The campus presentation of DHSM outcomes of Gorkha district-2073

Anusha Ban
Biplav Babu Tiwari
Kabita Devkota
Rupesh Karn
Seejan Lamichhane
2District Health System Management-2074, Gorkha

• Introduction
• District profile
• District Health Management System
• Institutional visit
• Epidemiological study on Depression
• Critical Analysis
• Mini Action Project
– Logistic Management
– Safe motherhood
• Five year plan on Immunization
• Learning reflection and recommendation
• Annex
District Health System Management-2074, Gorkha 3

District Health System Management (DHSM)
⁻ Comprehensive District Health System Management field practice, a
substantial district based practical oriented subject of four year curriculum,
enable students with the higher possible technical and managerial
competencies in the district level health programs, including problem
identification, planning, implementation, training, health education and
research. It also helps to explore the current state of district health system
management including functions, health programs and processes. Together
of five groups consisting five members in each spent 60 days from 2074-02-
15 to 2072-04-12 in five different districts out of which we spent two months'
period to assess District Health System in Gorkha District.

General objective
• To describe and analyze the district health system of Gorkha district so as to develop
managerial and technical skills.
Specific objectives
• To develop knowledge and skills to review and prepare district health profile including
demographic, socio-economic and cultural characteristics.
• To describe the different health program that runs in district.
• To visit line agencies and peripheral health institutions to study its health service
management system.
• To develop knowledge and skills to prepare epidemiological study in selected health
problem
• To develop knowledge and skills to critically analyze specific health/management issue.
• To develop knowledge and skills and prepare planning, implementation and evaluation of
mini action project on the selected management issue/health program.
• To develop knowledge and skills to prepare Five year plan on health program.

• Reviewed demographic and health profile of Gorkha
district.
• Conducted an epidemiological study on Depression.
• Analyzed critically on five different management
issues.
• Planned, implemented and evaluated mini action
project on a prioritized issue(Logistics Management)
at DPHO Gorkha and (Safe-motherhood) at Bunkot-
health post.
• Developed a five-year plan to improve the effectiveness
of specific aspect of district health system on
Immunization.

S.N. Activities Days Date
1 Departure from campus 1 15/02/2074
2 Informal introduction 1 16/02
3 Introduction, objective sharing and work plan presentation 1 17/02
4 Data collection 10 18/02 to 27/02
5 Visit to Govt. organization and I/NGOs 5 28/02 to 01/03
6 Peripheral visit to PHCCs, HPs, UHC, CHU etc. 5 02/03 to 06/03
7 Processing and analysis of data 5 07/03 to 11/03
8 Epidemiological study 8 11/03 to 18/03
9 Critical analysis 7 19/03 to 25/03
10 Mini Action Project I 6 26/03 to 31/03
11 Mini Action Project II 3 32/04 to 02/04
11 Strategic five year plan 5 03/04 to 07/04
12 Final presentation
I. Preparation
II. presentation
2
1
1
08/04 to 09/04
08/04
09/04
13 Departure from District 1 11/04/2074 7

• Study area: Gorkha District
• Study design: Descriptive and Cross- sectional
• Study duration: 60 days
• Study method: Qualitative and Quantitative
• Technique of data/information collection:
Secondary data review
Interview (key informants, In-depth interview)
Meeting –formal and informal
Observation

• Data collection tools
Interview guidelines
Observation checklist
Review format
• Analysis
Review, editing and tabulation of data

Longitude: 84°27’ East to 84°58’ East
Latitude: 27°15’ North to 28°15’ North
Altitude: 228m to 8163m
Area: 3610 sq. km.

Development Region Western
Zone Gandaki
State Number 4
East Dhading District and Tibet
West Tanahun, Lamjung and Manang District
North Manang District and Tibet
South Chitwan and Tanahun District
Electoral constituency 3
Ilakas 13
Municipalities 2 (Gorkha municipality and Palumtar municipality
VDCs 60

15.0% 10.0% 5.0% 0.0% 5.0% 10.0% 15.0% 20.0%
0 to 4
5 to 9
10 to 14
15 to 19
20 to 24
25 to 29
30 to 39
40 to 44
45 to 49
50 to 54
55 to 59
60 to 64
65 to 69
70 to 74
75 to 79
80 to 84
85 to 89
90 to 94
95+
Female%
Male%

Key Information Census 2001 Census 2011
Total Population 288134 271061
Male population 134407 121041
Female Population 153727 150020
Total Household 58923 66506
Av. Family Size 4.89 4.08
Population Growth Rate (%) 1.32 -0.61
Sex Ratio 87.43 80.68
Literacy Rate(%) 53.85 66.34
Population Density 79.82 Person/Km2 75.09 Person/Km2
Dependent Population -------------------------- 123714 (almost 46%)
HDI position -------------------------- 40
Poverty Index -------------------------- 41.7

District Health System
Modern Health
Care system
Supportive SystemTraditional Health
Care system
DPHO
PHCC (3)
Private
Hospitals
and
clinics
District
Aayurvedic
Health Center
(1)
District
Hospital
Ayurvedic System
Traditional
Healers
Traditional
Healing
System
HPs (66)
PHC/ORC
(240)
EPI clinic
(258)
FCHV
(624)
GOs
I/NGOs
Ayurvedic
Aushadhalaya
(6)

