HEALTH SYSTEM MANAGEMENT FIELD PROGRAM REPORT

HEALTH SYSTEM MANAGEMENT FIELD
PROGRAM
GROUP D2
MBBS BATCH 37
DEPARTMENT OF COMMUNITY MEDICINE
MMC, IOM

Group Members
S. NO. NAME ROLL. NO.
1. Abiral Wagle (GL) 1685
2. Prabin Sapkota 1717
3. Sobin Pant 1735
4. Sijan Karki 1736
5. Binaya Chapagain 1754
6. Bhuwan Raj Giri 1758

Health system management
• Program designed to help the students understand the
concepts of management in general and health service
management in particular as well as to provide the
students with opportunity for the exposure to the
health care delivery systems in the country.
• The field program aims to enable students to acquire
knowledge and skills to perform the managerial tasks
that they are supposed to carry out as a medical
officer.

Objectives
General Objective:
To explore the health system management of the
country and develop knowledge and skills required for
the management and development of the health care
delivery system

Specific Objectives:
• To identify the differences between the health service delivery
mechanism at provincial, district and community level health
institutions.
• To explore the structure and functions of Municipal Health
System.
• To perform critical analysis of an issue in a health institution.
• To perform epidemiological trend analysis of a selected health
problem.
• To formulate a five-year plan and thus address a particular
problem based on the local situation.
• To disseminate the information to the concerned stakeholders
and effectively advocate.

Methodology
S.N. Study area Study duration Activites
1. Highway Community
Hospital, Malekhu, Dhading
Benighat Rorang Rural
Municipality, Dhading
3 weeks from 17th
Falgun to 8th
Chaitra
Hopital Profile
Critical Analysis
Overall Municipal
Profile
Municipal Health
Profile
2. Hetauda Hospital, Hetauda 3 weeks from 9th
Chaitra to 29th
Chaitra
Epidemiological
Trend Analysis
3. Dhading Hospital, Dhading
Neelakantha Municipality,
Dhading
2 and half weeks
from 30th Chaitra
to 15th Baisakh
Five- year plan

Techniques and Tools
For municipal profile
Techniques Tools Source of Information
Key Informant
Interview
Interview
guidelines
Mayor and Deputy-mayor of the
Rural Municipality, Incharge of
different sections of the Rural
Municipality Office
Record Review Record Review
Format
Financial Report of the Rural
Municipality, Annual Education
Report of the Rural Municipality
Literature Review Review Format Benighat Rorang Rural
Municipality Profile-2075

For municipal health profile
Key Informant
Interview
Interview
guidelines
Health Section Incharge of the
Rural Municipality Office,
Health Posts Incharge and
other staffs of Health Posts,
FCHVs
Record Review Record Review
Format
HMIS Report
Observation Observation
Checklist
Health posts, Birthing Centers

For hospital profile and critical analysis
Key Informant Interview Interview guidelines CEO of hospital, Managing
Director, Doctor, HA, Sub
AHW, Lab technician,
Administrative staffs
Record Review Record Review Format HMIS Report of F.Y.2076/77
Literature Review Review Format Guidelines on Minimum
Service Standards (MSS) for
Primary Hospitals, Health
Infrastructure Development
Standards 2074
Observation Observation Checklist Hospital premises,
Emergency Room

For epidemiological trend analysis
Key Informant
Interview
Interview
guidelines
Medical recorder, Medical
Superintendent of the
Hospital
Record Review Record Review Format Hospital Inpatient Records
tally sheet,
EWARS weekly bulletins
published by EDCD

For five-year plan
Activities Technique Tools Sources of Information
Selection of
topic
 Secondary data
review
 Review of annual
report
 Key informant
review
 Group discussion
 Data review
format
 Interview
guidelines
 Annual report DoHS
(2075/76)
 District health
report(2075/76)
 Records from Neelakantha
Municipality Health Section
 Key informants
a. Incharge of health section,
Neelakantha municipality
b. Medical superintendent,
Dhading district hospital
Situation
analysis
 Secondary data
review
 Interview with
stakeholders.
 Data review
formats
 Interview
guidelines
 District health report,
Dhading(2075/76)
 Records from Neelakantha
municipality Health section
 Key informants
a. Incharge of Health section,
Neelakantha Municipality
b. Medical superintendent,
Dhading Hospital
c. DOTS center in-charge

