGO at each level.
During the workshop, the policy statements of each program were reviewed and refined in light of the present context. The data generated from the HMIS in the form of raw numbers were carefully and critically analyzed along with data available from other sources. These data were interpreted during a series of presentations and discussions.
The National Performance Review Workshop achieved the following objectives:
The achievements were reviewed against the target/plan set for the FY 2062/63 (2005/2006) by Divisions/Centres with respect to the released budget and expenditure and recommendations were made for further improvement.
The trend of service coverage for the FY 2062/63 was compared with the previous two fiscal years and progress was assessed toward achieving the targets set for the 10th plan.
Reviewed the progress made in achieving the objectives of the Nepal Health Sector Programme Implementation Plan (NHSP-IP) and its milestones.
Identified and addressed issues related to the handing-over of health facilities to local VDCs in relation to the delivery of health services.
The implementation status of recommendations made at the National Annual Performance Review of the FY 2061/62 (2004/2005) was reviewed and clarified the reasons for not being able to implement the recommendations made during the preceding year.
Identified specific modalities and programs for low-coverage districts to extend their coverage.
Discussed issues/problems/recommendations made by the Regional Annual Performance Review Workshop and made recommendations to MoHP for necessary action.
The outcome of this workshop can be seen in the programme-specific chapters of this Report. Detailed district-specific data and analyses are available in each of the five Regional Reports as well as in the annexes of this document.