External environment
PROCESS
Planning,
Organizing,
Staffing,
Directing,
Co-ordination,
Recording & Reporting,
Budgeting,
Monitoring & Supervision,
Evaluation
INPUT
Human
resources,
Budget ,
Logistics,
Information,
Training
Feedback
OUTPUT
Program indicators
Mortality and
Morbidity
indicators
Health service
utilization

District Health System Management-2074, Gorkha

S.N. Type of health Facilities Total
1 Government Hospitals 2
2 Primary Health Care Centers 3
3 Health Posts 66
4 Urban Health Center 7
5 Rural Community Health Unit 5
6 Community Health Unit 5
7 DOTS microscopic centers 6
8 DOTS treatment centers 71
9 Leprosy treatment centers 71
10 HIV diagnosis and treatment center 4
11 ART service 1
12 PHC ORC 240
13 EPI clinic 258
14 FCHVs 621
15 Private Hospitals 4
16 I/NGOs working in health 9

S.N. Category of Human Resources Total Sanctioned
Posts
Proportion of
Fulfilled Posts
1 Sr. Public Health Administrator 1 100
2 Medical Superintendent 1 100
3 Public Health Section In-charge 7 100
4 Medical Doctors 16 100
5 H.A. 69 91
6 Staff Nurse 16 69
7 A.H.W. 141 96
8 A.N.M. 141 98
9 Other Technical Staffs 15 80
10 Other Non-Technical Staffs 84 96

Particulars Budget (in Rs. 000)
Total allocated Budget 175196
Total expenditure 162477
Total expenditure as % of allocated budget 92.74%

• Planning in the DPHO Gorkha is not fully based on the
bottom-up approach rather the mixed is adopted.
• Types of planning prevailed
 Annual planning
 Short term/ operational planning
 Contingency planning
 Budget planning

• Decision making: In the DPHO, decisions were made by
discussion between staffs in staff review meeting
• Leadership: Sr. PHA was found to be taking leading role in
the program conducted by DPHO, Gorkha. In the absence of
Sr. PHA, power delegation was observed.
• Communication: Two way information flow through official
letters, telephone and reports was done on the district through
vertical and horizontal process.

• Monitoring, Supervision and Evaluation: Supervision
checklist and work plan was available however but no
effective integrated supervision was being carried out.
Program wise focal person meeting to monitor the progress of
specific health programs and participatory evaluation of Health
Facility including specific programs was done on annual
review quarterly meeting and discussion with NGOs to
monitor the progress and planning of future activities.
• Motivation: Training and deputation were the strong means of
motivation in the district. TA/DA (Travelling and Daily
Allowances) was another means of motivation for fieldwork in
the district.

Vertical co-ordination
MoHP
DoHS
RHD
DPHO I/NGOsGOs
Horizontal co-ordination
Co-ordination
DPHO
PHCC/HP

• For the recording and reporting purpose different HMIS and
LMIS formats were used in the DPHO
• HMIS reporting was done monthly
• LMIS reporting was done quarterly

87 87 87 84
69
77
83 82 83
69
75
83 83
78
66
0
10
20
30
40
50
60
70
80
90
100
BCG DPT3- Hep B-
Hib
OPV 3 Measles rubella TT/Td2+
Percentages
Antigens 2070/71
2071/72
2072/73
Source: Annual Report Gorkha 2072/73

75
83 83
78
66
99
82
97
79
71
87
81 79 77
66
0
20
40
60
80
100
120
BCG DPT3- Hep B-
Hib
OPV 3 Measles rubella TT/Td2+
Percentages
Antigens
Gorkha WDR National
Source: Annual Report Gorkha 2072/73 and Annual Report 2072/73

3.45
4.91
3.7
-6.8
3.14 3.3
-2.83
1.32 1.32
-8
-6
-4
-2
0
2
4
6
BCG vs. Measles DPT 1 vs. DPT 3 OPV1 vs. OPV 3
Percentages
Antigens
2070/71
2071/72
2072/73

S.N. Vaccines Gorkha WDR
2072/73
National
2072/73
2070/71 2071/72 2072/73
1. BCG 89 88 88 78 74
2. DPT-HepB-HiB 34 34 37 22 21
3. Polio (OPV) 37 35 39 26 23
4. PCV - 16 23 5 9
5. Polio (IPV) - 72 78 64 58
6. Measles 79 74 70 59 57
7. Td 47 45 47 32 33

S.N. Indicators Gorkha WDR
2072/73
National
2072/732070/71 2071/72 2072/73
1. Growth monitoring coverage among
under 2 children (%)
86 100 100 79.28 63.38
2. Proportion of malnourished
children (%)
0.38 0.38 0.2 1.93 3.26
3. Pregnant women supplemented
with iron tablets (%)
75 75.47 45 90 75.3
4. Pregnant women supplemented
with anthelminthic (%)
67 73 64 54.2 55.1
5. Postpartum women supplemented
with vitamin A (%)
47 47.36 42 44 40.3