Stakeholder
analysis
 Interview with
stakeholders
Interview
guidelines
a. Health section of
b. District Health Office
c. DOTS center in-charge
d. TB affected patients
e. FCHVs
Problem
analysis
 Key informant
interview
 Secondary data
review
Problem tree a. Incharge of health section,
b. DOTS center in-charge
Objective
analysis
• Key informant
interview
Interview
guidelines
b. DOTS center incharge
Logical
Framework
Matrix
preparation
 Key informant
interview
 Group
Discussion
Logical
Framework
Matrix template
a. Members of Health
Section, Neelakantha
Municipality
a. DOTS center in-charge,
Dhading Hospital
Budget
estimation
 Key informant
review
 Group
discussion
Budget
framework
b. Finance officer,

Data analysis and management:
• MS Excel
• Comparison of data in different fiscal years
• Comparison of local data with national level data
Data validity and reliability:
• secondary data obtained was from standard published documents
and from verified servers. The data of same entity was obtained
from multiple sources and cross-checked to ensure validity of data
and thus the findings obtained are reliable
Ethical considerations:
• Official letter form the campus given to the concerned study
area’s administration.
• The objectives of the study were explained beforehand and consent
was taken.

Benighat Rorang Rural Municipality
Profile
Area: 206.52 sq. km.
Boundaries:
– East: Gajuri Rural
Municipality,
Makwanpur District
– West: Chitwan District
– North: Gajuri Rural
Municipality,
Siddhalekh Rural
Municipality and
Chitwan District
– South: Chitwan and
Makwanpur Districts

Political and Administrative Division:
– Province: Bagmati
– District: Dhading
– Rural Municipality: Benighat Rorang
– Wards: 10
Demographic Status: (as of 2075 BS)
– Total Population: 33,029
– Population density: 159.93 people per square
kilometer
– Sex ratio: approximately 103 males per 100 females
– Total households: 5,854

15% 10% 5% 0% 5% 10% 15%
0-4
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70 and above
% Male % Female
Population Pyramid of Benighat Rorang Rural Municipality in 2075 B.S.

Major inhabitants Major religion Major occupation
Chepang (24%)
Janajati (14%)
Chhetri (13%)
Hindu (91%)
Buddhist (7%)
Christian (2%)
Agriculture and
Animal Husbandry
(84%)
Business (11%)
Private Sector
(2%)

Organogram of the Rural Municipality Office

Annual Budget for FY 77/78
Federal Government 428,403,992.00
Conditional Grants 232,662,760.00
Matching Grants 158,200,000.00
Fiscal Equalization Grants 12,178,490.00
Special Grants 25,362,742.00
Provincial Government 85,513,000.00
Revenue 164,601,010.00
Internal Source 215,269,990.00
Total 893,787,992.00

Inputs
1. Physical infrastructure
- 1 Room has been allocated for the Health Section
- 12 health institutions in the Rural municipality, all have
their own concrete buildings
2. Human Resources in Health Section of Rural
Municipality
- 2 members (Incharge of the health section and another
public health officer) in the Health Section
- 24 sanctioned posts by government in health institutions
- 53 working staffs

3. Finance
• Source of budget
- Federal Government
- Rural Municipality Office itself
• In F.Y. 2077/78 the Rural Municipality
allocated budget of Rs. 3,84,62,760 in the
health sector.

• Use of medicines:
– First Expired First Out (FEFO) protocol followed
• Storage:
– 2 store rooms in rural municipality office
– Cold chain maintenance facility only available in
Benighat HP

Outputs
Child Health
Program
Family Health
Program
Disease
Control
Program
Curative
Services
Additional
Services
National
Immunization
Program (NIP)
CB-IMNCI
Program
Nutrition
Program
Safe
Motherhood
Family Planning
FCHVs
PHC-ORCs
Malaria Control
Program
Tuberculosis
Control
Program
HIV/AIDS
Control
Program
Leprosy Control
Program
Abortion
Services
Rural
Ultrasound
Services
COVID-19
Related
Indicators

Immunization Status
Percentage of full immunized children aged 12-23 months of
Benighat Rorang Rural Municipality

• steady decrease in the percentage within the
past three years with BCG, PCV, MR1, TD2 and
TD2+ vaccination
• However, the wastage rate of vaccines has
been decreasing which is a good indicator
• The low immunization coverage in the recent
year can be attributed to COVID pandemic

Incidence of ARI and diarrhoea among U5 children (per 1000) in
respective years
CB-IMNCI program