549
1178
474
939
463
820
422
648
0
200
400
600
800
1000
1200
1400
Diarrhea ARI
Incidenceper1000
Diseases
2070/71 2071/72 2072/73 National

39.16 38.34
39.93
34
43
0
5
10
15
20
25
30
35
40
45
50
2070/71 2071/72 2072/73 WDR National
Percentages

77
84 88
97
42 42 41
51
0
20
40
60
80
100
120
2070/71 2071/72 2072/73 National
Percentages
ANC visits
ANC 1st Visit ANC 4th Visit

38
34
39
54 55
41
38
41
53 52
0
10
20
30
40
50
60
2070/71 2071/72 2072/73 WDR National
Percentages
Institutional Delivery PNC 1st visit

22
57
21
51
19
53
0
10
20
30
40
50
60
Condom Pills
Percentages
% distribution by FCHV among total distribution
2070/71
2071/72
2072/73

Services 2071/72 2072/73
Average person served at
PHC-ORC clinic
19 17
ANC checkup in PHC-ORC (%) 50 47

100
79
90
83 80
94
100
85
97
113
89 90
0
20
40
60
80
100
120
Case finding rate Sputum conversion rate Treatment success rate
Percentages
Indicators
2070/071 2071/072 2072/073 National

Indicators Gorkha WDR National
070/071 071/072 072/07
3
New case detection rate per
10000 population
0.23 0.77 0.19 7.89 10.67
Registered prevalence rate 0.45 0.35 0.19 0.71 0.89
Disability grade II 0 0 0 1.71 3.57

Indicators 70/71 71/72 72/73 WDR National
Number of person receiving ART 112 119 163 3214 12446
Total HIV positive among tested 32 22 15 - -
Prevalence rate per 1000
population
0.12 0.084 0.055 - -

S.N. Diseases Number Percentage
1 URTI 23186 7.92
2 Headache 19508 6.67
3 Gastritis 19130 6.54
4 Falls/ Injuries/ Fractures 18817 6.43
5 Acute Tonsillitis 9405 3.21
6 ARI 9227 3.15
7 AGE 8005 2.74
8 Backache (Musculoskeletal Pain) 7408 2.53
9 Arthritis 6650 2.27
10 Viral Influenza 6311 2.16

1. District Reconstruction Project (DRP)
2. District Treasurer Controller Office (DTCO)
3. District Coordination Committee (DCC)
4. District Police Office (DPO)
5. District Women and Children Development Office
(DWCDO)
6. District Education Office (DEO)
7. District Agricultural Developmental Office (DADO)

1. Gorkha District Hospital
2. Aaruchanaute PHCC
3. Barpak HP
4. Bunkot HP
5. Namjung HP
6. Nareshwor HP
7. Paslang UHC
8. Aarughat Polyclinic and Diagnostic Center
9. District Ayurvedic Health Center

1. Suaahara II
2. Health for Life
3. Medic Mobile
4. Ipas
5. Marie Stopes

• Depression is a common mental disorder,
characterized by persistent sadness and a loss of
interest in activities that you normally enjoy,
accompanied by an inability to carry out daily
activities, for at least two weeks.
• More than 300 million people are now living with
depression, an increase of more than 18% between
2005 and 2015

• Global Burden of Disease Study 2013 showed that depression ranked 2nd
highest specific cause of Years Lost Due To Disability (YLD) in both
developed and developing countries.
• It lies among the Top 10 causes of YLD in South Asia.
• There is highest suicidal rate of 24.9% per 100,000 in Nepal ; being the
leading cause of death for Nepalese women aged 15-49 and hospital
based studies showed majority of suicide attempters have depression.
• Depression is found to have an increasing trend in Gorkha district; Gorkha
alone covers 15% of all depression cases in Western development region.

• Study Area: Gorkha District
• Study Design: Descriptive and Cross Sectional
• Study Duration: 8 days
• Study Unit: Each cases of depression
• Data source: Annual Reports, OPD Morbidity
Sheets, TPO Nepal post earthquake survey on
mental health

• Data collection techniques: Secondary data
review
• Data Collection tools: Data Review Format

General objective
• To describe the epidemiology of depression in Gorkha district.
Specific objectives
• To analyze and interpret the Depression in terms of Time, Place
and Person.
• To identify the trend of the disease in last 3 years.
• To predict the factors associated with the problem trend and
provide input to manage the problem in future.

1088
897
2097
0
500
1000
1500
2000
2500
2070/71 2071/72 2072/73
Source : OPD morbidity sheet 2072-73

1828
269
VDC
Municipality
n=2097
Source : OPD morbidity sheet 2072-73

• Sex-wise Distribution
62%
38% Female
Male
n=513
Source : Post-Earthquake survey of TPO-Nepal, 2015

• Age-wise distribution
46.80%
31.50%
40.80%
0%
10%
20%
30%
40%
50%
60 years and above 20-59 years under 20
60 years and above
20-59 years
under 20
n=513

• Ethnicity-Wise distribution
48.90%
42.30%
30.90%
25.40%
0%
10%
20%
30%
40%
50%
60%
Dalits Janajatis Brahmins Chhetris
Dalits
Janajatis
Brahmins
Chhetris
n=513

• Many risk factors for depression and anxiety in Nepal,
including poverty, illiteracy, a low education level, living in
a conflict area, and experiencing disaster.
• Gorkha also consists of higher number of registered cases
of depression with 2097 OPD cases in 072/73. Out of total
48512 cases of depression nationally, Western development
region constitutes 13886 out of which 2097 (15%) is
covered within the Gorkha district alone.
• But the maintenance of records, services delivered and
attention provided towards mental health, being a disaster-
affected area, is found to need some improvement.

• Cold chain management
• Logistic management
• Hospital reporting
• Adolescent friendly health services
• Integrated supervision

Existing Problem
PESTLE Analysis
(Political, Economic, Social, Technological, Legal and Environment)
Gap Analysis
SWOT Analysis
Internal Appraisal
External Appraisal Opportunity
Strength Weakness
Threats

Critically Analyzed by:
Biplav Babu Tiwari
Roll no. 522

• High wastage rates in terms of all vaccines
compared to national and regional level
• Poor recording and reporting system
• Maintenance of cold chain at district level was
done appropriately but improper storage and
handling of the vaccines at visited peripheral
health facilities

• The main cause behind high wastage rates is improper
transportation of vaccine by the personnel transporting the
vaccine both from district to peripheral health facility and from
the health facility to the immunization sessions.
• Another cause was the lack of storage area to restore the
returned vaccine which has increased the wastage rate to such
high rates.
• Similarly, we found there was no proper planning of vaccine
procurement and distribution at district as well as peripheral
level.

• Establishment of sub-centers to increase coverage for northern part
of district
• Onsite coaching of cold chain management should be done
• Refresher trainings need to be provided to peripheral cold chain in-
charge and vaccine transporters
• Over/under estimated target population should be reviewed by
mobilizing ANM and AHW
• Awareness program on importance of vaccination need to be
intensified along with the programs to eliminate stigmas associated
with it
• Proper recording and reporting

Kabita Devkota
Roll no. 524

• Storage of drugs and medical equipments was
unsatisfactory.
• Records regarding expired and destroyed medicines
were unavailable.
• Need based supply and pull system on logistics
were found weak.
• Accountability of donated logistics was absent.

• Store section was understaffed.
• Unhygienic conditions was seen in the district store (pest
and insect ridden, mould growths, rat droppings).
• Storage of medicines was haphazard and unsystematic.
• FEFO wasn’t maintained.
• Waste management for expired medicines was absent. A
separate building was rented to store the expired drugs
instead of being disposed of.
• Push system was implemented in the district store.
• Web based LMIS system was used.
• Donated logistics were undistributed, and at present were
expired.

• An extensive and regularly updated database on expired
drug is required.
• A proper waste management system must be explored
• Pull system must be implemented
• District store personnel must be regularly trained on store
management
• To strengthen Web based LMIS, staff must be made competent
via regular refresher trainings.
• District store should take accountability of the medicines and
medical equipments donated during the 2015 earthquake

Seejan Lamichhane
Roll no. 538

• Under reporting and untimely reporting of data was
found in hospitals
• Private hospitals were not found involved in HMIS
reporting and thus fluctuations in data reported and actual
cases are seen.
• Human resources deployed were under qualified ; and
not trained for reporting through HMIS forms.

• Lack of proper monitoring and supervision to recording and
reporting department.
• Timely reporting unavailable due to geographical reasons.
• Under qualified and untrained personnel for recording.
• Inconsistencies and incomplete reporting.
• Less efforts were found to involve the private sectors in HMIS
reporting.

• Assignment of skilled personnel to recording and reporting unit
accompanied by better remuneration
• Sensitization of stakeholders involved with recording and reporting on its
importance and handling.
• Trainings on Revised HMIS indicators should be provided to staffs for
proper recording and reporting; Proper supervision, monitoring and
performance appraisal for staff motivation.
• Dissemination and use of information from the system for decision making.
• More emphasis on electronic than paper based recording and reporting.
• Programs for motivating the private sectors for reporting; should be
focused on. The collaboration and co-ordination with the private health
sectors by the government has been a basic requirement today.

Anusha Ban
Roll no. 517

• Poor functioning of Adolescent Friendly Service (AFS) sites in
the district.
• Low rate of service utilization at AFS sites.
• Commenced vertical reporting from FY 2073 Falgun.
• Irregular and inaccurate reporting.
• Increasing cases of teenage pregnancy and under 20 abortion.
• Adolescent health ; one of the major components of family health.
• About one-fourth of the total population of Gorkha are
adolescents.
83

• Altogether 13 AFS sites for adolescents all over the district
• Lack of integration in HMIS reporting form; Vertical reporting
done to the DPHO by AFS sites.
• Irregularity in recording and reporting;
– Lack of disaggregated ASRH data (by age/ sex).
– Only 4/13 AFS sites had submitted a report to the DPHO.
• Inadequately trained health workers and unstable staffing.
• Inadequate monitoring and Supervision of AFS sites; this FY- 3
AFS sites visited (1 health post, 2 PHCC).
• No activities done towards demand generation.