Nutrition Program
S.
N
Indicators 74/75 75/76 76/77
National
75/76
1
% of children aged 0-11 months
registered for growth monitoring
76.6 98.1 82.4 N/A
2
% of children aged 0-23 months
registered for growth monitoring
53.2 75.5 52.3 71
3
Percentage of children aged 12-23
months registered for growth
monitoring
72.6 124.6 59.2 N/A
4
Proportion of malnourished
children as % of new growth
monitoring (< 2 yrs)
3.2 3.1 5.6 3.5

Safe motherhood program
33.8
35.2
41.7
60
0
10
20
30
40
50
60
70
74/75 75/76 76/77 National 75/76
Percentage of deliveries attended by SBA

93.6
88.9
83.9
46.8 45.8
53.4
0
10
20
30
40
50
60
70
80
90
100
74/75 75/76 76/77
% of pregnant
women attending
first ANC checkup
% of pregnant
women who had
four ANC checkups

Family planning methods
• The Contraceptive Prevalence Rate (CPR) in the
Rural Municipality is 36(temporary modern
methods) which is similar to the national data (38)
• Most of the new users of family planning methods
have opted to adopt condom as the method of
family planning, followed by depo Provera implant
and pills

Disease control program
1. Tuberculosis

2. Leprosy
• new case detection rate (NCDR) per 100000
population in only one in FY 2076/77 which is
very low as compared to national data of 11.23 in
FY 2075/76.
• no any reported cases of leprosy among Under 14
children.
3. No any reported case of malaria

Additional Services
1. Safe Abortion Services
– started in the Rural Municipality in F.Y. 2076/ 78.
– 5 women in 76/77
– 11 women in 77/78 (upto Magh)
2. Rural Ultrasound Service
– started from the F.Y. 2075/76

3. COVID-19 related indicators
S.N INDICATORS FY 2076/77
1. No. of Quarantine centre 7
2. Total available bed in Quarantine 50
3. Number of isolation centre 1
4. Total available bed in isolation 20
5. Total PCR sample collection 222
6. Total infected person 0
7. Total death case 0

Highway Community Hospital
profile

• opened on 22nd October 2005 in Malekhu,
Dhading with the help of Amici del Monte
Rosaonlus-an Italian Social Organization and
Friends of Nepal-an NGO of Nepal
• with the noble objective of serving the local
community as well as accident victims.

Findings
• The input, process and output model has been
used to study and create the hospital profile:
• Input:
– Infrastructure, Human resources, Finance, Logistics
• Process:
– Planning, organization, staffing, coordinating,
recording and reporting, budgeting, supervision and
monitoring
• Output:
– Health services and Service utilization

Infrastructures of the hospital
• Land owned by the hospital: 3 ropani 5 anna
• Buildings: 2
– 1 building: Pharmacy, Dental OPD, and staff’s
quarter
– 1 building: OPD, Ward, laboratory and Doctor’s
quarter
• Rooms: 28
• Hospital beds: 15- bedded hospital with 3
beds in Emergency Room

Finances
• Income sources
- Not helped by the Rural Municipality
- Services fee
- Sales on medicine
- Donations
• Expenditure
- Salary
- Medicines and other material purchase
- Lab equipment
- Food, electricity and drinking water
- Repair and maintenance

Logistics management
• No free logistics from the Health Section of
the Rural Municipality
• Purchase from distributors via tender system
• Electronic recording of stocks done
• Stock maintenance on First Expired First Out
(FEFO) principle
• Cold chain maintained in the laboratory

Medical record department
• The records of the patients is kept through
electronic medical recording system- Medisoft
software in the reception
• The OPD department, Emergency Room, and
Laboratory all maintain an individual register
book manually.
• The data is compiled every month and filled in
the HMIS form and e-reporting is done with
DHIS2 software.

Human resources
• There are total 16 working staffs in the hospital
Position Number of staffs
Doctor 2 ( 1 MBBS and 1 BDS)
Health Assistant 1
Sub Auxiliary Health Worker 2
Staff nurse 1
Lab technician 2
Radiographer 1
Administrative Staff 3
Office Assistant 3
Ambulance Driver 1
Total 16

Planning, Staffing and Budgeting
• The overall planning, budgeting and decisions
regarding staffing of the hospital is done by the
Hospital Management Committee with inputs
from the Managing Director, and the CEO.
• Meetings are held biannually for reviewing the
plans and policies.
• The staffing is looked after by the Human
Resource Manager as per the directions from the
Hospital Management Committee.