• Focus on demand generation esp. targeting the Dalit and
marginalized population of Gorkha.
• Development of a better recording and reporting tool.
• Training health workers according to the training package
recommended by the government.
• Maintain stability in regard to staffing at AFS sites.
• Ensure proper evaluation of the health facility before declaring it
an AFS site
• Development of an action plan for yearly supervision is also
recommended.

Rupesh Karn
Roll no. 532

• Supervision checklists were not used in practice.
• Reporting and feedback system in case of integrated
supervision was poor.
• Integrated supervision being one of the priority programs of
GoN-Ministry of Health.
• Supervision tools are not practiced frequently and
systematically.
• Budget of the integrated supervision in the district is
taken as the facility rather than a program.
• Supervision was taken as the power to threaten health
workers rather than motivating and guiding them.

• Supervision status was unsatisfactory both
qualitatively and quantitatively.
• Upper belt of Gorkha district had not been
supervised since 2-3 years.
• Decreasing budget for integrated supervision.
• DPHOr was found to be unaware about supervisor
and his/her supervision.
• Supervision checklist was not in practice.
• Follow up of supervision was very much rare.

• There should be a separate unit for integrated supervision in
the district.
• Regular and compulsory use and reporting of checklists.
• Follow up of supervision method should be applied on regular
basis
• Provision of regular written feedback system after supervision
• Need for adequate orientation and training to supervising staffs
for the conceptual clarity on Integrated Supervision.
• Supervision schedule should be prepared in PHCC/HP level for
the supervision of community programs.

Observed
problems
Magnitude
Of
problem
Administrativ
e
feasibility
Support
from
DPHO
Capital
and
Equipmen
t
Human
resource
Tota
l
scor
e
Ran
k
Logistics
Management
4 4 4 4 3 19 1st
Hospital
Reporting
3 1 3 1 2 10 3rd
Integrated
Supervision
3 3 2 3 4 15 2nd
Adolescent
Friendly
Service Sites
1 3 1 2 1 8 4th

General Objective:
• To strengthen the store management at Gorkha DPHO.
Specific Objective:
• To describe the existing situation of the store at Gorkha
DPHO to the concerned authorities.
• To discuss on the existing situation and identify the factors
responsible and possible solutions.
• To develop a conceptual floor plan for the store in
participation with authorities concerned.
• To ensure the sustainability of MAP.

– Many of the unopened boxes of stock items were stored in a
haphazard manner.
– Lack of cleanliness - formation of dirt and mould on many stock
items.
– Stock items destroyed due to infestation of rodents.
– First Expiry First Out (FEFO) not maintained while storing stock
items on shelves.
– Many stock items were found to be expired; stocks provided for
relief at the time of 2015 earthquake were still stored in expired
condition.
The store management at the Gorkha DPHO was not
satisfactory

• Duration: 6 days
Activity Date No. of days
Preparation
• observation of store
• management of the stock items in
the store
• literature review
•Planning for the workshop
26/03 to 30/03 5 days
Implementation 31/03 1 day

• Methods: Presentation, Group activity and Group
discussion
• Approach: Participatory
• Tools: Laptop, pen, paper, chart papers, markers,
camera etc.
• Venue: Office of the Store keeper at Gorkha DPHO
• Participants: Cold chain officer, Store manager at
DPHO, DC of lifeline, DC of Ipas, assistant store
keepers and group members.
• Resource Persons: Store manager Mr. Chandra Sunar
and Cold chain officer Mr. Rishi Ram Khatri.

Activities
Methods/
Approach
Person
responsible
Welcome speech and registration
Seejan
Lamichhane
Sensitization on logistics management and
rationale presentation.
Power point
presentation
Anusha Ban
Concept presentation: develop a floor plan
3-D floor plan
presentation
Rupesh Karn
Discussion and Design finalization of floor
plan(activity)
Participatory Kabita Devkota
Point Summarization Participatory Biplav Tiwari
Concluding presentation and closing speech
Power point
presentation
Seejan
Lamichhane

• The key persons of our study at the DPHO expected
us to contribute our manual labor and manage the
store according to the floor plan finalized in the
workshop.
• Due to the extensive nature of these expectations we
were unable to meet them, this MAP was considered
to be incomplete and hence unacceptable.

General objective:
• To strengthen the safe motherhood program at the Bunkot
health post, Gorkha.
Specific objectives:
• To describe the existing situation of the indicators of safe
motherhood to the staff members of Bunkot health post.
• To identify factors responsible and find their possible
solutions through a discussion program.
• To ensure the sustainability of MAP.

• Safe motherhood is an important program that
aims to reduce maternal and neonatal mortality
and morbidity.
• Decreasing trend of key indicators of safe
motherhood program at Bunkot health post,
Gorkha.