Hospital services
• OPD services
• Emergency services
• Inpatient services
• Lab services
• Radiology services
• Pharmacy services
• Minor Operation Theater(OT) services
• Family Planning services
• Speciality Services
• Free Services(fasting blood sugar test, sputum test, TB treatment)
• Ambulance Services
• Dental Services

Critical analysis on Emergency
services of Highway Community
Hospital

Rationale:
• Highway community hospital is the first place where
accident victims are brought from the highway
vicinity. So, their basic care highly depends on the
emergency services provided by the hospital. Thus,
the emergency services of the hospital must be of
optimum standard.
• There are no other health facilities nearby that
provide emergency services.
• The hospital is being upgraded to Trauma Center.
This critical analysis can be used by the hospital to
ensure that the emergency services thus set-up will
fulfill the MSS standards.

General objective
• To critically analyze the emergency service in
Highway Community Hospital.

Specific Objectives
• To measure the Minimum Service Standards (MSS)
score of Emergency Service in Highway Community
Hospital.
• To understand the process of emergency service
delivery in Highway Community Hospital.
• To identify the existing gaps in emergency service
delivery.
• To carry out SWOT analysis on different aspects of
emergency service delivery.
• To find out the solutions to the issues and provide
appropriate recommendations.

Findings
• The Minimum Service Standards (MSS) scoring system
was first used to critically analyze the emergency
service of Highway Community Hospital
• On analyzing, a score of 23 out of 41 full points was
obtained on emergency service sub-section, i.e. a total
of 56.09% was obtained.
• The score is more than 50% that means the condition is
not very poor and alarming, however it is less than
70% which implies that the service is improving but
needs specific targeted areas support.

Analysis Matrix
• we used the SWOT matrix for analyzing various aspects
of emergency services in Highway Community Hospital.
POSITIVE/ HELPFUL
to achieving the goal
NEGATIVE/ HARMFUL
to achieving the goal
INTERNAL Origin Strengths (S) Weaknesses (W)
EXTERNAL Origin Opportunities (O) Threats (T)

• SWOT analysis was done in six building blocks,
namely:
• 1. Physical Infrastructure
• 2. Budgeting and Finance
• 3. Logistics
• 4. Human resources
• 5. Recording and Reporting
• 6. Service delivery

Physical Infrastructure
Strengths Weaknesses
● Earthquake resistant building
● Wheel-Chair friendly
● Light and ventilation adequately
maintained
● Satisfactory sanitation
● Color coded bins for waste collection
● Emergency room small and only 3 bedded
● Triage system (Red, Yellow, Green Areas)
not maintained
● No separate entry and exit for easy
patient transport
Opportunities Threats
● Donation worth Rs. 50 lakhs is expected
from the Federal Government for
upgrading the hospital into Trauma
Center Unit with advanced emergency
services
● Support from donor organizations and
local community
● Expansion of the emergency department
possible because of adequate land area
● Hospital close to Trishuli river, chance of
flooding and landslide

Budgeting and Finance
● Most of the financial input
from internal sources
● Donation worth Rs. 50 lakhs from the
Federal Government for upgrading the
hospital into Trauma Center Unit with
advanced emergency services
● Financial input largely dependent on
internal sources
● Financial Support from Italian social
organization Amici del Monte Rosaonlus
stopped from 2068 BS
● Financial sustainability could be
achieved if hospital management
collaborates with rural municipality
● Extension of hospital into trauma center
can attract donations from national and
international agencies
● Decrease in patient flow can severely
impact the finances
● Establishment of new hospitals nearby
● Donations and grants may not be
received in the future

Logistics
● Medical equipments worth Rs 30 lakhs
received from Ministry of Social
Development on fiscal year 2077/78
● Alternative source of electricity
(Generator) available during electricity
cut-off
● 2 Refrigerators for cold chain
maintenance
● vital equipments like ECG machine,
suction machine, neuliser set, etc.
available
● Only 3 beds available in emergency room
● Not enough emergency stock of medicines and
supplies for mass casualty management
● Equipments like defibrillator, portable
ventilator, noninvasive ventilator, positive
airway pressure machine not available .
● MSS score for Medicine and supplies for ER is
1/3 and ER equipment and instrument is also
1/3.
● Hospital management can collaborate
with rural municipality and required
equipment could be procured with rural
municipality support.
● Logistics expansion possible with
upgrade of the hospital into Trauma
Center
● Financial challenges in maintaining, expanding
and upgrading logistics
● Emergency situations like natural disasters,
pandemics can cause shortage of medicines
and equipment

Recording and Reporting
Record keeping is done according to HMIS
Records presented and reviewed on monthly
basis
Recording officer has been assigned
Patient registration software outdated and
not renewed
Electronic reporting system not present
Direct E-reporting to the local government Storing, preserving and maintaining manual
records can be a challenge

Service delivery
● Round the clock emergency services by
well-trained medical professionals
● Adequate number of beds in inpatient
ward for admission of emergency cases
● One ambulance providing 24hours
transportation facilities to patients
● Provision of subsidized services for
marginalized, needy and trauma patients
● Existing human resource may not be
enough in cases of mass casualty
● Only basic emergency services available
● Management of patients needing
operative services not possible at times of
absence of consultant
● No round the clock lab and radiological
services for emergency patients
● Lack of blood bank facility
● Construction of trauma center can
convert the hospital into a major
institution for trauma and mass casualty
management
● Finances of the hospital can impose a
challenge in expansion and upgrade of
health services

Epidemiological Analysis of
Acute Gastroenteritis
(AGE) in Hetauda Hospital

General Objective:
To conduct epidemiological study on Acute
gastroenteritis (AGE) cases in Hetauda Hospital.

Specific objectives:
• To study the burden of AGE in Hetauda
Hospital
• To analyze the trend of AGE and to compare
with the national figure
• To analyze the age and sex disaggregated data
of total AGE cases reported in Hetauda
Hospital

Rationale:
• Diarrhoea is a leading cause of malnutrition in children
under five years old.
• A significant proportion of diarrhoeal disease can be
prevented through safe drinking-water and adequate
sanitation and hygiene.
• AGE is one of the six priority diseases in Nepal reported
weekly in the EWARS.
• AGE was consistently found to be one of the most
common diseases in Hetauda Hospital while analyzing
the hospital inpatient records tally sheet.

12
4
13
7
16
13
15
12
6
18
10
0
4
3
5
3
4
8
0
2
4
6
8
10
12
14
16
18
20
No.
of
cases
Month
Month-wise trend of AGE cases

12
4
13
7
16
13
10
0
4
3
4
8
0
2
4
6
8
10
12
14
16
18
Shrawan Bhadra Ashwin Kartik Magh Falgun
No.
of
AGE
cases
Month
Comparison of AGE cases in two fiscal years
Year 2076/77 Year 2077/78

0
50
100
150
200
250
300
350
400
28th
week
2019
1st
week
2020
28th
week
2020
1st
week
2021
12th
week
2021
No.
of
AGE
cases
Week
Trend of AGE cases (National data - EWARS)

0
200
400
600
800
1000
1200
1400
1600
No.
of
cases
Month
Month- wise trend of AGE cases
(National data - EWARS)

Month-wise trend of AGE cases in National level and in
Hetauda Hospital:

0
30
33
18
10
12
16
13
8
13
0
5
10
15
20
25
30
35
< 28
days
<1
year
1- 4
years
5-14
years
15-19
years
20-29
years
30-39
years
40-49
years
50-59
years
60 and
above
No.
of
cases
Age group
Age-wise distribution of AGE cases from 2076
Shrawan to 2077 Falgun

10%
90%
% of AGE cases among total inpatients in age group
<1 year
AGE
Total inpatients

7%
93%
% of AGE cases among total inpatients in age group
1- 4 years
AGE
Total inpatients

46%
54%
Sex- wise distribution of AGE cases
Male
Female

Discussion and Conclusion:
• The cases of AGE is in decreasing trend.
This can be attributed to:
- introduction to Rotavirus vaccine in the NIP on 2nd
July 2020 (18th Ashad 2077)
- increased accessibility of health services,
- increased awareness among people, and
- overall increase in quality of life.

• The highest distribution of AGE cases is among
two age groups (< 1 year, and 1-4 years) :
- less than 1 year
(30 cases, contributes 10% of total inpatients in this
age group)
- age group 0-4 years
(33 cases, contributes 7% of total inpatients in this
age group),
- This data is in accordance with the National and
Global scenario.
- Age group <4 years has been seen as a risk factor for
AGE.

• Not much disparity between male and female
population.
- No any sex can be attributed to be risk for AGE.
• The peaks of AGE occur in spring and summer
season.
- This data is in accordance with the National scenario,
where the peak of cases is seen in Summer Monsoon.
- Spring and summer season has been seen as risk
factor for AGE.