• Duration: 4 days
Activity Date No. of days
Peripheral visit 04/03 1 day
Literature Review
Tool preparation
Planning for workshop
32/03 to 1/04 2 days
Implementation 2/04 1 day

• Methods: Chart Presentation, Brain storming,
Group discussion
• Approach: Participatory
• Tools: printer papers (A4 – size), chart papers,
markers, camera etc
• Venue: Training hall; Bunkot Health Post, Gorkha
• Participants: Staff of Bunkot health post, In-
charge of Bhorlang health post, FCHVs of Bunkot.
• Resource Persons: In-charge and senior AHW of
Bunkot health post

Activities Methods Responsible Person
Welcome speech and registration Anusha Ban
Introduction to key indicators of safe
motherhood and Rationale presentation
Chart
presentation
Kabita Devkota
Discussion on the existing situation of key
indicators. Identification of factors
responsible and possible solution
Brainstorming
Biplav Tiwari
Rupesh Karn
Group
discussion
Point summarization Participatory
Seejan Lamichhane
Ms.Manila Shrestha (ANM)
Closing speech and Vote of thanks
Mr. Chandra Bhusan Shah
(health post in-charge)

• Enthusiastic participation of the participants
• Feedback collection at the end of the session.
• Appreciation received from the health post
staff for this project.

• A word of commitment was received from all
of the health post staff and the FCHVs to
commit to the recommendations obtained from
the discussion and improve health service
delivery.

• The National Immunization Program (NIP) is a
priority 1 (P1) program of the Government of
Nepal
• “To reduce child mortality, morbidity and
disability associated with vaccine preventable
diseases.”

• The district has been largely focused on declaring
itself full immunization district and despite all the
efforts immunization coverage of all antigens is
steadily dropping
• High amount of dropout and wastage rate.
• Recommended by DPHO staff

• To reduce mortality, morbidity and disability
associated with vaccine preventable diseases
among children and pregnant mothers in
Gorkha district by the end of 2022 A.D.

• To increase immunization coverage in Gorkha
district.
• To reduce dropout rate and vaccine wastage rate.
• To improve the recording and reporting system of
immunization services.
• To strengthen communication, social
mobilization, and advocacy activities
• To improve monitoring and supervision system of
immunization program.

• Discussions and meetings with DPHOr., Cold
chain supervisor.
• Group discussion
• Secondary data collection

BY 2078/79
• To increase coverage of BCG to 94 %
• To increase coverage of DPT3- Hep B- Hib to 96 %
• To increase coverage of Measles Rubella to 95 %
• To increase coverage of TT/Td2+ to 93 %
• To decrease dropout rate of BCG Vs Measles to -0.36%
• To decrease dropout rate of DPT1 Vs DPT3 to 0.5%
• To decrease wastage rate of BCG to 59 %
• To decrease wastage rate of DPT3- Hep B- Hib to 27 %
• To decrease wastage rate of OPV 3 to 29%
• To decrease wastage rate of Measles Rubella to 55%
• To decrease wastage rate of TT/Td2+ to 31%

• Planning Matrix of LFA and budget final.docx

• Insight developed in managerial issues
• Developed analysis and problem solving skills
• Knew the gap between theory and practice.
• Developed life skills like
• Team work
• Group dynamism
• Decision making
• Communication skills
• Accountability

To DPHO
• Provide a copy of annual report to all
peripheral health facilities.
• Trainings shouldn’t be conducted just for the
sake of conducting trainings and finishing
budget.
• Supervision must be conducted regularly.

To campus
• Continuation of intermittent supportive
supervision.
• It would be more beneficial for the students if
they were sent to fields at middle of FY. The
DPHO staffs were willing to help us, but they
were extremely busy.

Activities

• Acute febrile illness outbreak in Namjung VDC
• Total cases (n=93)
– More in female (56.99 %) than male (43.01 %)
– More in age group 10-14 (18.27%)
– More in Brahmin/Chhettri ( 62%)
– Cases found more in Namjung Ward no 6 (42%)
• Quantitative Findings
– Interviewed 21 suspected cases of Acute Febrile Illness
– Symptoms were headache, excessive sweating and weakness
– Probable cause unsafe drinking water

Critical Analysis

Anusha Ban

Political:
•Unstable government.
•Political uncertainty and transition of our
nation into federalism.
Economic:
•Budget allocated-inadequate to provide
services at the AFS sites. [Rs. 10 thousand
distributed to each AFS site as of FY (2072/73).]
•Resource constraint.
Social :
•Existence of social stigma on issues related to
adolescent sexual and reproductive health
•Ethnic groups - Dalit community and
marginalized community (chepang) are highly
vulnerable and unreached population.
Technological :
•Mass media- Easier to reach out to the
adolescents
•Development of convenient and appropriate
IEC materials.
•Difficult to ensure reliability of information
received.
Legal:
•Government plans to continue funding all the
AFS sites and upgrade it to cover all districts.
•Make every health facility with abortion
services adolescent friendly.
Environmental:
• Lack of infrastructure in AFS sites to provide
services- No separate room to ensure privacy
for adolescents.