Limitations:
• No any hospital records of OPD data were available.
• Inpatient records before 2076 Shrawan were not
available.
• Inpatient records of 2 months (2076 Mangsir and
2076 Poush) were not available in hospital, so there
has been gap in the line graph of the epidemiological
trend.
• The hospital did not have systematic records of
ethnicity, place, and duration of hospital stay of the
inpatients.

• EWARS weekly bulletins of 5 weeks (32nd week 2019,
36th week 2019, 44th week 2019, 30th week 2020 and
35th week) were not available in the EDCD website.
• EWARS data record was available in English weeks
and Hospital data record was available in Nepali
months. So, the EWARS data has not been perfectly
accurate while calculating Nepali monthly data from
English weeks data.

Five Year Plan On
Strengthening Quality Of TB
Service Delivery In
From FY 2078/79 to 2082/83

Situation Analysis in Neelakantha Municipality:
Indicators 75/76 76/77
TB- Case Notification Rate (per 100,000 population) 65.1 129.5
TB- Case Notification Rate (New and Relapse Cases) 55.3 126.3
Total TB Cases (All forms of TB Cases) 40 80
Incident TB cases percentage (New and Relapse Cases) 85 97.5
Child TB Cases (0-14 yrs) 8.8 6.4
Patients Tested For HIV At The Time of TB Diagnosis 47.1 93.8
TB- Mortality Rate 0 4.7
TB- Treatment Success Rate 81.8 86.3
TB- Treatment Success Rate (New and Relapse) 80.0 85.7
Number of Sputum Smear Examined 15 188
TB- Sputum Smear Microscopy Positivity Rate 0 3.2

41 40 80
71.3
65.1
129.5
0
20
40
60
80
100
120
140
FY 74/75 FY 75/76 FY 76/77
Notified TB Cases and CNR by years in
Total TB Cases TB-CNR

Positive aspects of TB Control
Program:
• Community Awareness programs run time-to-
time
• Community screening program conducted once
each in Jyamgrung HP and Khalte HP
• Refresher Trainings run time-to-time
• Two supporting NGOs: Health Research and
Social Development Forum (HERD) and Saathi
• Cohort Meeting held in Municipality Office
once every 4 months

Negative aspects of TB Control
Program:
• No any community awareness programs targeted to
native community (Chepangs)
• Active screening in other high-risk settings not
conducted
• Only one microscopy center in the entire Municipality
• Gene Xpert diagnostic service not started
• Only one designated DOTS Clinic
• CB-DOTS not started
• No co-ordination with any donors or bilateral aid
agencies for the program
• Municipality facing financial constraints for effective TB
Control Program

Rationale:
• Reports from the Health Section of the Neelakantha
Municipality showed increasing burden of TB in recent
years
• Proportion of childhood TB cases diagnosed is also low
• Treatment success rate of TB patients in Neelakantha
Municipality is lower than the national figure
• The mortality rate due to TB increased in FY 76/77 in
• Many negative aspects were found in TB Control
Program of Neelakantha Municipality

High Influence Low Influence
High Importance Municipality Office
District Health Office
Health institutions
DOTS Center
Political leaders
Private Health
Institutions
TB affected patients
Low Importance FCHVs
Local media
Academic institutions
NGOs/ INGOs
Neighboring
Municipality Offices
Procurement Agencies
Stakeholder Analysis

Five-Year Plan:
Overall Objective:
The project contributes to improved TB
indicators in Neelakantha Municipality
Specific Objective:
The quality of TB service delivery in
Neelakantha Municipality is strengthened,
where men, women and children in the target
population have increased access to adequate
TB information and services, with special
emphasis to TB patients

Results:
1. Adequate testing sites, microscopy centers, and DOTS
Clinics equipped with trained human resources are
available for providing TB diagnostic and treatment
services
2. Accessibility of TB services is increased which covers
the entire target population, even in the event of
natural disaster or public health emergency
3. Effective co-ordination between the Municipality,
concerned stakeholders, and the target population is
established to ensure quality program
implementation
4. There is increased public awareness about TB in the
community
5. Operational research is conducted on need basis to
strengthen the 5 year plan

S.N. Activities
Responsible
institutions/persons
78/79 79/80 80/81 81/82 82/83
1.1
Filling of vacant positions and
recruitment of new additional
staffs
Municipality, Public
Service Commission,
Health institutions
1.2
Trainings and orientation to all
health personnel to diagnose and
manage TB including MDR and
childhood TB
Training session
coordinator
1.3
ACSM training for all healthcare
workers, school teachers, FCHVs
and NGO/CBO workers
1.4
Establish new microscopy centers
and DOTS Clinics
Municipality, Health
office
1.5
Provide continuous drug supply
to all DOTS clinics
Municipality, National
TB Control Center
1.6
Start Gene Xpert testing facilities
in Health Posts
Municipality
1.7
Roll out DR TB tracking at all
Gene Xpert sites

S.
N.
Activities
Responsible
78/79 79/80 80/81 81/82 82/83
2.1
Provision of DOTS in COVID
isolation centers
DOTS Clinic In-charge,
Isolation center
management committee
2.2
Provision for TB screening by
following COVID guidelines
HPs, FCHVs, Municipality
2.3
Conduct mobile screening camps in
hard-to-reach areas and in Chepang
inhabited areas
2.4
Conduct active TB screening camps
in high-risk settings (Factories, Jails,
Gumbas, Schools, and Slum areas)
2.5
Formulate plan of action for
continuation of TB services in event
of natural disaster and public health
emergency
District Health office,
Municipality
2.6
Financial support to poor TB patients
for transport and diagnosis
Municipality, NGOs
2.7 Start CB-DOTS in the Municipality
DOTS Clinic In-charge,
Volunteers

S.N
.
Activities
Responsible
institutions/perso
ns
78/79 79/80 80/81 81/82 82/83
3.1
Conduct an operational research to map
and estimate private sector contribution
to TB service
Municipality,
District Health
Office
3.2
Prepare a plan of action to enhance the
performance of PPM program
3.3
Conduct regular meetings between
NGOs, bilateral aid agencies and donors
involved in NTP
3.4
TB orientation to private practitioners to
notify the TB patients diagnosed at
private health facilities
3.5 Distribute NTP guidelines to all PMPs
3.6
Link DOTS centers to microscopic
centers through courier
3.7
Coordinate and collaborate NTP
activities with HIV/AIDS programmes

S.N
.
Activities
Responsible
78/79 79/80 80/81 81/82 82/83
4.1
Mass awareness through local
TV channels, radio and
newspapers
Local media focal person
4.2
Awareness program targeted for
native communities
Awareness program
coordinator
4.3 Celebrate World TB Day
World TB day program
coordinator
4.4
Press conference and workshops
for journalist at Municipality
level
Information department,
municipality
4.5
Door-to-door distribution of IEC
materials( posters, brochure,
stickers)
IEC department, FCHVs
4.6
Installation and maintenance of
information board on TB
Health office, Health
institutions
4.7 School health program
School health program
coordinator

Budget Summary:
S. N. Fiscal Year Phase Budget (in Rs.)
1 2078/79
Phase 1
21,80,850.00
2 2079/80 13,59,920.00
3 2080/81
Phase 2
12,06,400.00
4 2081/82 10,02,400.00
5 2082/83 22,16,050.00
Grand Total 79,65,620.00

Indicators
Phase 1
(by end of
FY 79/80)
Phase 2
(by end of
FY 82/83)
Outcome Indicators
TB- Treatment Success Rate 90% 95%
TB- Mortality Rate 2% 1%
Proportion of childhood TB cases among all notified cases 10% 15%
Process Indicators
Proportion of notified TB cases started on treatment regimen 80% 100%
Assessment score on KAP about TB among Chepangs 50% 75%
Assessment score on KAP about TB among students 70% 90%
Proportion of TB patients receiving DOT in their stay in isolation 100% -
Poor pts receiving financial support for transport & diagnosis 70% 90%
Input Indicators
Percentage of vacant positions filled 100% 100%
Percentage of health professionals trained on diagnosis and
management of TB including MDR and childhood TB 80% 100%
Number of microscopy centers 4 7
Number of DOTS Clinics 7 7
Targets:

Limitations of the five-year plan
• It can be difficult to conduct mass awareness campaigns and
training programs amidst the global pandemic
• There is a requirement of collaboration and cooperation between
multiple sectors which can be a challenge
• The plan is based on prolonged support from multiple sectors which
may not be possible in certain scenarios
• It can be difficult to smoothly conduct the program due to the
political instability in our country and the program being based on a
huge budget
• Time constraint can impose a challenge to the plan
• Successful completion of the plan requires lot of work, motivation
and patience from staffs, health professional, local people,
municipality and the government. So, programs like these can be a
challenge to accomplish

Conclusion
• The plan has focused on increasing the quality of
TB services by strengthening the health workers
through trainings, improving the health
infrastructure and setting up screening camps in
every nook and corner.
• It has also prioritized on mass awareness through
media and door to door IEC material distribution
programs
• While the program has its limitations and
challenges, a successful completion of the program
can bring a huge change in the health scenario of
the municipality and boost the overall
development.