Strength Weakness Opportunities Threats
• Active involvement of
adolescents in HFOMC
meetings.
• Establishment of IEC
corners in existing
Adolescent Friendly
Health Facilities
• Sensitization of
stakeholders and Health
Workers through
orientation programs.
• Strong collaborative
efforts made with
District Education Office.
• Inadequately trained
health workers at AFS
sites.
• No activity targeted
towards demand
generation.
• Inappropriate
operational hours.
• Unreliable recording and
reporting
• Lack of disaggregated
ASRH data and
integration in HMIS
• Unstable staffing at AFS
sites
• Assistance received
from various
organizations
• Future plan to
expand the existing
number of AFS sites
– 3 more facilities.
• Continuity of the
program ensured
through a review
meeting conducted
in the last fiscal
year.
• Prevalence of
misconceptions
and traditional
beliefs within the
Dalit community
and marginalized
community
(chepang) hence
are unreached
• Inaccessibility due
to geographical
constraints.

• No efforts have been made to address the
vulnerable adolescents of marginalized population
of Gorkha.
• No efforts made towards demand generation.
• Inadequately trained staff providing services in
AFS sites.
• Recording and reporting from AFS sites lacking
reliability.
• Economic constraint due to low budget allocated
for the program

Biplav Babu Tiwari

Political
• Government funded
• Political uncertainty and transition of nation
into federalism
• Change in export laws of the vaccine donor or
manufacturer
Economic
• Less incentive to vaccine handlers and
transporters
• Inflation of vaccine prices
• Demand uncertainty of vaccines
Social
• Lack of proper counseling to general
population
• Existence of stigma on vaccine use
• Vaccines were being utilized through private
sectors
Technological
• Availability of coolers and refrigerator
• Lack of storage area at peripheral health facility
Legal
• Change in export laws of the vaccine donor or
manufacturer
Environmental
• Geographical difficulties to reach upper belts
• Still recovering from damage from earthquake
of 2015
• Having high temperature and humidity to
freezing cold environment

Strength Weakness Opportunities Threats
• Sufficient Logistics
available at district
and sub-stores
• Cold chain officer at
the district level is a
long term staff
• Good practice of
VVM both at district
and peripheral level
• One day training to
AHW and two days
training to vaccine
transporter
• government funded
and P1 program
• Lack of storage areas to
restore the returned vaccines
• No proper planning for
procurement and distribution
of vaccine
• Lack of appropriate storage
area and equipment to store
vaccine at peripheral facilities
• Lack of proper counseling to
general population on
importance of vaccination
• Poor recording and reporting
system
• Lack of supervision and
monitoring
• Support from
different
organizations
(INGOs and
NGOs)
• HMIS training
to newly
appointed H.A.
• Demand
uncertainty of
vaccines
• Possibilities of
damage of vaccines
during
transportation
• Political uncertainty
and transition of
nation into
federalism
• Lack of additional
sub-centers for
northern belt of
district
• Geographic
difficulties

• Problems in identifying target populations
• No regular or refresher training to vaccine
handlers and transporters
• Lack of storage areas for the returned vaccines
• Lack of proper planning of vaccine
procurement and distribution in district as well
as in peripheral sites
• Geographical difficulties

Kabita Devkota

Political factors
 Federalism has not clearly defined where the logistics
management system will remain with the newly to be
formed local governance.
 Ongoing political instability will cause difficulties in
procurement and supply.
Economic factor
 Budget for logistics procurement at district level
is limited.
 In a poor country like Nepal cheaper commodities
are preferred over WHO certified GMP products,
which undermine the quality of services provided
 Stores and cold chain cannot afford state of the art
equipments for better functioning.
Social factors Technological factors
 Lack of trained skilled human resources in stores.
 International cooperation has led to many
countries donating medicine and equipment to our
country
Legal factors
 Formation of “Inventory Control And Basic Logistic
Procedure Manual” and other similar policies has
helped aid store keeping practices
Environmental factors
 The 2015 earthquake destroyed logistics
infrastructure, incurring huge losses

Strengths Weakness Opportunities Threats
 Computerized
recording at
district and
online reporting,
through Web
based LMIS
system.
 District had done
its PDNA
planning in
logistic
management.
 Timely reporting
of LMIS report
throughout
district HFs
 Inadequate number of staff
to manage the district store.
 Frequent turnover of staffs
 FEFO wasn’t maintained.
 Database on expired and
short expired drugs absent.
 Proper waste management
system not present.
 Push system is still in practice
 Logistic trainings carried out
infrequently.
 ASL, EOP not maintained in
peripheral health facilities.
 Supervision and monitoring
infrequent
 Inventory control and
basic logistic
procedure manual
has been developed
by Government of
Nepal
 International donors
(UNICEF, Save the
Children) providing
support after
earthquake.
 Regional Medical
Store is nearby the
district store
 Geographical barrier
 Over dependence on
INGOs
 Provision of
unregistered (non
GMP- Certified)
medicines and medical
equipments by many
external organizations.

• Inadequate number of technical staffs was
causing difficulty during procurement, storage
and supply
• Physical inventory not conducted regularly.