Recommendations
To the Department of Community Medicine
• The program is a great platform for us 4th year students
to have exposure of and to understand the health care
delivery systems in the country, so the program should
be continued.
• Details of logistics arrangement around the placement
site was studied by the Department, which has
certainly made us easier, we would like to suggest
continuing it.
• The introduction would have been more formal and
the rapport would have been more effective if the first
introduction between the students and the respective
stakeholders was accompanied by teachers from the
Department.

To Benighat Rorang Rural Municipality
• The rural municipality should strengthen the local
health institutions by upgrading capacity and
infrastructures.
• The health division of municipality should
conduct regular training to enhance the quality
and service delivery of health workers.
• The municipality should conduct health
awareness campaigns and expand the health care
facilities to increase health service accessibility
especially among the marginalized Chepang
people.

To Highway Community Hospital
• Maintain triage system in the emergency room.
• Maintain emergency stock of medicines and
supplies for mass casualty management.
• All basic ER equipment and instruments should
be made available.
• Training programs like PTC, ETM, BLS and ACLS
should be conducted by the hospital for nurses
and paramedics.
• Carry out at least one mock drill and disaster
preparedness every year.
• The hospital might as well establish a blood bank,
as it is the only hospital providing emergency
services in a large catchment area.

To Hetauda Hospital
• Start OPD based recording and reporting.
• Systematic storage of both out-patient’s and in-
patient’s data should be done.
• Electronic recording system should be started.
To Neelakantha Municipality
• Municipality should conduct regular meetings with
NGOs/ INGOs, donors, and bilateral aid agencies and
try to encourage them to fund for TB activities.
• More microscopy centers and Gene Xpert sites should
be established.
• Community awareness programs conducted from the
Health section of the municipality should include active
participation of native community (Chepangs) too.

Learning Reflections
• We learned about the health service delivery
mechanism at regional, district and community level
hospitals. Although there were differences in the
staffing and budgeting, overall organization and
planning was found similar in health institutions of
all levels.
• We came to know about the structure and functions
of Municipal Health System and came to know how
the Health Section of the Municipality co-ordinates
overall health sector of the Municipality.

• We came to know about how the information flows
from the health institutions to the Health Section,
and from there to higher levels and vice-versa.
• We understood the conceptual framework of critical
analysis and developed necessary knowledge and
skills required to carry out SWOT analysis to identify
the internal and external conditions/elements that
will affect the achievement of aims.
• We acquired the skills necessary to analyze the time,
place and person distribution data of a particular
disease.

• We have learned necessary knowledge and skills
required to analyze the pertinent health situation,
identify the core problem, make objectives, prepare
a logical framework matrix and thus formulate a five-
year plan to address the particular problem.
• We acquired rapport building and advocacy skills and
now can confidently deal with the concerned
stakeholders.
• We experienced group dynamics that has become an
added asset to our future professional practice.

Bibliography
• Benighat Rorang Rural Municipality Profile- 2075
• Benighat Rorang Rural Municipality Website
(http://benighatrorangmun.gov.np/)
• Annual Education Report of Benighat Rorang Rural Municipality- 2076
• Health Management Information System (HMIS) Guideline 2075
• HMIS Report of F.Y.2076/77 of Highway Community Hospital
• Minimum Service Standards (MSS) Checklist to Identify the Gaps in Quality
Improvement of Primary Hospitals
• Health Infrastructure Development Standards 2074
• Hospital Inpatient Records tally sheet from 2076 Shrawan to 2077 Falgun
of Hetauda Hospital
• EWARS weekly bulletins published by EDCD
• Hetauda Hospital Website (http://hetaudahospital.gov.np/)
• DoHS Annual Report F.Y. 075/76
• Neelakantha Municipality Website
(https://neelakanthamun.gov.np/en/node/13)
• National Tuberculosis Management Guidelines 2019

With Deputy Mayor of Benighat Rorang Rural Municipality

Report Submission to CEO of Highway Community Hospital

Photo with Director, Medical Superintendent and Manager after presentation at
Hetauda Hospital

Report submission to Health Section Officer at Neelkantha Municipality, Dhading

HEALTH SYSTEM MANAGEMENT FIELD PROGRAM REPORT

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