Rupesh Karn

Political factors
•Provision of supervision and training for staffs
responsible for integrated supervision was there.
•There was political instability
•Public support
Economic factors
•Routine Annual Budget Allocated for Integrated
supervision.
•Funding on integrated supervision is decreasing in
each fiscal year
•Lump sum of supervision was used in other field in
the name of supervision on papers.
Social factors
•Taking supervision as a power to threat health
workers
•Conventional attitude of health workers towards
supervision. It is a means of quarrel and conflict
among the staffs for their share in TA/DA rather than
for improving program outputs.
Technological factors
•Online communication system was weak for informal
support
•Supervision checklist was rare
•Written document for integrated supervision was
unavailable
Legal factors
•Supervision should be done at least 2-3 times/year
•Provision of supervision and training for staffs
responsible for integrated supervision was there.
•Destruction of roads during landslides in rainy
season.
•Routine supervision could be affected if there is
epidemic outbreak due to environmental variations.

Strength Weakness Opportunity Threat
•Sufficient
supervisors
available by this
year.
•Routine Annual
Budget Allocated
for Integrated
supervision.
•Supply of
supervision check
list
•Lack of planning
of supervision
schedule
•Lack of
Reporting/Recordi
ng
•Lack of
documented
feedback system
•Taking
supervision as a
power to threat
health workers
•Local and
private transport
availability
•Public support
•Local
governance act
•Problem of
transportation in
rainy season.
•Geographical
barrier
•Quarrel and
conflict among
the staffs for their
share in TA/DA
rather than for
improving
program outputs.

• There was the absence of supervision unit which
specially focuses on supervision
• Use of supervision checklist was rare
• Monthly meeting was held in Gorkha but there
was no discussion on integrated supervision
• Lack of written and documented feedback
• Training to the supervisors was found to be null
for integrated supervision
• There was no follow ups for the supervision

Seejan Lamichhane

Political factors
•A specific and scientific format for recording and reporting has
been provided to the hospitals i.e. HMIS form
•Number of trainings has been organized to train the health
facility staffs on recording and reporting.
•Somehow, the improper handling of recording and reporting
tools by the hospitals are not being supervised and monitored
Economic factors
•Large amount of fundings have been allocated
with the aim of making HMIS system more
systematic and proper.
•Trainings for staffs responsible for reporting and
recording are invested a lot.
Social factors
•No such environmental factors could be found that could
remarkably affect the hospital reporting.
Technological factors
•HMIS, as a web based recording and reporting
system, requiees a competent manpower with
correct computer as well as medical knowledge;
which is lacking in hospitals.
•Acceptance of new computer based technology
has become harder to operate for older staffs.
Legal factors
•Hospital reporting is provided with a certain form for recording
and reporting; distinguished for public hospitals and private
hospitals differently, i.e. 9.4 and 9.5 respectively.
•Provision of certain indicators, trainings for staffs responsible
for recording and reporting is there.
•No such environmental factors could be found
that could remarkably affect the hospital
reporting.
•However, during monsoons, due to the lack of
proper roads, reporting was found more delayed.

Strength Weakness Opportunity Threat
•Meetings and discussions
are held in the leadership
of Hospital management
Committee with
participation of hospital
staffs.
•Powerful tool for
assisting in health
program monitoring at all
levels; Service statistics
central database; HMIS
Intranet
•Large number of human
resources trained on
HMIS; adequate staffs for
recording and reporting
•Inconsistencies and
incomplete reporting.
•Under reporting from
hospitals and less
reporting from private
sector
•Gender specific,
marginalized group data
not yet fully incorporated
in the reporting.
•Training for newly
recruited health
personnel is limited
•Manually data collection,
less use of computer
•Under qualified and
untrained personnel for
recording.
•Computerized system for
data recording and
reporting.
•Large budget and
attention from health
sector towards training of
hospital staffs in HMIS
reporting
•I/NGOs are also
interested to work in co-
ordination with DPHO
•Geographical difficulties.
•Sanctioned posts have
been filled with under
qualified personnel with
no adequate knowledge
on health related terms
and issues.
•Lack of supervision to
recording and reporting
sections from DPHO.

• Under reporting and delayed reporting was found,
• Private sector reporting was found really weak; which
remarkably affected the annual figures and indicators of
the district.
• Sanctioned posts were filled with the under qualified
manpower; i.e. medical recorder and reporter post was
filled with a computer operator.
• Proper keeping and maintaining of data and records of
every year was found not really good.
• Records that could be related to the confidentiality of
the patient was maintained very well.

Increased morbidity and mortality and disability due to VPDs
Decreasing immunization coverage
EPI sessions irregular
and inadequate
Ineffective
management at district
and local level
Ineffective
information
management
system
Inadequate
physical
infrastructure
Demotivat
ed staffs
No
incentives
Inadequate
cold chain
equipment
Inadequate
supply
HFOMC
inactive
Immunization
supervisor
absent for
extended
periods of time
Overwork
due to
understaffing
Transport vehicle
not made
available by
DPHO
Roads
closed
during
rainy
seasons
Micro
planning not
done
Ineffective
governance
by DPHO
Inadequate
regular
supervision
Underreporti
ng from
outreach
sessions
Onsite
coaching
absent HMIS forms
and registers
not taken to
EPI sessions
Sanctioned
posts
unfulfilled
Lack of
awareness
among people
Illiteracy
BCC/IEC
materials
inadequate
Cultural
norms and
beliefs
EFFECT
FOCAL PROBLEM
C
A
U
S
E
S

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